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|  PRE  SBNTED  IN  MEMORY  OF 

^WILLIAMHENRYDRAPER 

1830-1901-P.axd  S-1855 
AND  HIS  SON 

WILLIAM  KINNICUTT  DRAPER 

1863-1926-P.and  S.-1888 


I 


PRACTICAL  TREATISE 


MEDICAL  DIAGNOSIS 


FOR  STUDENTS  AND  PHYSICIANS. 


BY 


JOHN  H.  MUSSEB,  M.D., 


PROFESSOR    OF    CLINICAL    MEDICINE    IN    THE    UNIVERSITY    OF    PENNSYLVANIA  ;     PHYSICIAN    TO    THE 

PHILADELPHIA  AND  THE  PRESBYTERIAN  HOSPITALS;  CONSULTING  PHYSICIAN  TO  THE  WOMAN'S 

HOSPITAL  OF  PHILADELPHIA  AND  TO  THE  WEST  PHILADELPHIA  HOSPITAL  FOR  WOMEN  ; 

FELLOW    OF    THE    COLLEGE    OF   PHYSICIANS    OF    PHILADELPHIA  ;    MEMEER 

OF  THE  ASSOCIATION  OF  AMERICAN  PHYSICIANS,   ETC. 


THIRD   EDITION,  REVISED  AND   ENLARGED. 


ILLUSTRATED  WITH  253  WOODCUTS  AND  48  COLORED  PLATES 


LEA  BROTHERS  &  CO., 
PHILADELPHIA   AND    NEW   YORK. 


ifll 


Entered  according  to  the  Act  of  Congress,  in  the  year  1899,  by 

LEA  BROTHERS   &   CO., 

In  the  Office  of  the  Librarian  of  Congress,  at  Washington.     All  rights  reserved. 


DOBNAN,     PRINTER, 
PHILADELPHIA. 


TO    THE 


MEMORY     OF    MY    FATHER 


BENJAMIN   MUSSER,  M.D., 


MY    GRANDFATHER 


MARTIN   MUSSEE,  M.D. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/treatiseonmedicaOOmuss 


PREFACE  TO  THIRD  EDITION. 


The  appearance  of  a  third  edition  seems  to  justify  the  author's 
convictions  expressed  in  the  preface  to  previous  editions  concerning 
methods  of  diagnosis. 

The  present  issue  has  been  largely  rewritten  and  rearranged.  The 
recent  advances  in  methods  of  diagnosis  which  have  proved  to  be 
reliable  have  been  added. 

I  am  indebted  to  many  kind  friends  for  valuable  assistance.  Dr. 
Joseph  Sailer  rewrote  the  chapter  on  Nervous  Diseases,  arranging  it 
to  conform  with  the  body  of  the  book.  Dr.  William  C.  Posey  wrote 
the  section  on  Diseases  of  the  Eye.  Dr.  Thomas  S.  Kirkbride,  Jr., 
wrote  the  pages  on  the  Pictoric  Records  of  Physical  Signs,  and  spared 
neither  time  nor  labor  in  the  preparation  of  the  new  plates.  Dr. 
W.  S.  Smith,  of  Boston,  most  kindly  revised  the  section  on  Sputum, 
making  valuable  additions.  Dr.  Fred.  H.  Howard  rendered  valuable 
assistance  and  prepared  the  index.  Finally,  I  am  indebted  to  my 
secretary,  Miss  Fannie  "V.  Coe,  for  valuable  assistance  rendered  while 
the  work  was  passing  through  the  press. 

1927  Chestnut  Street,  Philadelphia. 


PREFACE  TO  SECOND  EDITION. 


Success  in  treatment  requires  both  accuracy  and  completeness 
in  diagnosis.  Partial  knowledge  of  the  nature  of  the  case  differs 
merelv  in  degree  from  ignorance,  and  treatment  based  on  either 
invites  chances  unjust  alike  to  the  patient  and  to  the  interests  of  the 
physician. 

Diagnosis,  being  a  practical  art,  should  be  held  to  include  not 
merely  the  recognition  of  a  disease  or  a  complication  of  diseases, 
but  also  a  determination  of  the  health-value  of  the  patient.  Thus 
in  a  case  of  pneumonia  not  only  should  the  presence  of  the  malady 
be  established,  but  the  functional  condition  of  all  the  organs  should 
also  be  investigated,  in  order  that  rational  treatment  may  be  pre- 
scribed and  a  rational  prognosis  given.  In  other  words,  the  physi- 
cian should  never  forget  that  a  patient  is  a  unit,  comprising  closely 
interacting  organs,  and  that  the  response  to  treatment  will  be  satis- 
factory in  proportion  to  its  adaptation  to  the  condition  of  the  entire 
organism.  After  twenty  years  of  experience  as  a  general  practi- 
tioner, a  hospital  physician,  and  later  as  a  consultant,  the  writer 
is  confirmed  in  the  conviction  that  success  in  treatment  follows  only 
upon  diagnosis  of  the  most  comprehensive  character,  and,  further- 
more, that  the  status  prcesens  should  be  clear  to  the  physician,  not 
only  at  the  outset,  but  also  at  every  stage  of  the  disease. 

The  first  edition  of  this  work  was  prepared  with  these  ideas  of 
completeness  in  view,  and  its  early  exhaustion  is  gratifying  as  an 
eyidence  that  practitioners  and  teachers  recognize  the  vital  impor- 
tance of  complete  diagnosis,  and  have  given  their  approval  to  an 
earnest  effort  to  present  a  knowledge  of  it  in  available  form. 

This  opportunity  for  revision  has  been  conscientiously  utilized, 
and  the  new  edition  will  be  found  to  embody  the  latest  approved 
advances  and  the  newly  established  facts  and  methods  in  this  most 


viii  PREFACE  TO  SECOND  EDITION. 

active  and  .practical  branch  of  medicine.  The  series  of  illustrations, 
which  was  already  unusually  large  for  a  work  of  this  character,  has 
bean  enriched  with  many  new  engravings  and  colored  plates.  The 
author  can  claim  to  have  been  a  most  critical  student  of  his  own 
book,  and  likewise  to  have  profited  by  the  criticisms  of  other  teachers 
and  practitioners. 

Although  there  is  no  "royal  road"  to  diagnosis,  either  through 
compends  or  more  or  less  elaborate  catalogues  of  diseases  which  aid 
the  memory  at  the  expense  of  comprehension  and  judgment,  a 
serious  study  of  the  subject  is  repaid  in  the  accpuisition  of  a  most 
valuable  power.  Modern  research  has  placed  this  fundamental 
branch  upon  the  plane  of  an  exact  science,  and  has  correspondingly 
elevated  the  whole  superstructure  of  medicine.  Instruments  and 
methods  of  precision,  physical,  chemical,  microscopical,  and  bio- 
logical, are  now  so  readily  at  the  command  of  every  practitioner 
that  he  is  legally  as  well  as  morally  bound  to  exhibit  in  his  diag- 
nosis and  treatment  a  degree  of  certainty  far  greater  than  could 
formerly  have  been  exacted. 

In  conclusion,  it  has  been  the  primary  purpose  of  this  book  to 
deal  with  the  whole  subject  of  diagnosis  in  its  present  state  of 
development  in  clear  language  and  with  abundant  illustration,  to 
afford  the  practitioner  a  consultant  upon  which  he  might  rely,  and 
to  present  the  facts  and  principles  in  such  a  manner  as  to  give 
the  undergraduate  and  postgraduate  student  a  rational  grasp  and 
practical  working  knowledge  of  this  fundamental  science  and  art. 

The  author  takes  this  opportunity  of  acknowledging  his  renewed 
indebtedness  to  his  friend,  Dr.  H.  B.  Allyn,  for  valuable  assistance 
while  the  work  was  going  through  the  press ;  to  Dr.  J.  Allison 
Scott  for  the  care  and  patience  he  took  in  supervising  the  production 
of  most  of  the  drawings  and  for  suggestions  in  the  chapter  on  Dis- 
eases of  the  Kidney ;  to  Dr.  Joseph  Sailer,  Dr.  J.  Dutton  Steele, 
and  Dr.  James  Ely  Talley  for  timely  suggestions  and  great  aid  in 
verifying  references.  To  Mrs.  Philip  Putnam  Chase  the  author  is 
under  obligations  for  the  skill  and  patience  required  in  the  execu- 
tion of  many  of  the  drawings. 

1927  Chestnut  Street,  Philadelphia, 
October.  1896. 


PREFACE  TO  FIRST  EDITION. 


Moderx  methods  of  medical  education  demand  that  the  student 
should  be  taught  the  expressions  of  morbid  action,  or,  in  other  words, 
the  phenomena  of  disease.  He  must  be  brought  into  contact  with 
them  in  the  hospital-ward  and  the  outpatient-room,  which  are  the 
medical  laboratories  where  all  the  data  are  collected,  analyzed,  and 
used  in  discriminating  the  various  disorders. 

The  object  of  this  volume  is  to  aid  the  student  in  the  pursuit 
of  such  laboratory-studies,  and  at  the  same  time  to  furnish  the  prac- 
titioner with  a  reliable  practical  guide  to  diagnosis  for  use  in  his 
daily  work.  It  has  been  thought  best  to  combine  in  these  pages 
the  study  of  the  objective  phenomena  or  signs  of  disease,  the  subjec- 
tive phenomena  or  symptoms,  and  the  methods  employed  for  their 
determination.  Special  attention  has  been  paid  to  research  for  objec- 
tive phenomena  appearing  in  physical,  chemical,  and  biological  changes 
in  the  tissues  and  secretions.  The  necessity  for  elaborate  descriptions 
or  extended  lists  of  minutiae  as  guides  to  differentiation  is  being  rap- 
idly displaced  by  the  use  of  instruments  of  precision.  Formerly, 
for  instance,  extensive  tables  were  displayed  to  indicate  the  differen- 
tial diagnostic  features  of  anaemia  and  chlorosis  ;  now  a  few  moments' 
examination  of  the  blood  decides  the  nature  of  the  affection,  and 
whether  iron  or  arsenic  is  to  be  given  for  its  cure. 

The  following  pages  bear  evidence  that  the  author  does  not  under- 
value the  direct  and  collateral  data  obtained  by  inquiry.  Without 
them  an  examination  carefullv  conducted  according:  to  all  other 
methods  may  go  for  naught  in  the  distinction  of  disease. 

The  association  of  morbid  processes  with  their  phenomena  is  a  prac- 
tice of  the  utmost  importance  to  students,  and  a  chapter  has  there- 
fore been  inserted  upon  the  Symptomatology  of  Morbid  Processes. 
Bacteriological  Diagnosis  has  become  an  established  method  by  which 


x  PREFACE  TO  FIRST  EDITION. 

various  disorders  are  recognized,  and  it  is  essential  that  the  procedures 
in  this  new  means  of  research  should  be  fully  outlined.  The  chapter 
on  this  subject  is  included  not  merely  as  a  guide  and  reference  for 
the  trained  student,  but  it  is  hoped  that  it  will  also  emphasize  the 
possibilities  of  bacteriological  studies,  and  inspire  those  who  are  them- 
selves without  facilities  for  prosecuting  laboratory-work  to  have  exam- 
inations made  for  diagnostic  purposes  by  experts  with  laboratories  at 
their  command. 

My  best  thanks  are  due  to  my  associate  in  private  and  hospital 
work  and  teaching,  Dr.  H.  B.  Allyn,  for  assistance  without  which 
this  book  could  not  have  been  written ;  to  Dr.  H.  Toulmin  for  aid  in 
the  collaboration  of  the  sections  devoted  to  the  examination  of  Sputum 
and  Feces ;  to  Dr.  Charles  Burr,  of  the  Infirmary  for  Nervous  Dis- 
eases, for  the  articles  on  Cerebral  and  Spinal  Localization  and  on 
Electrical  Diagnosis ;  and  to  Drs.  Joseph  Sailer,  W.  H.  Fenn,  and 
J.  E.  Talley,  for  valuable  assistance. 

Fortieth  and  Locust  Streets,  Philadelihia, 
February,  1894. 


CONTENTS. 


PART    I. 
GENERAL    DIAGNOSIS. 

CHAPTEE   I. 

General  Observations. 

pages 
The  data  upon  which  a  diagnosis  is  based  :  The  data  obtained  by  inquiry. 
The  data  obtained  by  observation.  Object  of  diagnosis — Requirements  on 
the  part  of  the  student — Methods  of  diagnosis  :  Direct.  Indirect  (by  exclu- 
sion). Differential  —  Diagnosis  sometimes  impossible.  Avoid  haste — 
Diagnosis  should  not  be  limited — Modern  diagnosis — Case-record — Scope 
of  the  present  volume  ...........         17-23 

CHAPTER   II. 

The  Data  Obtained  by  Inquiry. 

The  Social  History:  Age,  sex,  occupation,  habits,  residence  (past  and 
present1,  family  relations,  exposure  to  contagion.  The  Family  History: 
Parents,  grandparents,  brothers  and  sisters  of  each — brothers  and  sisters  of 
patient — wife  and  children.  The  History  of  Previous  Diseases.  The  History 
of  the  Present  Disease:  Duration.     Mode  of  onset.     Evolution  of  the  disease         24-31 

CHAPTER    III. 

The  Data  Obtained  by  Inquiry — (Continued). 

The  Present  Condition  :  The  subjective  symptoms — Mode  of  determina- 
tion— Their  fallacy — Their  value.  Feigned  disease.  Local  Subjective  Symp- 
toms— General  Subjective  Symptoms   ........         32-35 

CHAPTER    IV. 
The  Data  Obtained  by  Inquiry  and  by  Observation — (Continued). 

Pain 36-58 

CHAPTER  V. 

The  Data  Obtained  by  Observation. 

The  objective  symptoms  correspond  to  phenomena  in  nature.  Method  of 
procedure;  method  of  the  observer.  Inspection,  palpation,  percussion.  The 
instruments  required •    59-63 


xii  CONTENTS. 

CHAPTER    VI. 

The  Data  Obtained  by  Observation — {Continued). 

PAGES 

The  first  sight  impressions.  General  abnormal  vital  conditions.  Fits  or 
Seizures.  Coma.  Collapse.  Shock.  1.  The  personal  appearance.  2.  The 
apparent  age.  3.  The  temperament  and  constitution.  4.  The  attitude  and 
gait.  5.  The  general  form  and  nutrition.  The  size — enlargement,  diminution. 
The  weight 64-79 

CHAPTER  VII. 

The  Data  Obtained  by  Observation — (Continued). 

The  face — the  facial  expression.  The  head.  Mumps — facial  hemiatrophy. 
Hydrocephalus.  The  hair.  The  lips.  The  neck — the  thyroid  gland — exoph- 
thalmic goitre — the  bloodvessels  of  the  neck  ......         80-90 

CHAPTER    VIII. 
The  Data  Obtained  by  Observation — (Continued). 
The  Eye  and  Ear 91-109 

CHAPTER    IX. 

The  Data  Obtained  by  Observation — (Continued). 

The  extremities — hands.  The  shape — temperament — occupation  —  "claw- 
hands" —  "seal-fin  hands" — rheumatoid  arthritis  —  nervous  affections — 
"spade"  hands— large  bones  of  acromegalia — osteo-arthropathy — wrist-drop. 
The  movements — spasm — tremor.  The  skin — color — moisture.  Fingers. 
Heberden's  nodosities — contraction  of  fascia — Dupuytren's  contraction — de- 
viation in  shape  The  nails.  Trophoneuroses — cold  hands  and  feet.  Ray- 
naud's disease  — erythromelalgia  .         .         .         .         .         .         .         .         .     110-118 

CHAPTER    X. 

The  Data  Obtained  by  Observation — (Continued). 

The  skin.  The  color — redness — pallor — jaundice — cyanosis — the  bronzed 
skin — Addison's  disease — hemochromatosis — chloasma — tinea  versicolor — 
vagabond's  disease — argyria — freckles.  The  nutrition.  Moisture  and  dry- 
ness— hyperidrosis — anhidrosis.  Scars.  Hemorrhages — mode  of  recogni- 
nition — cause — significance.  Eruptions — their  clinical  significance — nature 
of  the  lesion — distribution — associate  morbid  phenomena — general  symp- 
toms. Table  of  skin  diseases — erythema  nodosum — urticaria — medicinal 
rashes — erythema  of  infectious  diseases — roseola — milaria  or  sudamina. 
General  diagnosis         ...........     119-147 

CHAPTER    XI. 

The  Data  Obtained  by  Observation— (Continued). 

The  subcutaneous  connective  tissue.  GCdenia — causes — mode  of  recognition — 
situation— feet,  face,  arms,  and  head — oedema  of  trichinosis— angioneurotic 
oedema.  Mysoedema.  Connective-tissue  dystrophies.  Scleroderma.  Sar- 
comata—cysticercus  cellulosse — brawny  induration.  Subcutaneous  nodules. 
The  lymphatic  glands.  Enlargements — local — general.  Adenitis.  Hodgkin's 
disease.     Tuberculosis  and  leukpemia     ........     148-162 


CONTENTS.  xiii 

CHAPTER   XII. 
The  Data  Obtained  by  Observation—  {Continued). 

PAGES 

The  muscles  — idiopathic  muscular  atrophy — pseudo-hypertrophy— Thorn- 
sen's  disease  —  paramyoclonus  multiplex.  Myositis  —  myalgia — muscular 
rheumatism  ............     163-168 

CHAPTER    XIII. 

The  Data  Obtained  by  Observation — (Continued). 

The  bones — general  examination.  Enlargement — acromegaly — osteitis  de- 
formans— pulmonary  osteo- arthropathy  —  diminution  —  rhachitis  —  osteomalacia. 
Local  examination — position  and  shape — nodes — inflammation — osteomye- 
litis           169-190 

CHAPTER    XIV. 
The  Data  Obtained  by  Observation — (Continued). 
Chills  ;  fever  ;  subnormal  temperature  ........     190-208 


CHAPTER    XV. 

The  Data  Obtained  by  Observation — (Continued' 


Fever.     The  Intoxications 


209-216 


CHAPTER    XVI. 

The  Data  Obtained  by  Observation — (Continued). 

Fever.  The  Infections.  Causal  relation  of  bacteria  to  disease,  Koch's 
laws,  value  in  diagnosis.  Bacteria :  Saprophytes,  parasites,  pathogenic,  non- 
pathogenic, aerobic,  anaerobic,  facultative  anaerobic.  Morphology;  Micro- 
cocci, bacilli,  spirilla — Micrococci.  Morphology :  Form  and  size.  Repro- 
duction, fission  ;  grouping.  Biological  characters  :  Non-motile.  Pigment 
production.  Liquefaction  of  gelatin.  Production  of  acids.  Toxic  ptomaines 
and  toxalbumins — Bacilli.  Morphology :  Form  and  size.  Reproduction, 
fission,  spores  ;  grouping.  Biological  characters:  Motility.  Pigment  pro- 
duction. Liquefaction  of  gelatin.  Production  of  acids.  Putrefaction,  fer- 
mentation. Spirilla.  Morphology :  Form  and  size.  Reproduction,  fission  ; 
grouping.  Biological  characters.  Motility.  Pigment-production.  Lique- 
faction of  gelatin.     Production  of  acids  and  fermentation  wanting 


217-222 


CHAPTER    XVII. 
The  Data  Obtained  by  Observation — (Continued). 

Fever.  The  Infections.  Data  obtained  by  inquiry — By  observation. 
Local  infection — General  infection.  Pyaemia  ;  septicemia.  Terminal  infec- 
tions. Fever  in  carcinoma.  Afebrile  infections.  Infections  of  certain  bac- 
teriology ;  of  uncertain  bacteriology.  Bacteriological  diagnosis.  Method  of 
research :  Microscopical  examination,  cultivation,  inoculation.  Essentials 
in  technique— Method  of  research:  Blood,  discharges,  exudations;  mode  of 
collection.     Apparatus.     Preparation  of   apparatus.     Sterilization.     Micro- 


XIV 


CONTENTS. 


scopical  examination :  Technique,  cover-glass  preparations.  Methods  of 
staining  ;  spores.  "Hanging  drop'' — cultivation  of  micro-organisms.  Cul- 
ture-media. Tube-  and  plate-cultures.  Smear-  and  stab-cultures — Inocu- 
lation of  animals — Special  bacteriological  diagnosis 223-245 

CHAPTER    XVIII. 

The  Data  Obtained  by  Observation — (Continued). 

Fever.     The  infectious  diseases.     Infections  not  recognized  by  bacterio- 
logical or  blood  examination 246-273 

CHAPTER    XIX. 

The  Data  Obtained  by  Observation — {Continued). 

Fever.     The  infectious  diseases.     Infections  recognized  by  examination 
of  the  blood 274-308 


CHAPTER    XX. 

The  Data  Obtained  by  Observation — [Continued). 

Fever.  The  infectious  diseases.  Infections  recognized  by  the  examina- 
tion of  excretions  and  secretions  or  by  the  products  of  the  infectious  inflam- 
mations        ........... 


309-356 


CHAPTER    XXI. 

The  Data  Obtained  by  Observation — {Continued). 

Exploratory  puncture  or  aspiration  for  diagnosis:  Instruments.  Preparation 
of  instruments.  Preparation  of  skin.  Point  of  puncture.  — Exudations  (Pus- 
Sero-pus.  Gangrenous  debris.  Blood.  Serum.  Chyle)  :  Pus.  Blood- 
corpuscles.  Bacteria.  Protozoa.  Vermes.  Crystals —  Chemical  examina- 
tion: Sero-purulent  exudations.  Putrid  exudations.  Hemorrhagic  exu- 
dations. Serous  exudations.  Chylous  exudations.  Pleural  effusions.  Trans- 
udations.— The  contents  of  ousts :  Hydatid,  ovarian,  renal,  pancreatic 


357-368 


CHAPTER    XXII, 

The  Blood 


369-399 


CHAPTER   XXIII. 

The  Morbid  Processes  and  their  Symptomatology. 

Knowledge  of  symptoms  of  morbid  processes  essential  ;  they  control  con- 
clusions drawn  from  data. — Morbid  processes  are  few.  I.  Alterations  in 
blood  and  circulation.  Anaemia  and  plethora — Hyperemia,  active  and 
passive — Oedema  and  dropsy — Thrombosis  and  embolism — Hemorrhage — 
Blood-pressure.  IL  Disturbances  of  nutrition:  Inflammation — Gangrene 
and  necrosis — Fever — Atrophy  and  hypertrophy.  Degenerations:  Albu- 
minous —  Fatty  —  Colloid — Mucous — Pigmentary — Calcareous — Amyloid — 
Fibroid.     HI.  Anomalies  of  growth  :  Tumors — Cysts — Cancer   . 


400-416 


CONTENTS.  xv 

PART    II. 
SPECIAL    DIAGNOSIS. 

CHAPTEE   I. 

PAGES 

The  Nose  and  Larynx       ....     417-449 

CHAPTEE    II. 

Diseases  op  the  Lungs  and  Pleura   .        .        .     450-579 

CHAPTEE    III. 

Diseases  op  the  Heart,  the  Bloodvessels,  and  the  Mediastinum    580-685 

CHAPTEE    IV. 

Diseases  of  the  Mouth,  Fauces,  Pharynx,  and  (Esophagus    686-724 

CHAPTEE   V. 

Diseases  of  the  Stomach,  Intestines,  and  Peritoneum  .     725-853 

CHAPTEE    VI. 

Diseases  of  the  Liver,  Spleen,  and  Pancreas         .     854-899 

CHAPTEE    VII. 

Diseases  of  the  Kidneys    ....     900-968 

CHAPTEE    VIII. 

Diseases  of  the  Nervous  System      .        .        .  969-1062 


ERRATA 


Page  203,  third  line  from  top,  omit  "disease"  after  "malingering." 
Page  230,  twelfth  line  from  bottom,  for  "moist,"  read  "most." 
Page  268,  seventh  line  from  bottom,  for  "in  a  week,"  read  "in  about  three  weeks." 
Page  272,  fourth  line  from  bottom,  insert  "actinomycosis"  after  "glanders." 
Page  277,  fifth  line,  omit  the  "comma"  after  "malignant." 

Page  282,  fourth  paragraph,  second  line,  for  "  four  hours,"  read  "forty -eight  hours.' 
Page  284,  third  line  from  top, for  "roseate"  read,  "rosette." 
Page  289,  third  paragraph,  fifth  line,  insert  "combined"  after  "ulceration." 
Page  299,  third  line  from  bottom,  for  "  forms  are  decreased,"  read  "forms  are  rela- 
tively increased." 

Page  305,  fourth  paragraph,  fifth  line,  for  "  1  to  5,"  read  "  1  to  50." 
Page  359,  thirteenth  line  from  bottom,  for  "intercellularis,"  read  " intracellulars. " 
Page  369,  sixth  line  from  bottom,  for  "identity,"  read  "entity." 
Page  373,  fifteenth  line  from  bottom,  for  "value,"  read  "volume." 
Page  386,  third  paragraph,  first  line,  for  "acidity  of  blood,"  read  "alkalinity  of 
blood"  in  both  places. 

Page  489,  fifth  line  from  top,  insert  "tissue"  after  "pulmonary." 

Page  491,  thirteenth  line  from  top,  for  "implies,"  read  "applies." 

Page  496,  fifth  line  from  top,  for  "tympanite"  read  "tympanitic." 

Page  611,  second  paragraph,  third  line,  for  "distended"  read  "distending." 

Page  821,  fourth  line  from  top,  for  "tubules"  read  "intestines." 


MEDICAL    DIAGNOSIS. 


PART  I. 

GENERAL   DIAGNOSIS. 


CHAPTER    I. 

GENERAL  OBSERVATIONS. 

The  data  upon  which  a  diagnosis  is  based  :  The  data  obtained  by  inquiry.  The  data 
obtained  by  observation.  Object  of  diagnosis — Requisites  on  the  part  of  the 
student — Methods  of  diagnosis :  Direct.  Indirect  (by  exclusion).  Differential 
— Diagnosis  sometimes  impossible.  Avoid  haste — Diagnosis  should  not  be  lim- 
ited— Modern  diagnosis — Case  records — Scope  of  the  present  volume. 

The  sufferings  of  one  who  comes  under  the  care  of  a  physician  are 
indicated  by  symptoms  of  which  the  patient  himself  is  cognizant,  and 
for  which  usually  he  applies  for  relief  ;  or  by  alterations  of  the  physical 
or  chemical  structure  of  the  whole  or  a  part  of  the  body,  or  of  the 
functional  activity  of  organs — alterations  which,  although  not  apparent 
to  him,  are  evident  to  the  observer,  the  physician.  The  symptoms  of 
which  the  patient  complains,  and  of  which  he  alone  has  knowledge, 
are  known  as  the  subjective  symptoms  of  disease.  The  symptoms  which 
the  physician  observes,  some  of  which,  as  the  changes  of  the  exterior, 
may  be  apparent  to  the  patient,  are  known  as  the  objective  symptoms  of 
disease. 

The  subjective  symptoms  of  disease,  as  well  as  such  objective  symp- 
toms as  the  patient  is  aware  of,  have  a  history.  It  may  be  the  brief 
one  of  sudden  onset,  or  a  long  one  of  rise  and  fall,  of  ebb  and  flow,  of 
the  mingling  of  complex  phenomena  from  time  to  time.  The  story  of 
the  evolution  of  the  disease  is  written  as  the  history  of  the  present 
disease. 

The  present  disease  may  be  due  to  previous  attacks  of  disease,  or  be 
modified  by  the  occurrence  of  previous  disease.  We  may  be  consulted 
for  the  effects  of  one  link  in  a  chain  of  morbid  disorders  which  began 
in  infancy  or  early  adult  life.  We  should  learn,  therefore,  of  the  occur- 
rence of  previous  disease.  Certain  types  of  constitution  and  some  few 
diseases  are  transmitted  by  parents  to  offspring  ;  we  should,  therefore, 
inquire  into  the  family  history.  A  further  insight  into  the  nature  of 
the  suffering  may  be  obtained  by  a  knowledge  of  the  age,  sex,  habits, 

2 


18  GENERAL  DIAGNOSIS. 

occupation,  environment,  etc. — in  short,  by  a  knowledge  of  the  social 
history — for,  if  the  cause  of  the  disease  under  consideration  is  deter- 
mined, a  distinction  from  other  affections  with  allied  phenomena  can 
frequently  be  made. 

The  subjective  symptoms,  the  history  of  the  present  disease,  the  previous 
history,  the  family  history,  and  the  social  history  are  learned  by  inquiry 
of  the  patient  or  the  friends  of  the  patient  by  methods  and  within 
limitations  hereafter  to  be  described.  It  is  proper  that  they  should  be 
ascertained,  if  practicable,  before  the  objective  symptoms  are  studied. 

After  the  story  of  the  patient  is  ascertained  in  full,  the  objective  symp- 
toms  are  sought  for.  Examination  of  the  patient  by  the  use  of  the 
senses  of  sight,  of  touch,  of  hearing,  with  the  instruments  of  precision 
to  aid  them — the  physical  examination — and  by  chemical  and  bacteri- 
ological methods,  reveals  the  presence  or  absence  of  the  latter  class  of 
symptoms. 

The  phenomena  of  disease  are  ascertained,  therefore,  by  inquiry 
and  by  observation.  The  facts  or  data  thus  collected  and  the  dis- 
criminate interpretation  of  them  constitute  diagnosis. 

Object  of  Diagnosis.  The  object  of  diagnosis  is  to  determine  the 
condition  of  the  living  patient  who  may  be  suffering  from  disease.  It 
implies  not  only  that  the  phenomena  of  disease  are  detected,  but  also 
that  the  effects  of  the  disease  on  the  organism  are  determined,  and 
that  the  morbid  process  which  is  the  cause  of  the  phenomena  is  ascer- 
tained. Even  this  is  too  restricted  an  idea  of  diagnosis.  It  should 
include  also  the  recognition  of  the  cause  of  the  morbid  process.  The 
latter  is  known  as  the  (Etiological  diagnosis.  In  addition  to  naming  the 
disease  and  its  cause  we  should  include  in  the  diagnosis  a  determina- 
tion of  the  stage  of  the  disease  and  the  recognition  of  its  complications. 
Moreover,  diagnosis  implies  such  knowledge  of  the  patient's  condition 
as  to  enable  an  estimation  of  the  dangers  liable  to  arise  and  of  the 
outcome  of  the  disease — the  prognosis. 

Diagnosis  is  not  made  in  order  to  give  the  disease  a  name  alone  but 
to  treat  it,  and  as  it  is  not  disease  that  we  treat  but  a  patient  with  an 
ailment,  full  knowledge  of  the  patient  and  of  his  environment,  his 
mode  of  life,  habits,  occupation,  etc.,  must  be  obtained  by  inquiry. 

The  practical  result  of  diagnosis  is  the  ability  to  remove  or  prevent 
the  occurrence  of  the  morbid  processes,  or  to  mitigate  their  effects  by 
rational  therapeutics. 

Requisites  on  the  Part  of  the  Student.  As  data  are  to  be  col- 
lected by  inquiry  and  by  observation,  it  is  obvious  that  he  who  would 
inquire  and  observe  intelligently  and  successfully  must  be  possessed  of 
knowledge  and  qualifications  of  a  high  order.  The  phenomena  of 
health  must  be  familiar  to  him.  He  must  have  a  full  knowledge  of 
physiology,  to  recognize  the  aberrations  of  function,  and  of  pathology,  to 
understand  the  production  of  symptoms  by  disease.  He  must  know 
the  organic  results  of  pathological  processes — morbid  anatomy.  He 
must  have  learned,  by  reading  and  experience,  the  significance  of  symp- 
toms, or  of  groups  of  symptoms,  and  their  relation  to  morbid  processes. 


GENERAL  OBSERVATIONS.  19 

He  must  have  a  knowledge  of  the  evolution  of  disease  and  the  phe- 
nomena of  each  period  in  its  development,  to  secure  an  accurate  account 
of  the  disease  under  consideration.  He  must  know  the  influence  of 
morbid  processes  on  the  body  and  their  effect  in  the  production  of  sub- 
sequent disease,  in  order  to  ascertain  correctly  the  various  diseases  of 
the  patient  and  infer  rightly  their  relation  to  the  phenomena  under 
consideration.  The  significance  of  the  family  history  can  be  appreciated 
and  correctly  applied  only  by  a  knowledge  of  the  diseases  which  are 
inherited  or  which  arise  in  certain  physical  types  of  individuals,  which 
type  is  inherited.  The  social  history  is  not  worth  securing  unless  the 
inquirer  knows  the  influence  of  age  and  sex,  of  race,  of  occupation,  of 
habits,  of  residence,  of  degree  of  labor,  in  the  development  of  disease, 
or  the  influence  of  the  environment  on  the  individual — the  action  and 
reaction  of  external  forces  on  forces  within. 

To  ascertain  the  objective  symptoms,  he  who  would  observe  properly 
must  know  anatomy,  to  recognize  the  seat  of  the  disease,  and  'physiology, 
to  discern  the  departures  from  health.  He  must  be  trained  at  the  bed- 
side in  the  use  of  the  senses,  and  know  how  to  discriminate  and  inter- 
pret phenomena  observed  by  them.  He  must  know  how  to  use  instru- 
ments of  precision,  as  the  microscope,  and  must  learn  its  revelations. 
The  laws  of  chemistry  and  the  methods  of  chemical  examination  must 
be  familiar  to  him.  Bacteriology  and  the  data  obtained  from  its 
methods  must  be  appreciated  fully. 

It  is  thus  seen  that  the  inquirer  must  have  knowledge  gained  by 
reading  and  knowledge  gained  by  observation  at  the  bedside  and  in  the 
post-mortem  room.  He  acquires  thus,  on  the  one  hand,  the  recorded 
experience  of  others,  and  learns  that  certain  symptoms  under  certain 
circumstances  indicate  a  definite  malady.  On  the  other  hand,  he  learns 
that  certain  symptoms  are  associated  with  definite  lesions. 

Methods  of  Diagnosis.  But  we  must  not  only  secure  facts,  we 
must  also  be  able  to  utilize  them  for  analysis  and  induction — the  result 
of  which  is  the  formation  of  the  diagnosis.  The  diagnosis  is  obtained 
by  three  methods — the  direct,  the  indirect,  and  the  differential.  By  the 
direct  method  the  data  collected  are  sufficient  to  warrant  a  positive  con- 
clusion. An  indirect  diagnosis  is  made  by  exclusion.  A  symptom 
group  may  represent  several  diseases.  Each  affection  is  passed  in 
review  and  excluded  until  one  is  found  to  correspond  more  closely  to 
the  data  of  the  case  under  consideration.  It  is  not  one,  because  of  the 
absence  of  certain  symptoms  ;  it  is  not  another,  because  of  the  presence 
of  certain  essentially  different  symptoms.  A  negative  is  thereby 
proven.  By  the  differential  method  the  diagnosis  of  one  of  a  few  pos- 
sible diseases  must  be  made,  the  data  for  and  against  which  are  passed 
in  review.  The  direct  method  is  scientific,  rational,  and  the  most  prac- 
tical.    It  is  a  process  of  pure  inductive  reasoning. 

Diagnosis  Sometimes  Impossible.  Notwithstanding  our  efforts 
to  collect  data  by  inquiry  and  by  observation,  we  are  often  unable  to 
make  a  diagnosis.  This  arises  when  promises  are  wanting  for  the  pro- 
cess of  induction.     The  subjective  symptoms  may  not  tally  with  the 


20  GENERAL  DIAGNOSIS. 

known  processes  of  disease,  or  the  narrator  of  the  history  of  the  present 
disease  may  omit  important  evidence  from  lack  of  memory  or  knowl- 
edge, from  design,  or  for  other  reasons.  The  objective  phenomena  may 
be  developed  in  an  ill-defined  way,  or  they  may  be  obscure,  as  the  state 
of  the  abdominal  contents  in  a  person  who  is  obese  ;  or  they  may  point 
to  one  or  more  processes  the  subjective  symptoms  of  which  are  not 
present.  At  the  time  of  observation  the  disease  may  not  have  devel- 
oped fully,  may  not  have  "  spelled  itself  out."  Under  these  circum- 
stances a  provisional  diagnosis  must  be  made  or  conclusions  held  in 
abeyance.  If  Ave  are  considering  a  contagious  disease,  for  sanitary 
reasons,  the  infectious  disease  should  be  given  the  benefit  of  the  doubt. 
If,  on  the  other  hand,  the  disease  requires  prompt  remedial  action,  the 
symptoms  must  be  taken  as  the  indication  for  therapy. 

Avoid  Haste.  If  prompt  action  is  not  required,  too  great  haste 
should  be  avoided.  It  is  not  necessary  to  make  a  diagnosis  at  once, 
and  it  is  not  a  confession  of  ignorance  if  time  is  asked  before  an  opinion 
is  given.  Repeated  observation  and  reflection  should  be  employed 
before  a  conclusion  is  arrived  at.  This  particularly  applies  to  the  class 
of  cases  which  represent  a  condition  the  resultant  of  improper  environ- 
ment, for  the  proper  detection  of  which  social  data,  knowledge  of  tem- 
perament, etc.,  must  be  acquired.  Then,  again,  it  may  be  necessary  to 
observe  the  patient  under  changed  circumstances,  or  study  the  effects 
of  diet  on  renal  secretion,  or  on  the  function  of  other  organs.  Haste 
leads  to  faulty  diagnosis,  and  therefore  to  misdirected  therapeusis. 

Diagnosis  Should  Not  be  Limited.  It  is  not  sufficient  to  give  a 
name  to  a  group  of  symptoms  and  be  satisfied  that  the  diagnosis  is 
made.  Every  method  must  be  used  to  collect  data.  The  exact  physi- 
cal condition  of  the  patient  must  be  ascertained  and  the  functional 
powers  of  all  the  organs  correctly  determined.  We  thus  learn  if  the 
more  evident  disease  is  the  single  expression  of  a  morbid  process,  or  if 
it  is  the  surface  storm,  the  currents  of  which  are  underneath.  A  pleu- 
risy or  pneumonia  may  be  the  outcome  of  or  complicate  a  latent 
nephritis.  A  peritonitis  may  be  the  sequela  of  an  appendicitis  or  pyo- 
salpinx.  Or  diseases  in  two  or  more  organs,  due  to  the  same  process, 
may  exist  at  the  same  time,  as  suppurative  pleuritis  and  pericarditis. 
It  would  not  be  sufficient  to  recognize  one  of  the  affections  alone. 

For  purposes  of  treatment  it  is  not  sufficient  to  recognize  a  neuralgia 
or  a  spasm.  The  state  of  the  patient  on  account  of  which  the  neuralgia 
developed  must  be  ascertained.  Attention  must  be  called  to  the  im- 
portance of  not  being  lulled  into  a  false  security  by  the  belief  that  the 
diagnosis  of  the  first  day  is  sufficient.  Complications  may  arise  or  the 
morbid  process  invade  new  territory.  Thus,  in  the  course  of  pneu- 
monia, in  a  few  days  a  meningitis  may  arise  or  an  ulcerative  endocar- 
ditis ensue. 

Modern  Diagnosis..  Anyone  Avho  takes  the  trouble  to  recall  the 
methods  of  diagnosis  that  were  in  use  twenty  years  ago  will  be  struck 
by  the  wonderful  expansion  of  the  means  now  at  hand  to  unravel  the 
mysteries  of  disease.     Then  a  few  instruments  of  precision  and  a  few 


GENERAL  OBSERVATIONS.  21 

chemical  reagents  were  required.  The  microscope  was  employed  to 
examine  only  a  few  of  the  excretions  and  the  blood.  Now  the  instru- 
ments of  precision  are  multiplied  and  the  scope  of  their  explorations  is 
increased.1  Chemistry,  among  other  things,  helps  to  fathom  the  mys- 
teries of  gastric  disease.  The  microscope  has  extended  its  domain, 
and,  with  the  new  methods  of  staining  fluids  and  tissues,  has  become 
the  key  that  unlocks  many  of  Nature's  secrets.  The  new  science  of 
bacteriology  has  come  to  our  aid,  and  now  instead  of  waiting  to  estab- 
lish a  diagnosis  until  an  epidemic  counts  its  victims  by  hundreds  it  is 
obtained  at  once. 

Certainty  in  diagnosis,  for  these  reasons,  has  made  a  decided  advance. 
The  number  of  diseases  which  can  be  positively  diagnosticated  has  in- 
creased. Methods  of  investigation  and  new  instruments  of  precision 
are  increasing  daily.  May  we  not  hope  that  in  the  future  the  horizon 
of  absolute  knowledge  will  be  extended  far  beyond  its  present  limits  ? 
New  instruments  and  new  methods  will  surely  avail. 

The  use  of  the  large  number  of  instruments  that  are  essential,  and 
the  chemical  and  bacteriological  examinations  that  are  made,  require 
a  great  deal  of  time.  Often  the  diagnosis  is  a  question  of  hours  or 
even  of  days.  The  patient  profits  thereby.  The  tax  on  the  physician 
is  far  greater  than  it  was  a  few  years  ago.  The  bedside  labor  is  great, 
and,  in  addition,  he  must  have  a  laboratory  at  his  command  for  micro- 
scopical, chemical,  and  bacteriological  work.  The  outcome  is  that  the 
scientific  physician  must  have  a  clientele  limited  in  number,  or  else  have 
one  or  more  assistants  to  aid  him  in  his  investigations.  Without  doubt 
the  latter  will  soon  occur.  Not  as  in  days  of  old  will  we  find  in  the 
practitioner's  office  the  apprentice,  compounding  drugs  and  rolling 
bandages,  assisting  in  the  operations  of  bleeding  and  dressing  ulcers, 
but  the  highly  trained,  scientific  assistant,  who  by  labors  in  the  labora- 
tory and  at  the  bedside  is  competent  to  collect  data  suitable  for  scien- 
tific methods  of  reasoning. 

Case  Records.  Records  of  cases  should  be  kept  for  obvious  reasons. 
The  habit  compels  a  general  survey  of  the  case,  and  tends  to  prevent 
oversight  in  the  examination.  It  naturally  aids  in  the  training  of  the 
powers  of  observation.  It  teaches  precision  in  the  narration  of  cases. 
The  memory  is  aided  by  repetition  and  by  lack  of  haste  in  ascertaining 
phenomena.  The  data  are  on  record  for  more  mature  reflection,  and  to 
aid  in  the  study  of  the  literature  of  similar  cases.  The  record  is  of 
value  in  case  the  patient  returns  for  advice  after  a  lapse  of  time.  It 
may  be  of  medico-legal  value.  The  mental  effect  on  the  patient  is 
good,  for  the  taking  of  notes  requires  time  and  accurate  studied  obser- 
vation. In  case  it  is  desired  to  study  a  large  number  of  cases,  records 
are  scientific  data.  The  records  may  be  kept  on  loose  sheets  and  filed 
for  future  use.  When  a  sufficient  number  are  secured  they  may  be 
classified  and  bound  in  volumes  devoted  to  the  various  diseases,  or 
they  may  be  noted  in  a  blank-book.     At  the  end  of  the  year  the  book 

1  As  a  most  simple  illustration,  witness  the  knee-jerk  and  reflexes,  learned  by  per- 
cussion, an  old  method,  in  extended  use. 


22  GENERAL  DIAGNOSIS. 

is  indexed  according  to  the  diseases  and  the  names  of  the  patients.  A 
better  method  is  by  a  system  of  cards.  The  cardboard  should  be  six 
by  eight  inches.  One  card  is  devoted  to  each  case,  although  more  can 
be  used.  They  are  arranged  and  catalogued  according  to  the  library 
system  of  card  catalogues. 

Method  of  Record.  A  systematic  plan  must  be  pursued  in  noting 
the  cases.  It  need  not  correspond  to  the  lines  of  inquiry  in  the  exami- 
nation of  the  patient,  which  are  modified  by  the  circumstances  of  the  case. 

The  following  outline  explains  itself.  The  various  data  should  be 
recorded  in  sequence,  and  in  such  manner  that  the  facts  of  each  line  of 
investigation  can  be  readily  culled  for  review  and  analysis.  (See  Chap- 
ters II.  and  III.). 

EECOED  OF  CASE  NO.  — . 

Diagnosis.  Result. 

Name  and  residence,  place  of  birth,  and  former  residence. 

I.  •  Social  history  :  Age,  sex,  race,  married  or  single,  children,  the  number  and 

health ;  miscarriages. 
Occupation :  Present  and  previous  home  surroundings,  sanitary  conditions,  etc. 
Habits:   Tobacco,  alcohol,  tea,  narcotics;   sexual   habits;   regularity  of   meals, 

character  of  food,  and  method  of  eating;  number  of  hours  of  sleep,  degree  of 

fatigue ;  brain-use,  exercise. 

II.  Family  history:  Hereditary  tendency;  health  of  parents,  brothers,  sisters, 

etc.     Cause  of  death  and  age  at  which  it  occurred. 

III.  History  of  previous  diseases  :   Character  of  convalescence  from ;  syphilis 
and  gonorrhoea ;  injuries. 

IV.  History  of  the  present  disease  :  Date,  mode  of  onset,  and  probable  exciting 
cause  of  present  trouble ;  evolution  of  the  disease  to  date  of  examination. 

V.  The  present  condition  : 

A.  Inquiry :  The  subjective  symptoms. 

B.  Observation :  The  objective  symptoms. 

External  appearance,  development,  color,  figure,  height  and  weight,  attitude, 
expression  of  face. 

Temperature,  perspiration,  eruption,  swelling.     Condition  of  limbs  and  joints. 

Examination  of  the  digestive  apparatus :  Mouth,  tongue,  gums,  and  pharynx  ; 
abdominal  organs ;  contents  of  stomach,  fseces. 

Examination  of  respiratory  apparatus:  Nose,  mouth,  and  larynx.  The  lungs :  inspec- 
tion, palpation,  percussion,  auscultation,  mensuration.    Cough  and  expectoration. 

Examination  of  circulatory  apparatus:  Inspection  and  palpation  of  cardiac  area 
percussion,  auscultation  of  heart ;  similar  examination  of  arteries  and  veins ; 
the  pulse  ;  examination  of  the  blood. 

Examination  of  the  urinary  apparatus :  Kidneys,  ureters,  and  bladder  ;  examina- 
tion of  urine. 

Examination  of  the  nervous  system :  Intelligence,  subjective  nervous  phenomena, 
sleep,  gait,  station,  reflexes,  paralysis,  tremor,  pain,  convulsions,  headaches, 
disturbances  of  sensation,  disturbance  of  speech.     The  organs  of  special  sense. 

Examination  of  fluids  obtained  by  puncture. 

Bacteriological  examination  of  blood,  sputum,  secretions,  exudations,  etc. 

Diagnosis. 

Prognosis. 

Treatment. 


GENERAL  OBSERVATIONS.  23 

How  to  Use  the  Book  for  Diagnosis.  We  must  anticipate  a 
little.  The  student  can  by  ready  reference  make  practical  use  of  the 
work  as  the  hand-book  is  used  in  the  laboratory.  It  is  supposed  that 
the  case  has  been  thoroughly  investigated,  according  to  the  directions 
indicated  in  the  book,  and  the  data  arranged  in  accordance  with  the 
case  record.  An  analysis  of  the  data  is  then  made.  The  value  of 
that  obtained  by  inquiry  and  that  obtained  by  observation  is  carefully 
considered.  The  diagnostic  significance  of  the  respective  data  may  be 
found  by  consulting  the  index  or  by  a  review  of  the  chapters  devoted 
to  the  special  subject.  An  estimate  of  the  value  of  the  data  obtained 
by  inquiry,  including  the  subjective  symptoms  of  disease,  will  be  found 
in  the  sections  devoted  to  general  diagnosis  if  the  data  are  general 
(Chapters  II.  to  XXII.  inclusive).  If  the  data  obtained  by  inquiry 
refer  to  special  organs  they  will  be  estimated  in  the  sections  on  special 
diagnosis  that  treat  of  the  manifestations  of  disease  in  the  respective 
organs.  In  the  same  manner  data  obtained  by  observation  that  are  of 
a  general  character  are  considered  in  the  sections  on  general  diagnosis. 
Data  pointing  to  disease  of  special  organs  are  considered  in  the  chapters 
treating  of  the  respective  organs. 

It  must  be  understood  by  the  student  that  by  general  data  we  mean 
such  as  may  be  expressive  of  the  disease  of  various  internal  organs. 
Thus,  the  student  of  internal  medicine  examines  the  eye  not  with  the 
view  of  finding  any  special  disease  of  that  organ,  but  to  note  any 
changes,  physiological  or  anatomical,  which  may  have  resulted  from 
primary  disease  elsewhere.  Diseases  of  the  nervous  system,  of  the 
blood,  of  the  heart,  or  of  the  kidneys  may  be  expressed  in  eye  altera- 
tion of  some  kind.  Similarly,  the  skin,  the  bones,  and  joints,  as  well 
as  other  structures,  are  studied.  Many  internal  diseases  will  have  their 
outward  or  physical  expression  in  general  anatomic  change  or  in  the 
change  of  one  set  of  tissues.  When  this  is  the  case  the  disease  will 
be  discussed  when  considering  its  most  manifest  external  expression,  as 
myxoedema  under  "  enlargements  "  of  the  body  and  acromegaly  under 
"  bones  and  joints."  The  book  is  arranged,  therefore,  for  diagnostic 
convenience  and  not  for  pathological  classification. 


CHAPTER   II. 

THE  DATA  OBTAINED  BY  INQUIBY. 

The  Social  History :  Age,  sex,  occupation,  habits,  residence  (past  and  present),  family- 
relations,  exposure  to  contagion.  The  Family  History :  Parents,  grandparents, 
brothers  and  sisters  of  each — brothers  and  sisters  of  patient — wife  and  children. 
The  History  of  Previous  Diseases.  The  History  of  the  Present  Disease :  Duration. 
Mode  of  onset.     Evolution  of  the  disease. 

Mode  of  Procedure.  First  the  subjective  symptoms  of  the  disease 
are  elicited,  so  that,  if  necessary,  measures  may  be  directed  for  the 
patient's  relief  at  once,  and  that  we  may  have  the  advantage  of  obser- 
vation of  the  patient's  intelligence,  expression,  etc.,  and  at  the  same 
time  ascertain  the  direction  further  inquiry  should  take,  in  order 
that  embarrassment  may  pass  off  and  composure  ensue  before  an 
objective  examination  is  made.  It  seems  preferable,  however,  to  begin 
the  record  with  the  social  history  of  the  case,  for  a  scientific  and  orderly 
procession  in  the  data  acquired,  and  then  proceed  to  record  the  facts  of 
family  history,  previous  history,  and  history  of  present  disease.  Cer- 
tainly it  is  immaterial  how  they  are  considered  in  the  following  discus- 
sion, and  for  convenience,  therefore,  the  above  order  will  be  followed. 
It  is  to  be  remembered  that  the  patient's  complaints  and  the  objective 
phenomena — or,  if  the  patient  is  unconscious  or  otherwise  unable  to 
speak  intelligently,  the  latter  alone — are  the  central  threads  around 
which  the  diagnosis  is  woven. 

The  Social  History. 

The  aid  to  diagnosis  obtained  from  inquiry  into  the  social  history 
cannot  be  considered  exhaustively.  Works  on  hygiene  must  be  con- 
sulted. General  ideas  will  be  given  ;  reference  to  the  influence  of 
various  factors  will  be  found  under  the  individual  diseases.  That 
such  data  are  of  value  is  illustrated  in  various  forms  of  colic.  For 
instance,  knowledge  that  the  patient  labored  in  lead  will  often  simplify 
the  diagnosis  of  the  nature  of  this  symptom. 

The  Age.  The  age  is  learned,  for  each  period  in  the  evolution  and 
involution  of  life  has  its  peculiar  physiological  processes  susceptible  to 
variations  by  external  influences. 

A  large  group  of  affections  arise  in  the  first  period  of  infancy,  from 
inheritance  or  congenital  malformations,  from  accidents  incident  to 
parturition,  and  from  improper  management  of  the  cord.  In  a  later 
period,  in  acquiring  adaptability  to  environment,  by  the  feebly  resist- 
ing organism,  disturbances  of  digestion  from  poorly  prepared  or  improper 
food  arise  ;  pulmonary  disorders  from  improper  clothing,  ventilation, 
etc.,  occur.     The  developing  nervous  system  has  more  acute  suscepti- 


THE  DA  TA  OB  TA  IN  ED  BY  INQ  UIR  Y.  25 

bilities,  and  hence  a  long  array  of  reflex  symptoms  or  diseases  is  ob- 
served at  this  period.  Another  group  of  diseases,  the  exanthemata,  and 
almost  all  contagious  diseases,  are  more  prevalent  in  childhood,  because 
they  arise  out  of  exposure  to  a  specific  cause  which  usually  occurs 
before  the  child  attains  many  years.  The  anatomical  arrangement  of 
the  larynx,  disproportionately  small,  makes  the  diseases  of  that  organ 
most  frequent  in  childhood,  and  a  serious  factor  in  mortality. 

At  puberty  we  see  the  perversions  (from  earlier  years)  liable  to  arise 
as  adolescence  advances.  Anaemia  and  chlorosis  are  prone  to  develop 
at  this  period.  In  the  middle  period  the  diseases  that  arise  from  occu- 
pation, from  exposure  to  external  agencies,  from  habits,  are  seen. 
Moreover,  processes  beginning  in  adolescence  are  reaching  their  acme, 
and  find  expression  in  later  life,  as  the  cysts  of  hydatid  disease,  or  renal 
calculi,  or  manifestations  of  gout.  In  later  life  degenerations  of  the 
vascular  and  cerebro-spinal  systems  occur ;  affections  due  to  fibrosis, 
a  resultant  of  wear  and  tear,  as  atheroma ;  cancer ;  calculous  disease, 
and  other  diseases  prevail. 

The  Sex.  The  prevalence  of  various  diseases  in  the  sexes  in  undue 
proportion  arises  because  of  difference  in  the  anatomical  structure  and 
physiological  offices  of  the  two,  and  because  of  the  difference  in  expo- 
sure to  varying  causal  agencies.  Diseases  more  common  to  the  male 
sex  occur  on  account  of  occupation,  from  exposure,  from  over-activity 
of  mind  and  body,  and,  finally,  from  the  formation  of  bad  habits. 
The  diseases  of  the  female  sex  that  are  more  prevalent,  apart  from  their 
own  peculiar  affections  arising  out  of  menstruation  and  childbearing, 
take  place  because  of  the  more  or  less  sedentary  nature  of  their  lives, 
and  hence,  among  other  things,  the  opportunities  for  introspection. 
Hysteria,  neurasthenia,  and  nerve  disorders  abound  with  them.  Males 
are  more  subject  to  epilepsy,  gout,  diabetes,  locomotor  ataxy,  and  vesi- 
cal disease.  Females  are  more  subject  to  exophthalmic  goitre,  rheu- 
matoid arthritis,  chorea,  and  the  above-mentioned  nervous  disorders. 

Occupation.  This  must  be  ascertained  in  the  inquiry,  for  each 
occupation  demands  effort  in  one  particular  direction,  or  compels  expo- 
sure to  deleterious  influences.  Writer's  cramp,  eye-strain,  and  a  series 
of  disorders  thus  arise.  Knowledge  of  exposure  to  particular  irritants, 
coal  or  fine  particles  of  metal  or  stone,  gases,  chemicals,  effluvia  of  all 
kinds,  and  to  diseases  contracted  from  animals,  is  valuable  in  diagnosis. 

The  manner  and  degree  of  employment  of  the  mind  must  be  inquired 
into. 

It  is  not  to  be  forgotten  that  the  occupation  at  different  periods  of 
life  must  be  found  out,  the  age  at  which  life's  battle  began,  and  the 
circumstances  that  surrounded  the  early  career.  The  deleterious  influ- 
ence of  a  former  occupation  may  be  observed  after  the  patient  is  in  an 
entirely  different  sphere  of  labor. 

Habits.  Habits  as  to  clothing  (catarrhal  affections  and  rheumatism), 
as  to  hours  of  rest  and  sleep  (neurasthenia),  as  to  character  of  food, 
time,  regularity,  and  manner  of  eating  (the  indigestions,  gout),  as  to 


26  GENERAL  DIAGNOSIS. 

exercise,  and  as  to  the  use  of  alcoholic  stimulants  (cirrhosis  of  the  liver, 
neuritis,  brain  affections).,  of  tobacco  (amblyopia,  cardiac  palpitation), 
of  tea  or  coffee,  of  narcotics,  must  be  inquired  into.  Methods  of  work, 
methods  of  recreation,  domestic  joys  or  sorrows,  must  be  ascertained. 
A  knowledge  of  the  habits,  of  the  life  (of  the  inner  life,  indeed)  of 
the  individual,  is  essential  to  a  rational  diagnosis,  and  hence  a  true 
therapeusis. 

Place  of  Residence  and  Dwelling.  A  knowledge  of  the  place  of 
residence  is  of  service.  Town  residence  and  country  residence,  a  resi- 
dence in  a  damp  locality,  by  the  sea  and  in  the  mountains,  in  particular 
valleys,  in  different  water-sheds,  in  tropical  or  frigid  clime,  each  makes 
an  impress  on  the  constitution,  even  if  actual  disease  is  not  created. 
Hence  malarial  regions,  goitre  districts,  localities  in  which  individuals 
have  to  an  unusual  degree  vesical  calculi,  or  in  which  special  epidemic 
diseases  abound,  as  yellow  fever,  cholera,  or  dysentery,  must  be  inquired 
for.  Knowledge  of  the  places  of  residence  at  different  periods  of  life 
and  the  duration  of  such  is  often  important  information. 

The  situation  and  degree  of  comfort  for  habitation  of  the  dwelling 
must  be  learned.  The  sanitary  arrangements — drainage,  ventilation, 
water-supply,  heating — are  to  be  scrutinized. 

Family  Relations.  Marriage  and  the  number  of  children,  with 
their  degree  of  health,  must  be  recorded.  If  a  woman,  the  number  of 
children  born,  the  character  of  the  labors,  the  number  of  miscarriages. 

Is  there  trouble  in  the  marital  relation  ?  Has  there  been  sorrow,  or 
sudden  shock,  or  long  nursing,  or  great  care "?  Are  the  financial  cir- 
cumstances easy  ?  Has  there  been  recent  malfeasance  ?  How  many 
invalid  women  arise  out  of  such  ashes  ! 

Questions  so  personal  can  only  be  put  after  long  acquaintance,  or 
information  obtained  through  judicious  inquiry  of  friends. 

Frequently  more  delicate  questions  must  be  put,  as  to  masturbation 
or  excessive  venery,  but  with  great  caution,  and  only  when  conditions 
demand  it.  In  epileptiform  convulsions,  profound  hysteria,  neuras- 
thenia, the  development  of  locomotor  ataxy,  or  spinal  paralysis,  prompt, 
clear,  manly  questions  as  to  these  habits  are  to  be  put,  not  reference 
made  to  them  in  prudish  or  mawkish  suggestion. 

Exposure  to  Contagion.  If  the  suspected  ailment  partakes  of  the 
nature  of  a  contagious  disease,  the  probability  of  exposure  to  the  disease 
must  be  looked  into  and  the  presence  of  epidemics  ascertained.  The 
period  of  incubation  must  be  known  in  such  cases.  The  prodromal 
symptoms  must  also  be  known. 

The  Family  History. 

This  inquiry  is  instituted  in  order  to  determine  the  affections  which 
may  or  may  not  be  hereditary.  We  learn  also  the  average  duration 
of  life  in  the  family  and  the  relation  of  the  mortality  to  the  physio- 
logical epochs  in  life.     Data  of  the  latter  character  are  of  value  in  esti- 


THE  DATA  OBTAINED  BY  INQUIRY.  27 

mating  the  possible  duration  of  life  for  purposes  of  life  insurance,  and 
they  also  throw  light  on  abnormal  conditions  ;  thus  to  learn  that  most 
of  the  members  of  the  family  died  of  apoplexy  at  a  comparatively  early 
age,  or  of  aneurism  or  of  arterial  degenerations,  is  to  learn  that  vascular 
changes  developed  earlier  than  usual.  To  secure  accurate  data,  the 
age  and  state  of  health  of  parents,  brothers,  and  sisters,  if  living,  are 
ascertained  ;  or,  if  dead,  the  cause  of  death  and  age  at  which  it  took 
place.  Similar  questions  may  be  applied  to  several  generations  of  the 
family  and  to  collateral  branches. 

Inherited  Diseases.  Concerning  the  question  of  direct  inheritance 
of  disease,  but  few  are  strictly  so.  Of  these,  nervous  diseases  are  the 
most  common,  as  progressive  muscular  atrophy,  hereditary  chorea, 
Thomsen's  disease,  Friedreich's  ataxia,  migraine,  epilepsy,  and  forms 
of  insanity.  The  writer  has  seen  chronic  Bright' s  disease,  or  a  state  of 
the  constitution  that  predisposes  to  it,  occur  in  several  generations 
without  the  usual  exciting  causes  of  that  affection.  Syphilis  may  be 
inherited.  Haemophilia  is  the  most  striking  affection  that  is  trans- 
mitted by  inheritance.  Generally  it  is  not  the  diseases  themselves  that 
are  hereditary  but  types  of  tissue  that  predispose  to  disease,  as  in 
tuberculosis  or  cancer ;  or  conditions  of  the  organism  that  favor  imper- 
fect metabolism,  as  is  seen  in  gout  or  rheumatism. 

The  family  physician,  who  comes  in  contact  with  one  or  more  gener- 
ations, profits  most  by  the  knowledge  of  the  family  history.  He  learns 
the  predisposition  to  various  minor  ailments — to  headaches  and  attacks 
of  indigestion,  "  bilious  attacks,"  for  instance  ;  he  learns  the  power  of 
resistance  to  disease  in  the  family,  or  their  capability  to  undertake 
large  duties  in  life  ;  he  learns  their  susceptibility  to  drugs  and  their 
tendency  to  take  stimulants.  Nerve  force  is  the  capital  with  which 
the  battle  of  life  is  kept  up.  If  it  is  at  a  minimum  in  groups  of 
families,  diseases  or  conditions  of  poor  health  due  to  its  use — a  use  not 
excessive  in  others — arise. 

Contagious  Diseases.  In  the  inquiry  it  may  be  well  to  ascertain 
the  probability  of  disease  being  transmitted  from  husband  to  wife,  or 
the  opposite.  Syphilis  and  gonorrhoea  and  tuberculosis  are  examples. 
Not  only  may  this  probability  apply  to  the  transmission  of  disease  from 
husband  to  wife,  but  to  its  transmission  along  lines  of  families.  Then, 
too,  we  must  inquire  of  mothers  for  the  manifestations  of  syphilis  in 
the  children. 

Caution  must  be  exercised  in  the  pursuit  of  knowledge  of  this  kind, 
as  strained,  or  even  ruptured,  marital  relations  may  result  from  injudi- 
cious intimations. 

Malignant  Disease.  Caution  must  be  employed  in  order  not  to 
arouse  family  pride  if  evidence  of  "  scrofula  "  is  sought  for,  or  to  pro- 
voke undue  alarm  when  inquiry  into  the  family  history  of  cancer  is 
made.  Disarm  suspicion  by  inquiring  for  the  symptoms  of  the  disease 
in  various  organs  in  which  it  may  occur,  as  jaundice,  uterine  hemor- 
rhage, etc.,  or  ask  about  growths  or  tumors.  Do  not  use  the  specific 
terms,  consumption  and  cancer. 


28  GENERAL  DIAGNOSIS. 

Obscure  Terms.  Moreover,  care  must  be  exercised  to  secure  defi- 
nite data,  not  to  over-estimate  statements  as  to  tlie  cause  of  death  being 
"  dropsy,"  or  "  jaundice,"  or  "  cold/'  or  "  teething,"  or  "  change  of 
life."  Control  questions  must  be  put  by  inquiry  into  the  character  of 
the  symptoms  that  attended  the  fatal  illness,  and  by  giving  the  affections 
the  various  popular  names  that  are  given  them  in  different  countries. 

Common  Morbid  Processes.  The  data  of  the  family  history  are 
of  no  avail  unless  it  is  remembered  that  many  fundamental  affections 
have  various  modes  of  expression.  Various  diseases  may  be  allied  to 
the  one  suspected  to  exist  in  the  patient,  and  be  overlooked  because  of 
this  difference  of  expression.  One  member  of  the  family  may  die  of 
heart  disease,  another  of  rheumatism,  or  some  have  had  chorea,  or 
cutaneous  affections,  or  renal  calculi ;  such  ailments  are  expressions  of 
the  same  morbid  process.  Finlayson  veil  puts  them  into  groups  and 
fittingly  portrays  them  as  follows  :  "  In  regard  to  scrofulous  [tuber- 
culous] diseases,  we  ask  for  swollen  glands  or  '  waxy  kernels/  or  running 
in  the  neck,  diseases  of  the  spine  and  other  bones,  bad  joints,  white 
swellings,  or  '  incomes/  as  they  are  termed  in  Scotland  ;  disease  of  the 
glands,  of  the  bowels,  water  in  the  head,  consumption  of  the  lungs,  or 
decline,  or  weakness  of  the  chest,  with  spitting  of  blood,  and  so  on. 

"  Heart  disease,  rhemnatism,  chorea,  psoriasis,  and  some  other  cuta- 
neous affections,  and  perhaps  renal  concretions  and  emphysematous 
bronchitis,  appear  to  replace  each  other  in  different  members  of  the 
same  family. 

"  The  neurotic  group  includes  the  various  forms  of  neuralgia,  epi- 
lepsy, hypochondriasis,  hysteria,  and  insanity  ;  apoplexy  and  hemiplegia 
may  (perhaps  doubtfully)  be  included  in  this  group  ;  their  hereditary 
character  seems  rather  to  be  associated  with  vascular  disorders.  Gout, 
disease  of  the  liver,  contracted  kidney,  renal  calculus  and  gravel,  and 
angina  pectoris  form  another  allied  group  ;  and  these  have  also  some 
affinity  with  the  disorders  connected  with  arterial  degenerations.  Syph- 
ilis, which,  of  course,  has  marked  hereditary  characters,  assumes  such 
a  multitude  of  forms  as  to  preclude  enumeration  ;  but  the  tendency  is 
for  such  syphilitic  diseases  to  fail  in  the  course  of  time  from  early  death 
or  sterility.  Abortions,  stillbirths,  early  deaths  in  infancy,  associated 
with  cutaneous  eruptions  on  the  buttocks  and  with  snuffles,  are  im- 
portant in  man}'  family  histories  ;  nervous  deafness,  opacities  of  the 
cornea,  notched  teeth,  epilepsy,  and  imbecility  are  occasional  manifes- 
tations of  the  same  disorder  in  those  children  who  survive." 

Conclusions.  It  is  thus  seen  that  in  securing  the  family  history 
data  are  acquired  which  may  be  (1)  complete  and  of  value  in  estimat- 
ing family  tendencies  or  (2)  vague  and  of  doubtful  value.  The  latter 
is  due  to  lack  of  memory  on  the  patient's  part  or  to  his  ignorance  of 
technical  terms.  The  difficulties  must  be  overcome  by  control  ques- 
tions prompted  by  our  knowledge  of  the  nature  of  the  disease  and  its 
frequency  at  different  ages,  by  an  inquiry  for  symptoms,  and  by  inves- 
tigation into  collateral  and  remote  branches  of  the  family. 


THE  DATA  OBTAINED  BY  INQUIRY.  29 

The  fact  that  diseases  skip  a  generation  (atavism)  must  be  remem- 
bered. A  generation  may  be  small  or  decimated  by  accidental  disease, 
and  hence  the  force  of  the  family  history  be  weakened.  At  times  in  a 
family  sufficient  time  has  not  elapsed  for  predisposition  to  arise,  as 
when  we  inquire  into  the  illness  of  a  child  whose  parents  are  in  early 
adult  life.  Finally,  all  negative  facts  must  be  recorded.  Such  knowl- 
edge must  act  as  a  control  element  in  estimating  the  value  of  the  family 
history. 

The  History  of  Previous  Diseases. 

The  remote  effects  of  disease,  and  of  its  sequelae,  as  impressed  on  the 
organism,  make  it  essential  to  inquire  into  the  nature  of  the  previous 
diseases  of  the  patient  whom  we  are  studying.  The  date  and  character 
of  the  disease,  the  duration,  the  degree  of  severity,  and  the  completeness 
of  convalescence  must  be  determined. 

Many  diseases,  as  the  exanthemata,  usually  occur  but  once  in  the 
same  person,  and,  therefore,  in  the  diagnosis  of  obscure  cases,  if  a  his- 
tory of  their  occurrence  has  been  ascertained,  they  can  be  excluded  in 
the  count.  Others  recur  from  time  to  time,  as  croupous  pneumonia, 
chorea,  acute  rheumatism,  and  tonsillitis.  The  history  of  a  previous 
attack  of  a  certain  disease  may  point  to  the  nature  of  a  second  attack 
which  otherwise  may  be  obscure.  Some  diseases,  as  rheumatism, 
syphilis,  and  gonorrhoea,  have  pronounced  sequelae.  Knowledge  of 
the  occurrence  of  the  primary  disease  may  solve  doubts  as  to  the  nature 
of  the  sequelae. 

Infectious  diseases  lead  to  forms  of  neuritis  and  to  brain  affections, 
or  to  inflammations  of  organs.  The  seat  of  the  specific  inflammatory 
process  varies  in  different  diseases.  After  measles  we  find  the  mucous 
membranes  impressionable ;  and  after  scarlet  fever,  the  serous  mem- 
branes, the  ears,  the  kidneys  liable  to  inflammation.  The  history  of  an 
attack  of  hepatic  or  renal  colic  may  point  to  the  diagnosis  of  an 
otherwise  obscure  process  in  the  liver  or  kidney. 

The  history  of  injury  must  be  sought  for  in  brain  and  spinal  affec- 
tions. The  occurrence  of  a  surgical  operation  in  the  past  may  point  to 
lesions  for  which  it  was  resorted  to,  which  again  may  be  the  source  of 
disease. 

The  History  of  the  Present  Disease. 

Scope  of  Inquiry.  The  history  of  the  present  disease  includes  an 
account  of  the  sufferings  of  the  patient,  which  I  have  said  are  the  sub- 
jective symptoms,  of  the  duration  of  the  disease,  of  its  mode  of  onset, 
and  of  the  evolution  of  its  symptoms  up  to  the  time  it  was  seen  by  the 
physician.  The  patient  also  gives  an  account  of  such  objective  symp- 
toms as  could  be  noted  by  him,  as  swelling  of  the  legs,  the  date  of  its 
commencement,  mode  of  onset,  and  progress.  In  the  case  record  the 
history  to  the  date  of  examination  is  first  recorded,  and  then  the  sub- 
jective symptoms  are  noted.  The  same  order  will  be  followed  in  the 
text.  Practically,  it  is  better  to  learn  the  symptoms  on  account  of 
which  the  patient  applied  for  treatment,  and,  with  them  as  a  guide,  to 
inquire  into  the  date  of  origin  and  mode  of  development  of  the  disease. 


30  GENERAL  DIAGNOSIS. 

Method  of  Inquiry.  The  history  and  subjective  symptoms  are  best 
learned  in  the  language  of  the  patient.  If  the  memory  fails  or  the 
symptoms  are  not  clearly  narrated,  judicious  questions  will  suffice  to 
complete  the  story.  Leading  questions  must  not  be  put  until  the 
patient's  own  account  is  fully  given. 

Often  the  patient  will  be  too  voluble  and  introduce  irrelevant  matter, 
or  too  taciturn  from  modesty  or  a  desire  to  conceal  facts,  as  when  illegit- 
imately pregnant.  While  much  time  is  lost  in  listening  to  a  prolix 
account  of  sufferings,  the  student  will  do  well  at  first  to  bear  with  the 
patient,  for  it  gives  him  the  opportunity  to  study  character,  observe 
the  mental  and  emotional  characteristics  of  the  patient  and  the  expres- 
sion of  the  countenance.  To  suppress  the  loquacious,  free  the  tongue 
of  the  silent,  gather  scintillations  of  intelligence  out  of  the  dense  clouds 
of  ignorance,  requires  knowledge  of  human  nature  of  a  high  degree, 
acquired  only  by  long  practice.  (Allied  difficulties  have  been  discussed 
in  the  paragraphs  devoted  to  the  family  history.)  Indeed,  the  wonder- 
ful faculty  of  seeking  information  in  this  manner  has  been  the  capital 
of  many  physicians  of  large  practice.  It  is  by  this  means  and  by 
tricks  that  the  charlatan  plies  his  vocation.  A  favorite  method  of  the 
quack,  after  a  few  words  from  the  patient,  is  to  tell  him  how  he — the 
patient — feels.  They  have  some  knowledge  of  the  march  of  the 
disease,  and  portray  its  full  development  to  the  surprised  and  credulous 
victim.  Elsewhere  (see  Subjective  Symptoms)  the  reliability  of  such 
data  is  discussed,  and  the  student  must  not  for  one  moment  consider 
the  data  obtained  by  inquiry  as  of  equal  value  with  those  obtained  by 
observation — the  former  is  the  mere  skeleton  of  the  diagnosis. 

It  is  particularly  important  to  secure  a  chronological  order  of  events 
in  the  disease.  They  are  essential  and  logical  and  throw  much  light 
on  the  progress  of  the  affection.  The  diagnosis  is  much  easier  if  such 
sequence  is  followed.  Of  course,  there  are  circumstances  when  only 
the  minimum  amount  of  information  of  this  character  can  be  secured. 
The  patient  may  be  unconscious,  or  in  a  convulsion,  or  unable  to  speak 
from  dyspnoea.  It  then  becomes  necessary  to  rely  on  the  testimony  of 
friends  or  to  gather  the  information  from  the  circiunstances  that 
surround  the  patient. 

Mode  of  Onset  and  Duration  of  the  Disease.  It  is  well  to  learn 
if  the  onset  of  the  disease  was  sudden  or  gradual.  If  the  former,  the 
most  striking  phenomena  are  to  be  ascertained — a  chill,  convulsion, 
sudden  pain,  sudden  vomiting,  a  profuse  diarrhoea — each  points  to  lines 
of  further  inquiry.  If  the  latter,  did  it  follow  upon  an  acute  illness, 
or  did  each  symptom  gradually  increase  in  intensity,  and  as  each  week 
or  each  month  passed  by  new  phenomena  creep  into  the  symptom  com- 
plex. We  thus  learn  if  the  affection  under  consideration  is  acute  or 
chronic — its  duration.  It  must  not  be  forgotten  that  certain  affections 
may  be  two  or  three  days — or,  on  the  other  hand,  as  many  weeks — in 
developing,  as  typhoid  fever,  which,  nevertheless,  is  acute.  It  must 
be  remembered,  also,  that  diseases  may  have  sudden  acute  expressions, 
and  that  a  chronic  disease  may  be  in  existence  a  long  time  without  the 
patient's  knowledge.     An  acute  colliquative  diarrhoea  or  a  convulsion 


THE  DATA  OBTAINED  BY  INQUIRY.  31 

is  often  the  first  intimation  of  a  chronic  nephritis,  and  an  attack  of  angina 
pectoris  the  first  symptom  of  organic  heart  disease  of  long  standing. 
To  appreciate  the  relationship  of  acute  to  chronic  disease,  or  of  acute 
phenomena  to  chronic  morbid  processes,  requires  a  full  knowledge  of 
the  processes  of  disease. 

Evolution  of  the  Disease.  In  making  inquiry  concerning  the  evo- 
lution of  the  subjective  symptoms,  the  frequency,  duration,  character, 
and  degree  of  severity  of  each  symptom,  and  its  relationship  to  the  func- 
tion of  the  organ  apparently  affected,  must  be  inquired  into.  Thus  in 
the  case  of  pain  in  the  abdomen,  we  must  learn  its  character,  its  fre- 
quency, its  duration,  its  intensity,  and  its  location,  and  whether  asso- 
ciated with  functional  disturbance  of  any  of  the  viscera  hi  which  the 
pain  presumably  has  its  origin.  Or,  if  there  is  frequency  of  micturi- 
tion, the  length  of  time  the  symptom  has  been  present,  the  degree  of 
frequency,  the  time  in  the  twenty-four  hours  when  the  micturition  is 
most  frequent ;  its  relation  to  food,  exercise,  or  emotions  ;  the  charac- 
ter of  the  act  of  micturition,  and  its  association  with  other  evidences  of 
functional  disorder  or  organic  disease  of  the  genito-urinary  tract. 

Having  ascertained  the  full  story  of  the  patient,  including  all  data 
obtained  by  inquiry,  special  attention  must  be  paid  to  the  sufferings  or 
complaints  of  the  moment.  They  must  be  further  inquired  into  in  the 
manner  above  indicated.  They  may  have  been  detailed  in  the  begin- 
ning ;  but  information  obtained  from  an  account  of  the  evolution  of  the 
disease  or  the  previous  history  will  require  a  repetition,  with  the  put- 
ting of  fresh  questions  or  control  questions.  Having  obtained  the 
chronological  account  of  the  factors  of  life  and  of  disease,  we  are  prepared 
to  examine  into  the  significance  of  subjective  symptoms. 

The  steps  thus  far  taken  in  the  diagnosis  are  four  in  number.  While 
considerable  that  is  not  essential  may  be  gathered,  the  very  gleaning 
of  the  facts  enables  the  student  to  acquire  objective  information  from 
the  speech,  the  gesture,  the  expression,  etc.,  of  the  highest  value. 
Moreover,  the  facts  ascertained  are  of  value  in  determining  a  line  of 
treatment  to  be  pursued  which  will  be  scientific  and  rational,  for  in 
addition  to  the  diagnosis  the  causal  factors  of  the  disease  are  often 
found. 

To  repeat,  preceding  the  fifth  and  final  step  in  the  diagnosis,  the  data 
secured  by  inquiry — (1)  the  social  history,  (2)  the  family  history,  (3) 
the  history  of  previous  diseases,  (4)  the  history  of  the  present  disease — 
must  be  fixed  in  the  mind.  Marshalling  the  facts  thus  obtained  in 
orderly  procession,  we  are  enabled  to  systematically  add  the  facts  of  the 
present  condition.  Consideration  of  the  data  thus  secured  leads,  by 
inductive  reasoning,  to  the  desired  conclusion — a  diagnosis. 


CHAPTER   III. 

THE  DATA  OBTAINED  BY  INQUIRY— {Continued). 

The  Present  Condition  :  The  subjective  symptoms — Mode  of  determination — Their 
fallacy — Their  value.  Feigned  disease.  Local  subjective  symptoms — General 
subjective  symptoms. 

We  now  come  to  the  final  step  in  the  investigation — the  determi- 
nation of  the  present  condition,  the  status  prmsens.  To  determine  the 
present  condition  inquiry  and  observation  are  necessary.  This  chapter 
and  the  succeeding  one  will  discuss  only  the  data  obtained  by  inquiry. 
They,  therefore,  include  the  subjective  symptoms  other  than  those  that 
pertain  to  special  organs  or  systems.  Caution,  circumspection,  adroit- 
ness, combined  with  tact  and  good  judgment,  are  more  essential  to 
secure  a  true  account  of  the  patient's  sufferings  even  than  to  obtain  a 
correct  history  of  the  disease. 

The  subjective  symptoms  are  expressive  of  the  sensations  of  the  patient, 
and  vary  in  accordance  with  the  sensibilities  of  the  individual  affected. 
Thus  acute  pain  may  apparently  represent  a  severe  process  in  one, 
while  in  another  the  same  severity  of  process  may  be  represented  by 
the  minimum  amount  of  pain.  It  is  well  known  that  individuals  of 
one  nationality  bear  pain  with  greater  fortitude  than  individuals  of 
another. 

Caution.  The  patient.  Individuals  vary  not  only  as  to  pain 
sense  but  as  to  other  subjective  symptoms.  The  morale  is  shattered 
in  some  more  readily  than  in  others — thus,  for  instance,  oppression  of 
the  prtecordia  may  strike  terror  to  some,  while  to  others  it  would  be 
simply  a  sense  of  discomfort.  Moreover,  subjective  symptoms  are  con- 
stantly before  the  patient  while  in  distress,  if  only  in  the  mind's  eye. 
Because  of  this  perturbed  state  they  grow  in  magnitude  rather  than 
diminish.  We  must  study  them  from  many  points  of  view.  The  mode 
of  onset,  frequency,  degree,  and  character  of  the  symptoms  must  be 
inquired  into.  The  competency  of  the  witness  under  the  circumstances, 
from  lack  of  accurate  noting  of  symptoms,  failure  of  memory,  varying 
degree  of  susceptibility  to  impressions,  etc.,  may  well  be  doubted. 

The  physician.  But  not  only  does  the  varying  "  personal  equation  " 
of  the  patient  render  subjective  symptoms  fallacious,  the  same  factor 
in  the  physician  contributes  to  the  fallacy.  The  latter  may  have  unfor- 
tunately formed,  by  hearsay  regarding  the  patient,  a  preconceived  notion 
of  the  nature  of  the  disease  ;  or  from  personal  bias  in  favor  of  particular 
diseases,  on  account  of  narrow  lines  of  study  or  lack  of  breadth  of  view 
of  pathological  processes,  he  may  set  out  to  prove  a  theory  rather  than 
to  establish  a  fact.  In  either  case,  by  leading  questions,  by  placing 
emphasis  on  certain  parts  of  the  testimony,  the  subjective  symptoms 
can  be  juggled  with  and  made  to  tell  any  but  the  truthful  story. 


THE  DATA   OBTAINED  BY  INQUIRY.  33 

It  is  to  be  remembered  that  it  is  our  province  not  only  to  ascertain 
the  cause  of  suffering  in  the  sick,  but  also  to  detect  the  flaws  in  the 
testimony  of  him  who  would  feign  sickness.  The  malingerer  utilizes 
subjective  symptoms  to  hide  his  deception  because  they  cannot  be  seen, 
felt,  weighed,  measured,  or  ascertained  by  hearing. 

Feigned  Disease.  To  detect  feigned  sickness  demands  much  acu- 
men on  the  part  of  the  physician.  He  must  not  only  be  able  to  make 
an  accurate  and  exhaustive  objective  examination  of  the  patient,  but  be 
alert  to  appreciate  surroundings  and  conditions.  Feigning  may  be 
suspected  if  there  is  a  motive,  as  in  the  case  of  prisoners,  pension 
applicants,  students  at  school  or  college,  and  persons  who  hold  policies 
of  insurance  indemnifying  in  case  of  sickness.  The  hospital  "  beat" 
thus  plays  upon  charity. 

If  sickness  recurs  frequently  without  definite  cause,  while  the  sub- 
jective symptoms  are  mild  and  quickly  relieved  and  the  objective  symp- 
toms negative,  the  use  of  instruments  of  precision  will  detect  the 
malingerer.  With  their  aid  we  can  usually  find  out  if  the  subjective 
and  objective  phenomena  tally.  The  failure  of  such  tally  proves  the 
deception.  The  thermometer  frequently  exposes  the  deception,  as  fever 
can  rarely  be  simulated,  although  tricks  with  the  thermometer  may  be 
carried  on.  A  favorite  method  is  to  rub  it,  and  thus  cause  the  mercury 
to  rise.  Frequently  the  suspected  person  must  be  placed  under  close 
surveillance,  unknown  to  him,  and  tricks  of  all  sorts,  suggested  by  the 
surroundings  and  circumstances,  played  upon  him  to  make  him  unwit- 
tingly testify  to  his  deception. 

The  student  will  learn  later  that  there  is  a  mimicry  of  disease,  and 
that  in  certain  nervous  affections  the  simulation  of  subjective  symp- 
toms is  its  chief  role.  In  hysteria,  subjective  and  objective  symptoms 
are  masked.  Long  experience  and  acumen  are  required  by  the  physi- 
cian to  unmask  the  deceptions.  The  age  of  the  patient,  the  sex,  the 
state  of  the  emotions,  the  varying  expressions  of  the  symptoms  (under 
varying  circumstances) — with  attention  fixed  or  removed — the  mobility 
of  the  symptoms  under  excitement  or  emotional  disturbance,  the  lack 
of  harmony  between  functional  disorder  and  organic  change,  are  the 
elements  to  be  considered  in  order  to  fathom  the  mysteries.  Often 
anaesthesia  must  be  induced  in  order  to  dissipate  simulated  tumors, 
relax  rigid  joints  or  contracted  limbs.  Magnetism,  electricity,  and 
other  tests  are  likewise  employed.  In  the  chapter  on  Hysteria  its 
manifold  expressions  will  be  adverted  to,  and  it  will  be  seen  that  func- 
tional disorder  of  almost  every  organ  or  special  sense  is  simulated  in 
this  affection.  Organic  processes  even  are  imitated,  as  joint  inflamma- 
tions, peritonitis,  and  other  grave  conditions. 

Value  of  Subjective  Symptoms.  Notwithstanding  the  fallacy  of 
subjective  symptoms  in  that  they  may  be  feigned  or  mimicked,  they  are 
valuable  evidences  in  the  hands  of  the  scientific  inquirer.  If  the 
patient  is  a  good  witness  their  value  is  much  enhanced.  He  must  be 
intelligent  and  truthful.  His  testimony  is  of  value  if  he  can  array  in 
logical  order  the  sequence  of  symptomatic  events  which  culminated  in 

3 


34  GENERAL  DIAGNOSIS. 

the  condition  for  which  he  seeks  relief.  If  he  can  clearly  narrate  the 
events  in  his  past  life,  or  in  the  lives  of  his  ancestors,  which  appertain 
to  physiological  aberrations,  his  story  is  an  aid  to  the  searcher  for  truth. 
If,  with  this,  the  doctor  is  possessed  with  a  scientific  turn  of  mind, 
considering  evidence  without  allowing  previous  conceptions  to  influence 
him,  capable  of  discerning  the  truth  and  discarding  the  false,  of  an- 
alyzing and  weighing  statements,  and  of  appreciating  their  relationship 
to  what  is  known  of  morbid  processes,  the  patient's  statements  of  sub- 
jective symptoms  are  of  value  in  the  discernment  of  disease. 

Local  Subjective  Symptoms.  The  symptoms  of  which  the  patient 
complains  may  be  general  or  local.  The  former  will  be  briefly  consid- 
ered in  this  section  ;  the  latter  will  be  discussed  in  the  respective  sec- 
tions devoted  to  disease  of  the  various  organs  to  which  the  subjective 
symptoms  refer.  They  are  symptoms  due  to  functional  disturbances 
of  the  respective  system  that  is  the  seat  of  disease,  as  dyspnoea  or  cough 
in  diseases  of  the  respiratory  system,  anorexia  or  nausea  in  diseases 
of  the  digestive  system.  An  exception  will  be  made  in  the  case  of  pain. 
While  there  may  be  such  general  suffering  as  to  constitute  pain  (gen- 
eral soreness,  aching,  rhachialgia),  yet  the  symptom  has  its  point  of 
origin  most  frequently  in  some  local  disorder.  Notwithstanding  this 
fact,  however,  as  it  is  a  symptom  common  to  so  many  affections,  and  as 
general  rules  apply  to  the  recognition  of  its  multitudinous  forms,  a  brief 
section  will  be  devoted  to  its  study. 

General  Subjective  Symptoms.  The  general  subjective  symptoms 
— that  is,  the  abnormal  and  disagreeable  sensations  which  extend  more 
or  less  over  the  whole  body,  or  are  referable  to  more  than  one  organ 
or  apparatus — are  few  in  number  and  are  not  diagnostic  of  any  partic- 
ular affection.  They  are  at  times  the  only  symptoms  complained  of  by 
the  patient,  and  require  investigation.  They  include  abnormal  sensa- 
tions of  strength  or  weakness,  general  numbness  or  tingling,  and  general 
paresthesia  of  all  kinds  ;  general  vasomotor  disturbance,  causing  sen- 
sations of  heat,  such  as  occur  in  flashes,  or  sensations  of  cold,  from  mild 
chilliness  or  "  creeps  "  to  the  pronounced  chill  or  rigor,  sudden  perspi- 
rations, general  throbbings  or  pulsations,  and  general  discomfort,  to 
which  the  term  nervousness  is  applied.  Irritability,  disorders  of  sleep, 
and  the  more  distinct  nervous  manifestations  above  mentioned,  will  be 
referred  to  in  sections  on  nervous  diseases,  and  particularly  discussed 
under  Hysteria  and  Neurasthenia. 

A  feeling  of  strength,  or  the  idea  of  an  ability  to  perforin  great  feats 
of  strength  or  endurance,  or  a  great  mental  feat,  is  a  subjective  symp- 
tom that  is  dwelt  upon  by  the  patient  who  is  developing  or  passing 
through  certain  stages  of  paretic  dementia.  It  is  accompanied  by  other 
evidences  of  exhilaration.  Exhilaration  attends  chlorosis  and  forms  of 
hysteria  and  neurasthenia,  the  physical  or  mental  exhibition  of  strength 
taking  place  in  the  after  part  of  the  day  and  evening  or  upon  undue 
excitement.     Corresponding  depression  usually  follows. 

A  sense  of  weakness,  or  exhaustion,  or  of  fatigue  is  often  complained 
of.     If  an  absolute  demand  is  made  upon  the  bodily  strength  it  can 


THE  DATA  OB  TA I  NED  B  Y  INQ  UIB  Y.  35 

respond,  but  otherwise  it  is  not  exerted.  The  patient  complains  of 
being  more  tired  in  the  morning  than  upon  retiring,  or  of  a  sense  of 
inability  to  perform  accustomed  or  special  duties.  Mental  depression 
usually  attends  the  phenomena.  It  is  due  to  neurasthenia  generally, 
but  is  a  frequent  accompaniment  of  and  dependent  upon  the  forms  of 
toxaemia  to  which  malaria,  gout,  and  rheumatism  belong ;  of  the 
toxaemia  of  certain  varieties  of  indigestion,  of  tobacco,  alcohol,  and 
other  narcotic  poisons  (tea  or  coffee),  and  of  mineral  poisons.  The 
same  sense  of  fatigue  attends  the  prodromal  stage  of  the  specific  fevers. 
It  has  been  a  symptom  observed  frequently  of  late  in  the  sequential 
period  of  influenza. 

The  sensation  of  weakness  must  not  be  confounded  with  true  weak- 
ness or  muscular  prostration.  While  the  patient  is  aware  of  its  pres- 
ence, it  is  well  to  consider  it  under  the  objective  phenomena  of  disease, 
for  it  is  a  readily  recognized  sign  of  disease. 

Numbness,  or  tingling,  or  burnings  may  be  general  or  local.  It  is  a 
common  form  of  paresthesia,  to  be  discussed  in  the  section  on  nervous 
diseases.  It  must  be  remembered  that,  while  a  disorder  of  sensation, 
it  is  due  to  morbid  conditions  outside  the  pale  of  the  nervous  system. 
It  may  be  of  reflex  origin,  from  irritation  at  a  distant  point,  or  it  may 
be  and  usually  is  due  to  toxaemia,  as  lithaemia.  Other  subjective  vaso- 
motor disturbances  that  are  of  frequent  occurrence  are  likewise  mani- 
festations of  nerve  disorder  from  reflex  or  toxic  causes.  Flushings, 
and  a  constant  sensation  of  heat,  with  or  without  perspiration,  which 
attend  the  perturbation  of  the  menopause,  are  common  in  uterine  dis- 
orders and  in  chronic  gastritis. 

The  student  will  learn  that  the  curious  manifestations  to  which  refer- 
ence has  been  made  are  all  evidences  of  ill  health,  of  a  depressed 
vitality,  of  a  condition  in  which  there  is  malnutrition,  poverty  of 
nerve-force,  and  lack  of  blood-richness  (anaemia).  There  may  be 
peripheral  irritation  or  a  toxaemia,  but  the  under-current  of  ill  health 
is  the  fundamental  derangement. 

Chill  and  fever.  Both  are  subjective  as  well  as  objective  phenomena, 
but  as  one  can  be  accurately  estimated  by  an  instrument  of  precision 
(thermometer),  and  as  both  are  generally  associated,  the  discussion  of 
them  will  be  postponed.     (See  Objective  Signs.) 

The  abnormal  sensation  of  cold  or  of  heat  will  be  discussed  in  the 
chapter  on  Nervous  Diseases. 


CHAPTER    IV. 

THE  DATA  OBTAINED  BY  INQUIRY— (Continued). 
PAIN.1 

Definition.  Pain  is  a  general  term  used  in  medicine  to  describe  a 
number  of  subjective  symptoms  connected  with  morbid  processes.  It 
may  be  denned  as  a  sensation  which  produces  on  the  part  of  the  organ- 
ism, as  a  whole,  the  desire  to  abolish  or  escape  from  it.  It  is  the 
expression  in  consciousness  of  injury  to  the  peripheral  or  central  ner- 
vous system  by  irritation  or  lesion  ;  at  times  the  central  end  of  the 
peripheral  nerves  may  be  the  seat  of  irritation,  causing  so-called  referred 
pains.  This  definition,  however,  fails  to  include  the  hyperesthesias, 
the  hyperalgesias,  and  all  simulated  pains.  But  the  latter  are  to  be 
included  in  this  section,  on  the  ground  of  clinical  convenience,  whilst 
the  two  former  are  only  of  significance  as  conducing  to  the  production 
of  pain. 

Pathology.  The  pathology  of  pain  is  generally  believed  to  be  a 
state  of  impaired  nutrition,  and  hence  of  injury,  gross  or  microscopic, 
either  at  the  periphery  or  in  the  afferent  nerve  tract.  The  cause  may 
be  purely  functional,  as,  for  example,  when  pain  is  due  to  the  over- 
stimulation of  the  tract  by  its  normal  stimulus  and  its  consequent  ex- 
haustion ;  or  to  strictly  local  conditions,  as  pressure,  injury,  or  inflam- 
mation ;  or  to  systemic  conditions  acting  locally,  as  the  neuralgias  of 
anaemia.  There  is  also  the  so-called  sympathetic  or  reflex  pain,  due  to 
irritation  in  a  part  removed  from  the  locality  to  which  the  sensation  is 
referred. 

Pains  in  reference  to  the  general  nervous  system  may  be  classified 
according  to  the  localization  of  the  lesion  into  (1)  peripheral,  (2)  cen- 
tral, and  ( 3)  general.  Peripheral  pains  are  those  due  to  some  alteration 
either  in  the  structure  or  nutrition  of  the  peripheral  nerves,  and  the 
disturbance  may  be  situated  at  the  sensory  terminations,  or  anywhere 
in  the  course  of  the  nerve  or  in  the  nerve-roots.  Pains  due  to  causes 
situated  in  the  latter  place  are  usually  perceived  at  the  peripheral  dis- 
tribution of  the  nerve,  and  are,  therefore,  spoken  of  as  referred  pains. 

1  Pain  is  treated  in  a  suggestive  manner,  and  so  much  space  is  given  to  it  because 
it  is  too  frequently  improperly  managed.  Its  cause  is  never  thoroughly  investigated. 
Anodynes  are  given  for  its  relief,  thus  too  frequently  creating  victims  of  the  morphine- 
chloral-,  or  other  habit  The  following  articles  are  suggestive  :  Head  :  On  Disturb- 
ances of  Sensation,  with  Especial  Keference  to  the  Pain  of  Vrisceral  Disease,  Brain, 
vol.  xvi.,  Part  L,  1893;  Koss :  Brain,  1888:  Mackenzie:  Medical  Chronicle.  1888; 
Mackenzie:  Points  Bearing  on  the  Association  of  Sensory  Disorders  and  Visceral 
Disease,  Brain,  vol.  xvi.,  Part  III.,  1893.  Also,  papers  by  Starr.  See  Section  on 
Nervous  Disorders. 


THE  DATA  OBTAINED  BY  INQUIRY.  37 

The  nature  of  central  pain  is  not  at  present  clearly  understood.  Cer- 
tain cases  have  been  reported  in  which  pain  has  been  perceived  in  one 
part  of  the  body,  usually  an  extremity,  and  at  post-mortem  no  lesion 
whatever  could  be  found  in  any  portion  of  the  afferent  nervous  system 
coming  from  this  region.  Lesions,  however,  have  been  found  in  these 
cases  in  the  brain  itself,  and  it  is  supposed  that  these  are  responsible 
for  the  painful  impression.  General  pains  are  those  due  to  some  toxic 
condition  of  the  blood,  or  impairment  of  the  nutrition  of  the  nervous 
system  as  a  whole,  and  manifested  as  pain  in  the  regions  of  least  resistance. 

Cause.  Conditions  acting  upon  the  peripheries  of  the  sensory  nerves 
are  injuries  or  disease  of  the  surfaces  or  of  the  viscera.  Conditions 
acting  upon  the  nerve  in  its  course  may  be  either  internal  or  external. 
Among  the  internal  causes  are  the  chronic  and  acute  forms  of  neuritis. 
Among  the  external  causes  are  tumors,  perineural  inflammatory  pro- 
cesses, or  anything  causing  mechanical  injury  to  the  nerve  itself. 
Nerve  roots  are  usually  involved  in  intraspinal  growths,  in  spinal  men- 
ingitis, and,  occasionally,  as  a  result  of  disease  of  the  vertebral  column. 
The  lesions  causing  the  central  pain  are  embolism,  hemorrhage,  soften- 
ing, inflammatory  processes,  tumors,  and  injuries.  General  causes  are 
the  anaemias,  the  intoxications,  the  infectious  fevers,  and  perhaps  certain 
drug  habits,  as  morphia ;  although  it  is  usual  to  include  the  pains  com- 
plained of  by  opium  eaters  among  those  due  to  simulation. 

Variations  in  Disease.  Pain  is,  perhaps,  the  most  variable  symp- 
tom in  disease.  It  ranges  from  a  sensation  of  mere  discomfort,  as  the 
dull  ache  of  chronic  lumbago,  to  the  stabbing  pain  of  pleurisy,  or  the 
intolerable  anguish  of  heart-pang.  It  is  at  times  compatible  with  the 
highest  mental  endeavor  or  the  severest  physical  exertion,  or  the  whole 
energy  of  the  organism  is  absorbed  in  resisting  it.  It  may  be  definitely 
localized  in  any  part  of  the  body,  in  any  of  the  tissues,  or  distributed 
over  an  ill-defined  area. 

The  Recognition  of  Pain. 

The  Mode  of  Expression.  As  a  rule,  the  physician  learns  of  its  ex- 
istence by  the  complaint  of  the  patient.  Thus  he  learns  more  or  less 
accurately  its  location,  character,  degree,  and  duration,  and  usually 
something  concerning  its  causation.  But  the  value  of  this  source  of 
information  is  variable.  The  patient  may  be  voluble,  and  describe  too 
much ;  or  taciturn,  and  shrink  from  admitting  his  suffering ;  or  ignorant, 
and  unable  to  give  a  clear  account.  Fortunately,  there  are  other  ways 
by  which  suffering  is  expressed  which  may  be  grouped  among  the 
objective  symptoms.  They  are  :  (a)  Facial  expression,  the  most  common 
interpreter  of  the  emotion,  is  far  more  reliable.  The  tense  and  drawn 
lineaments,  the  clinched  jaws,  the  dilated  pupils,  the  livid  countenance, 
make  a  picture  of  agony  which,  with  the  labored  respiration,  the  general 
shrinkage  of  the  body,  are  unmistakable.  (See  Chapter  VII.,  The  Face.) 
Or,  in  a  less  intense  form,  the  shrieks  and  struggles  or  the  groans  of 
more  prolonged  suffering  are  no  less  impressive  in  their  suggestiveness. 
(6)  Not  less  characteristic  are  the  various  postures  assumed  ;  the  sudden 
fixity  of  heart-pang  ;  the  retracted  head  of  meningitis  ;  the  immobile  side 


38  GENERAL  DIAGNOSIS. 

of  pleurisy  ;  the  crouching  attitude  or  restlessness  of  colic  ;  the  flexed 
thighs  and  immobile  trunk  of  peritonitis  ;  the  shoulder  drooping  to  the 
affected  side  in  renal  colic  ;  or  the  bent  knee  of  arthritis,  (e)  Further, 
there  are  certain  reflex  actions  that  are  associated  with  local  irritations  ; 
thus  the  closing  of  the  eyelid  on  irritation  of  the  conjunctiva  ;  the  sneeze 
or  cough  on  irritation  of  the  nasal  or  laryngeal  mucous  membrane ;  the 
erection  following  irritation  of  the  urethra  ;  or  even  the  limp  character- 
istic of  pain  on  moving  or  resting  the  weight  of  the  body  on  an  affected 
limb.  Then  there  is  the  sudden  shrinking  of  the  whole  body,  the 
attempt  to  defend,  or  the  sudden  movement  of  the  hand  to  the  affected 
part,  or  the  sudden  jerking  away  of  the  part  itself  if  the  act  be  possi- 
ble ;  these  are  true  reflexes,  and  sufficiently  diagnostic  of  local  suffering. 
It  scarcely  need  be  mentioned  that  in  children,  in  the  insane,  in  persons 
unable  for  many  reasons  to  communicate  their  thoughts,  the  expression 
of  pain  is  of  the  greatest  diagnostic  value  in  determining  its  seat,  id)  The 
phenomena  of  the  associate  morbid  processes  may  serve  to  indicate  the 
occurrence  of  pain  and  its  seat.  Thus  pain  is  one  of  the  cardinal  symp- 
toms of  inflammation  ;  it  is  commonly  associated  with  nerve-injury  ;  it 
is  frequently  accompanied  by  local  flushing  or  herpetic  eruptions  in 
neuralgia. 

Sources  of  Error.  In  estimating  the  presence  or  absence  of  pain, 
or  its  degree,  certain  control  conditions  must  be  borne  in  mind.  Un- 
fortunately pa  in  is  one  of  the  most  unreliable  of  symptoms.  It  is  neces- 
sarily a  subjective  symptom,  with,  in  all  probability,  qualitative  as  well 
as  quantitative  variations.  The  particular  degree  in  either  respect  is 
of  importance  in  diagnosis,  and  as  only  the  roughest  means,  if  any,  are 
available  to  estimate  it  objectively,  the  physician  is  compelled  to  rely 
almost  wholly  upon  the  statements  and  appearance  of  the  patient.  His 
statement  can  err  in  two  directions  :  the  patient  can  exaggerate  his 
sufferings  or  depreciate  them.  The  tendency  to  exaggeration  is  most 
marked  in  the  nervous  temperament ;  in  those  suffering  from  chronic 
disease  of  long  standing  •  in  those  accustomed  to  in-door  and  mental 
labor  ;  in  women  and  in  the  young.  The  tendency  to  depreciation  is 
most  marked  in  the  phlegmatic  temperament ;  in  those  accustomed  to 
hardship,  especially  if  of  small  intellectual  development ;  in  men  and 
in  the  aged.  Both  tendencies  are  to  be  corrected  as  nearly  as  possible 
by  observing  the  associated  symptoms  and  the  character  of  the  patient, 
and  by  skilful  questioning.  The  appearance  can  deceive  because  of 
undue  susceptibility  to  suffering  on  the  part  of  the  patient,  or  unusual 
inhibitory  power.  There  can  be  no  question  that  painful  stimuli, 
usually  easily  borne,  in  some  produce  almost  unbearable  misery.  Such 
exaggerated  sensibility  occurs  in  the  emotional,  in  the  weak  and  debili- 
tated, and  in  the  delicately  nurtured.  Mental  association  is  a  powerful 
factor  ;  it  is  well  known  that  soldiers,  who  in  the  heat  of  battle  disre- 
gard serious  and  necessarily  painful  wounds,  will  suffer  intensely  under 
the  probably  less  painful  offices  of  the  surgeon ;  and  it  is  unfortunately 
a  common  experience  that  the  surroundings  of  the  operating-room  make 
the  most  trifling  and  briefest  operations  full  of  serious  suffering. 
Habitual  use  of  opium  seems  to  increase  this  susceptibility  in  a  remark- 
able manner.     Patients  will  even  submit  to  operations  for  the  relief  of 


THE  DATA  OBTAINED  BY  INQUIRY.  39 

a  supposed  ailment  that  is  found  to  have  no  physical  basis  ;  and  this 
occurs  in  cases  in  which  there  is  no  reason  to  believe  that  the  pain 
is  simulated  as  an  excuse  for  the  indulgence.  Moreover,  a  pseudo- 
neuralgia  is  wont  to  occur  in  victims  of  the  morphine  habit.  It  may 
simulate  a  gastralgia  or  an  intestinal  colic.  The  writer  has  seen  an 
innocent  victim  of  morphine  suffer  from  pseudo-hepatic  colic,  with- 
drawal of  the  drug  causing  subsidence  of  the  periodical  attacks  of  pain 
and  vomiting.  Inhibition  is  a  much  more  serious  source  of  error,  for 
while  undue  attention  to  one  part  is  only  reprehensible  when  practised 
to  the  neglect  of  others,  a  patient  who  disregards  pain  may  fail  to  direct 
attention  to  the  real  seat  of  disease.  It  is  sometimes  exercised  to  a 
most  remarkable  degree.  The  stoicism  of  the  American  Indian  under 
torture  is  attested  by  many  observers  ;  certain  religious  sects  among 
the  Hindus  habitually  afflict  themselves  in  the  most  ingenious  ways  ; 
the  early  Christian  martyrs  rejoiced  in  misery.  It  is  common  to  find 
this  disregard  of  pain  among  those  exposed  by  occupation  to  discom- 
forts and  injuries,  and  the  Teutonic  and  Slavic  races  appear  to  possess 
it  in  a  higher  degree  than  the  Celtic  or  Semitic.  Shock  either  inhibits 
pain  or  diminishes  the  normal  response  to  it.  Lastly,  and  by  no  means 
to  be  neglected,  a  most  common  source  of  error  is  undue  credulity  or 
skepticism  on  the  part  of  the  physician,  for  he  may  be  deceived  by  an 
eloquent  and  persuasive  complaint,  or  discredit  true  suffering. 

Simulated  Pain  (see  Feigned  Disease)  is  to  be  recognized  by  the 
existence  of  a  motive  for  deception.  The  simulation  is  common  enough 
in  those  who  seek  damages  for  injuries,  or  in  those  who  have  a  morbid 
craving  for  sympathy  and  attention.  Its  detection  depends  upon  the 
skill  of  the  physician,  who,  by  distracting  the  attention  from  the  part 
complained  of,  observes  that  the  pain  disappears,  or,  on  the  other  hand, 
that  pain  is  admitted  in  a  part  to  which  attention  is  directed  ;  more- 
over, the  physician  observes  an  absence  of  adequate  physical  alteration, 
and  usually  inconsistency  in  the  symptoms,  for  the  malingerer  is  seldom 
able  to  simulate  a  correct  clinical  representation  for  any  length  of  time. 
Especially  in  the  latter  case  is  the  observation  of  the  invalid's  sur- 
roundings of  considerable  importance.  The  so-called  hysterical  mask 
is  of  much  value,  for  the  bitter  complaints  and  the  placid  or  even  smiling 
features  cannot  fail  to  strike  the  observer  by  their  incongruity.  True 
hysteria  is  apt  to  be  deceptive,  and  more  than  one  humiliating  failure 
is  recorded  of  even  the  most  skilful  of  our  craft.  The  difficulty  is  in- 
creased because  actual  physical  changes  occur,  as  amaurosis  with  dila- 
tation of  the  pupil,  contracture  and  induration  about  the  joints,  unques- 
tionable anaesthesias,  and  palsies.  True  hysteria  is  often  to  be  detected 
only  after  prolonged  and  painstaking  study  of  the  case  ;  the  careful 
exclusion  of  organic  visceral  disease  ;  by  the  absence  of  the  character- 
istic symptoms  of  the  nervous  degenerations,  such  as  ankle-clonus,  or 
altered  electrical  reactions,  or  changes  of  the  fundus  oculi ;  and  often 
by  the  impossibility  of  associating  the  sensory  lesions  with  the  known 
anatomical  distribution  of  the  nerves. 

Objective  Investigation  of  Pain.  In  order  to  estimate  accurately 
the  diagnostic  value  of  pain,  the  statement  of  the  patient  must  be  cor- 


40  GENERAL  DIAGNOSIS. 

rected  by  his  expression,  posture  and  manner,  and  the  apparent  nature 
of  the  disease.  Pain  is  one  of  the  cardinal  symptoms  of  inflammation  ; 
vasomotor  and  muscular  disturbances  are  often  associated  with  neural- 
gia ;  any  morbid  condition  exerting  pressure  on  a  nerve-trunk,  as  a 
neoplasm,  callus,  etc.,  commonly  causes  pain.  Hence  if  the  objective 
phenomena  of  these  disorders  are  present,  they  lend  color  to  the  com- 
plaint of  pain,  and,  if  not,  they  should  be  inquired  for.  Attempts  have 
been  made  to  estimate  the  acuteness  of  the  pain-sense  with  scientific 
accuracy,  or  at  least  to  secure  a  practical  method  for  measuring  its 
varying  intensity  in  different  localities  in  the  same  case.  Bjornstrom, 
of  Upsala,  has  contrived  a  pair  of  forceps  that  compress  a  fold  of  skin  ; 
the  amount  of  pressure  required  to  produce  pain,  which  can  be  read 
from  a  scale,  indicates  the  degree  of  sensibility  or  rather  resistance  to 
painful  impression.  Another  instrument,  Bitch's,  accomplishes  the 
same  thing  by  direct  pressure,  and  hence  can  be  used  over  the  super- 
ficial nerve-trunks.  Another  method  more  generally  available  is  the 
application  of  an  induced  faradic  current  of  variable  strength — single, 
naked-wire  electrodes  being  best  for  this  purpose.  The  common  clinical 
method,  by  far  the  most  inaccurate  and  only  applicable  in  cases  of 
marked  analgesia,  is  a  pin  or  needle  forced  through  a  fold  of  skin.  Xo 
method  has  yet  been  suggested  for  even  the  approximate  estimation  of 
the  acuteness  of  sensibility  to  internal  pain,  and  it  must  still  be  left  to 
the  judgment  of  the  patient. 

The  Clinical  Value  of  Pain.  The  presence  of  pain  is  recognized 
by  the  above-mentioned  circumstances.  Its  degree,  with  the  limita- 
tions indicated,  has  been  estimated.  Its  clinical  value  is  then  to  be 
considered.  From  what  has  been  said  above,  the  converse  of  many  of 
the  propositions  is  true.  By  pain  and  the  mode  of  its  expression  we 
can  judge  of  the  character,  temperament,  and  nervous  susceptibility  and 
perturbability  of  the  patient.  It  aids  us  in  the  recognition  of  hysteria 
and  helps  to  detect  the  malingerer.  AYe  learn  the  patient's  capability 
of  resistance,  and  hence,  in  a  measure,  his  strength.  AYe  learn  the 
quickness  of  receptivity  in  consciousness  of  the  peripheral  irritation,  or 
the  degree  of  intelligence,  or  the  amount  of  stupor ;  or,  if  conditions 
are  present  which  usually  cause  pain,  its  absence  may  show  disease  of 
the  conducting  paths  to  the  brain.  Further,  the  absence  of  pain  under 
the  above  circumstances  points  to  the  occurrence  in  the  local  process  of 
such  change  as  has  destroyed  peripheral  nerve-endings.  Thus,  when 
pain  ceases  in  dysentery  gangrene  has  ensued.  In  intestinal  obstruc- 
tion its  cessation  indicates  the  same  process.  In  profound  shock  pain 
is  not  complained  of  ;  the  amount  of  pain,  therefore,  indicates  the 
degree  of  shock.  Hence,  in  peritonitis,  in  which  shock  frequently 
occurs,  pain  may  be  wanting  entirely.  The  abdominal  surgeons  welcome 
its  occurrence  after  an  operation,  as  it  indicates  the  absence  of  shock. 

While  the  above  lessons,  from  the  presence  or  absence  of  pain,  are 
not  to  be  under-estimated,  the  value  of  pain  to  the  physician  is  from 
the  stand-point  of  diagnosis.  By  this  symptom  we  may  be  enabled  to 
determine  the  location  of  disease  and  the  nature  of  the  causal  morbid 
process. 


THE  DATA   OBTAINED  BY  INQUIRY.  41 

(A)  The  location  of  the  disease  is  determined  (a)  by  the  seat  of  the 
pain  and  (6)  in  part  by  the  mode  of  expression.  The  mode  of  expression 
also  indicates  its  point  of  origin  in  a  general  way  and  its  probable  cause. 
They  are  (1)  the  facial  expression,  (2)  the  posture,  (3)  the  reflex  actions, 

(4)  the  associate  phenomena.  They  need  not  be  referred  to  again. 
(See  page  37.)  (B)  The  nature  of  the  causal  morbid  process  is  judged 
by  the  study  of  pain  from  various  stand-points.  Thus  in  the  consider- 
ation of  the  symptoms  of  pain  we  must  learn  (1)  the  mode  of  onset, 
(2)  the  duration,  (3)  the  time  of  occurrence,  (4)  the  character  or  variety, 

(5)  the  location,  (6)  the  modifications  produced  by  pressure,  tempera- 
ture, rest,  motion,  posture,  electricity,  drugs,  and  climate. 

1.  Mode  of  Oxset  The  mode  of  onset  of  pain  is  in  the  majority  of 
cases  an  indication  of  the  acuteness  of  the  morbid  process.  (A)  The 
onset  may  be  sudden,  as  (1)  in  gout  or  acute  inflammations  of  serous 
membranes,  as  pleurisy  or  peritonitis  ;  (2)  in  certain  headaches,  particu- 
larly in  those  of  congestive  or  emotional  origin  ;  (3)  in  acute  obstruction 
of  canals ;  (4)  in  contraction  of  muscular  structures  in  their  effort  to 
remove  a  foreign  body,  as  in  the  intestines,  the  gall-ducts,  the  vermi- 
form appendix,  the  ureters,  bladder,  or  uterus ;  (5)  in  rupture  of  the 
structure  in  which  it  is  developed.  Here  we  have  the  most  typical 
sudden  pain.  Thus,  in  rupture  of  an  aneurism  or  of  the  heart  there 
is  sudden,  sharp  pain.  In  rupture  or  perforation  of  the  stomach  or 
intestines,  or  any  of  the  hollow  viscera,  this  character  of  pain  arises. 

(6)  Sudden  pain  also  occurs  in  certain  neuralgias  or  neurosal  affections. 
It  is  seen  in  its  most  striking  form  in  angina  pectoris,  locomotor  ataxia, 
and  in  acute  brow-ague,  or  trigeminal  neuralgia.  (B)  The  onset 
may  be  gradual,  and  may  be  associated  with  continuous  increase  in 
intensity  or  variation.  Such  onset  indicates  that  the  process  is  one  of 
slow  development  and  not  attended  by  a  "  solution  of  continuity,"  as 
from  rupture  or  tear.  It  usually  occurs  in  various  forms  of  rheuma- 
tism, in  inflammations  of  muscles  and  of  mucous  membranes,  in  chronic 
inflammations  of  serous  structures,  in  chronic  bone  disease,  and  in 
slowly  developing  mechanical  pressure,  as  tumors. 

2.  Duration  The  duration  of  the  pain  indicates  the  acuteness  or 
chronicity  of  the  causal  morbid  process,  (a)  Pain  of  short  duration 
is  seen  in  the  affections  in  which  it  develops  suddenly  (see  Mode  of 
Onset),  in  acute  serous  inflammations,  and  in  neuralgias.  (6)  Pain  of 
long  duration,  if  constant,  is  usually  due  to  organic  lesions  ;  if  inter- 
mittent, it  may  be  due  to  neuralgia.  Pain  that  is  continued  over  a 
long  period  of  time  excludes  the  sudden  accidents  that  were  previously 
mentioned,  unless  change  in  the  character  of  the  pain  takes  place. 

Pain  is  also  divided,  as  to  duration,  into  temporary  and  constant 
pain.  Temporary  pain  indicates  an  abeyance  or  relief  of  the  morbid 
process,  while  the  constant  pain  points  to  its  continuance.  Constant 
pains  are  seen  in  bone  affection,  in  inflammation  of  muscles,  in  reflex 
pains  due  to  chronic  disease  elsewhere,  as  the  backache  of  uterine 
disease,  or  the  inframammary  neuralgias  from  the  same  cause.  Pain 
may  also  be  intermittent  or  remittent,  paroxysmal  and  periodic,  (a)  In- 
termittent and  remittent  pains  are  characteristic  of  neuralgias,  or 
point  to  a  functional   origin  ;  they  are    recurring  because  the   cause 


42  GENERAL  DIAGNOSIS. 

which  superinduces  them  is  again  operative.  Thus  recurring  head- 
aches due  to  eye-strain  may  be  intermittent  or  remittent  in  the  sense 
that  they  occur  only  when  the  eye  is  used.  Attacks  of  such  pain  recur 
over  a  long  period,  (b)  Paroxysmal  pain  is  the  form  which  occurs 
when  there  is  obstruction  of  channels,  as  the  gall-ducts  in  biliary  colic, 
the  intestines,  the  uterus,  and  the  ureters  in  the  various  forms  of  colic 
to  which  they  are  liable.  The  paroxysms  of  pain  recur  in  the  course 
of  the  attacks,  (o)  The  term  periodic  is  applied  to  pains  that  occur  at 
distinct  intervals.  Pain  that  is  periodic  has  frequently  for  its  cause 
malaria  in  some  form.  The  toxic  headaches  and  nerve  headaches,  as 
migraine,  are  often  periodic.     (Consult  Headaches.) 

3.  The  Time  of  Occueeence.  The  time  of  the  occurrence  of 
pain  is  important.  Pains  may  occur  in  the  daytime,  or  during  the  night 
exclusively.  Nocturnal  pains  are  common  in  syphilis.  They  are  usually 
due  to  periosteal  inflammation.  Diurnal  pains  are  usually  reflex  from 
functional  disorders.  Some  pains,  as  headache  due  to  cardiac  weakness 
and  to  forms  of  ansemia,  are  present  during  the  day,  because  the  patient 
is  in  the  upright  position.  They  disappear  in  the  recumbent  position, 
and  hence  are  absent  at  night. 

The  time-relation  of  pain  to  functional  acts  is  of  importance.  Thus 
in  gastric  pain  its  relation  to  the  taking  of  food  is  to  be  ascertained. 
Pain  coming  on  before  meals  is  gastralgic  ;  occurring  after  meals,  it  is 
due  to  ulcer  or  cancer,  sometimes  to  indigestion.  Chest  pains,  in- 
creased by  the  act  of  breathing,  are  muscular  or  pleuritic. 

4.  Chaeactee.  Pain  may  be  sharp,  lancinating,  or  stabbing  ;  it 
may  be  throbbing,  or  it  may  be  dull.  Sharp,  lancinating,  or  stabbing 
pain  is  usually  due  to  inflammation  of  serous  membranes,  to  colic  in 
various  forms,  and  to  forms  of  neuralgia.  Cutting  pain  is  a  sharp  form 
that  occurs  in  flatulent  colic.  Throbbing  pain  is  usually  associated 
with  acute  inflammation,  whether  superficial  or  deep.  It  may  be 
rhythmical  with  the  pulsations  of  the  heart.  Dull  pain  is  due  to  slow 
chronic  inflammation  in  the  bones  and  in  the  viscera  ;  it  is  the  pain  of 
myalgia  and  of  fatigue  in  the  muscles.  It  may  be  of  an  aching  charac- 
ter. But  aching  pains  may  also  be  general ;  they  are  found  among  the 
prodromata  of  the  acute  diseases,  attend  and  follow  a  chill,  and  occur 
in  most  characteristic  form  in  influenza  and  dengue.  Pressing  pain  is 
complained  of  when  it  attends  an  attempt  to  remove  material  from  the 
viscera,  as  the  passage  of  water  when  the  bladder  is  inflamed  ;  the 
passage  of  faeces  in  dysentery.  The  term  tenesmus  is  applied  to  it, 
so  that  we  have  vesical  tenesmus  and  rectal  tenesmus.  The  passage 
of  clots  or  other  material  from  the  uterus  is  attended  by  pain  with 
pressure  or  "  bearing-down,"  as  it  is  termed. 

Nature  of  the  Disease.  Finally,  the  character  of  pain  is  often  an 
indication  of  the  nature  of  the  disease  as  well  as  of  the  tissue  affected  : 

1.  Thus  boring  and  constant  pain  is  seen  in  bone  and  periosteal  disease. 

2.  Soreness  or  aching  in  muscular  affections.  3.  The  pain  is  sharp  and 
stabbing  when  serous  membranes  are  affected.  4.  Smarting  and  burn- 
ing, or,  perhaps,  dull  and  sore  when  mucous  membranes  are  inflamed. 
5.  Burning  or  itching  in  affections  of  the  skin.  6.  Dull  and  usually 
constant  in  visceral  affections,  although  in  malignant  disease  of  various 


THE  DATA  OBTAINED  BY  INQUIRY.  43 

organs  it  may  be  sharp  and  paroxysmal.  7.  Aching,  burning,  and 
throbbing  in  the  nerve-trunk  and  its  distribution,  with  tenderness, 
commonly  indicate  neuritis.  8.  A  sense  of  swelling,  distention,  or 
bursting  attends  the  pain  of  obstructions  of  hollow  viscera,  as  in  renal 
or  hepatic  colic.  9.  Rending  or  tearing  pain  may  be  complained  of 
when  a  hollow  viscus  or  sac  is  ruptured,  as  notably  in  the  rupture  of 
the  sac  of  extra-uterine  pregnancy.     (See  "  pain  crises,"  page  44.) 

5.  Location  and  Distribution.  It  may  be  of  questionable  advan- 
tage in  some  cases  that  the  localization  of  pain  generally  indicates  the 
situation  of  the  morbid  process.  Too  often  an  apparently  adequate 
explanation  of  the  symptoms  may  thus  be  found,  whilst  other  pathologi- 
cal changes  may  be  overlooked.  But,  on  the  other  hand,  the  condi- 
tion to  which  attention  has  been  called  by  the  pain  might,  on  account 
of  its  obscurity  or  unusual  location,  altogether  escape  observation. 

The  location  is,  in  general,  an  indication  of  the  seat  of  the  disease. 
It  may  be  accepted  as  an  almost  universal  rule  that  pain  due  to  a  local 
process  is  limited  to  the  immediate  or  associated  nerve-supply  of  the 
diseased  region.  This  holds  true  even  when  the  referred  pains — that 
is,  those  felt  in  the  associated  nerve-supply — are  as  far  distant  from  the 
site  of  the  morbid  process  as  the  knee  pain  of  coxitis,  the  shoulder  pain 
of  hepatic  disease,  pain  in  the  neck  from  pericarditis  or  diaphragmatic 
pleurisy,  the  ear  and  temporal  pain  of  lingual  carcinoma,  the  pain  in 
the  legs  from  cancer  or  ulcer  of  the  rectum,  the  testicular  and  thigh 
pain  of  renal  colic,  or  the  umbilical  pain  of  vertebral  disease. 

On  the  other  hand,  Hilton  lays  down  the  rule  that  pain  in  any  part, 
in  the  absence  of  a  local  process,  is  due  to  exalted  sensitiveness  of  the 
nerves  of  that  part,  and  depends  upon  a  cause  remote  from  the  painful 
area.  The  term  sympathetic  is  applied  to  this  group  of  pains.  Further, 
Hilton  remarks  that  pain  on  the  surface  of  the  body  must  be  expressed 
by  the  nerve  which  resides  there,  and,  hence,  the  cause  of  the  pain 
must  be  situated  between  the  peripheral  termination  and  its  central 
origin.  This  applies  particularly  to  the  pains  which  arise  from  disease 
of  the  vertebra?  and  the  referred  pains  described  above.  As  a  corol- 
lary to  this,  in  the  investigation  of  the  cause  of  pain,  the  nerve,  its 
anastomoses,  and  the  organs  supplied  by  it  should  be  investigated. 

But  the  pains  may  be  general  as  well  as  local. 

1.  General  pains  are  due  either  to  central  or  to  peripheral  dis- 
turbance of  the  nervous  system  by  a  poison  circulating  in  the  blood. 
This  may  be  the  poison  of  fevers,  or  it  may  be  a  rheumatic  or  gouty 
poison.  It  is  seen  in  the  common  affection  known  as  "  cold,"  when 
the  pains  are  probably  myalgia  In  syphilis,  malaria,  lead-poisoning, 
and  toxemias  generally  there  is  general  pain,  soreness,  and  fatigue. 
General  pains  are  not  confined  to  the  muscles,  but  are  also  seated  in 
the  fibrous  structures  and  bones.  In  their  more  severe  forms  such 
pains  occur  in  dengue,  and  are  known  as  "  break-bone." 

2.  Local  pains  may  be  (a)  superficial  or  deep-seated  ;  (b)  circum- 
scribed or  diffused. 

(a)  Superficial  pains  are  due  to  involvement  of  the  superficial  nerves 
distributed  to  the  skin  or  to  the  muscles  directly  underneath,  or  to  the 
structures  in  close  relation  to  the  skin,  as  the  peritoneum,  the  pleura, 


44  GENERAL  DIAGNOSIS. 

or  the  pericardium.  Deep-seated  pains,  when  in  the  extremities,  are 
due  to  bone  disease  ;  when  in  the  abdomen,  to  disease  of  the  viscera, 
particularly  inflammatory  affections,  to  aneurism,  or  bone  disease  ;  when 
in  the  chest,  to  disease  of  the  aorta  and  mediastinum. 

(6)  Circumscribed  pain  is  always  due  to  a  small  area  of  disease,  or  is 
reflex.  Thus,  in  ulcer  of  the  stomach  the  pain  is  usually  circumscribed 
to  a  small  area  in  the  epigastrium  ;  in  inflammation  of  the  appendix,  to 
the  region  of  that  structure.  Diffused  pain  indicates  involvement  of  a 
large  area  with  less  intensity  of  process  than  when  circumscribed. 
When  the  pain  is  diffused,  or,  as  it  is  sometimes  called,  radiating,  over 
an  area  of  nerve  distribution,  its  point  of  origin  may  be  found  somewhere 
in  the  course  of  the  nerve,  either  in  the  trunk  or  in  one  of  its  branches. 
Corollary :  Given  pain  in  a  locality,  study  the  nerve-supply  of  that 
region  aud  the  nerve  anastomoses  connected  therewith.  We  learn  much 
from  the  study  of  this  distribution.  The  referred  pains  have  been  indi- 
cated (page  43).  Among  others,  the  pain  of  angina  radiates  down  the 
arms.  The  pain  of  diaphragmatic  pleurisy  is  referred  to  the  front  of 
the  abdomen  above  the  umbilicus.  Radiating  pains,  however,  are  chiefly 
due  to  disease  in  the  course  of  the  nerve,  the  pain  being  referred  to 
its  trunk  and  terminal  distributions,  as  pain  in  the  foot  in  sciatica. 
Pain  from  pressure  upon  the  nerves  at  their  exit  from  the  spinal 
canal  is  at  the  periphery  of  the  nerves,  as  in  the  centre  of  the  ab- 
domen, and  not  at  the  point  of  exit.  Pain  in  this  locality  is  frequently 
an  indication  of  disease  of  the  vertebra?,  propagated  by  the  sixth  or 
seventh  dorsal  nerve.  Pain  between  the  shoulders  is  often  due  to 
aneurism  which  presses  upon  the  vertebra?.     (See  Pain  in  the  Heart.) 

Bilateral,  symmetriccd,  and  superficial  pains  indicate  a  central  or  bilat- 
eral cause  ;  while,  on  the  other  hand,  unilateral  pain  implies  a  seat  of 
origin  which  is  one-sided. 

Peripheral  Pain  of  Central  Origin.  We  have  referred  to 
pains  of  the  extremities  or  trunk  due  to  central  disease.  In  meningitis 
and  other  general  organic  affections  of  the  brain  and  cord  peripheral 
pains  are  frequent,  and  may  be  the  earliest  and  most  striking  symp- 
toms. Indeed,  it  is  very  common  to  find  patients  with  spinal-cord 
disease  who  have  been  treated  for  a  long  time  for  what  was  supposed 
to  be  rheumatism.  The  pains  in  the  joints  of  central  origin  may  be 
constant,  or  paroxysmal  and  lancinating  when  the  disease  is  chronic. 
(See  Character.)  The  cardinal  rule,  that  all  peripheral  pains,  without 
obvious  local  cause,  should  lead  to  an  examination  of  the  nervous 
system,  must  never  be  forgotten.  The  paroxysms  of  pain  may  be  most 
excruciating,  and  sometimes  cause  collapse.  They  are  known  as  painfull 
crises.  Pain  may  be  complained  of  in  various  viscera,  as  well  as  in  the 
joints.  Sudden,  intense  pain,  with  functional  disturbances  of  the  affected 
viscera,  occurs  independently  of  any  lesion  of  the  part  or  of  any  apparent 
exciting  cause.  One  class  of  the  attacks  is  known  as  gastric  crises. 
The  pain  is  in  the  epigastrium,  and  is  associated  with  vomiting.  In 
another  class  laryngeal  crises  occur,  with  pain  in  the  larynx  and  violent 
spasmodic  cough,  with  dyspnoea.  The  pain  extends  over  the  shoulders. 
Or  we  may  have  rectal  crises,  with  sensation  of  burning  in  that  situation  ; 
urinary  crises,   simulating  renal  colic,   and  genital  crises.     Pains,   in 


THE  DATA   OBTAINED  BY  INQUIRY.  45 

crises,  also  occur  in  the  muscles.  Crises  occur  chiefly,  if  not  entirely, 
in  locomotor  ataxia.  They  are  distinguished  from  pain  due  to  other 
causes  by  their  sudden  onset,  their  extreme  severity,  the  absence  of 
organic  disease  or  local  cause  in  the  affected  viscera,  the  sudden  termi- 
nation, the  normal  condition  between  the  attacks. 

6.  Pain  Modified  by  Pressure,  Movement,  Rest,  or  Mental 
Diversion.  We  also  study  pain  under  the  influence  of  pressure, 
movement,  temperature,  rest,  etc.  Pain  that  is  modified  by  pressure  is 
generally  superficial.  It  is  usually  of  an  inflammatory  origin.  The 
variety  of  the  pressure  gives  some  clue  to  the  nature  of  the  pain.  If 
the  pain  is  increased  by  pressure  of  the  finger-tips,  it  is  due  to  ulcer  or 
inflammation  when  internal  and  to  inflammation  if  external.  Although 
of  visceral  origin,  gastralgia  and  colicky  pains  in  the  intestine,  which  may 
be  a  neurosis,  are  relieved  by  pressure,  particularly  if  the  whole  hand 
is  applied.  Pain  from  the  dislocation  of  an  organ,  as  a  movable  kidney 
or  displaced  uterus,  or  from  dependent  viscera,  may  be  relieved  by 
judicious  pressure  in  the  proper  direction,  so  as  to  relieve  the  displace- 
ment. 

Pain  from  affections  of  the  nerve-trunks  can  be  distinctly  localized 
by  pressure  in  the  course  of  the  nerve-trunk,  and  particularly  at  the 
points  where  the  cutaneous  filaments  of  the  nerves  come  through  the 
fascia.  These  points  in  the  thorax  are  along  the  vertebral  column,  in 
the  axillary  region,  and  anteriorly  about  the  parasternal  line — the  points 
of  Valleix.  We  distinguish  neuralgias  from  myalgias  by  the  presence 
of  these  tender  points.  Pain  due  to  bone  disease  can  frequently  be 
distinguished  in  this  way.  By  pressure  or  weight  upon  the  head  or 
shoulders  we  may  ascertain  if  pain  is  due  to  vertebral  disease.  The 
23resence  of  renal  calculus  or  of  gall-stones  may  be  determined  by  the 
excitation  of  pain  by  pressure. 

Pain  increased  by  movement  points  to  an  affection  of  the  bone, 
muscle,  joint,  or  nerve  in  the  part  moved  ;  groups  of  muscles  may  be 
isolated  for  the  tests.  Some  few  pains  are  relieved  by  movement  of 
the  body,  only  because  the  mind  is  diverted  in  this  act.  Pain,  when 
superficial  and  increased  by  movement,  is  due  to  neuritis,  myalgia,  or 
rheumatism. 

Almost  all  pains  are  modified  by  rest.  Its  influence  has  but  little 
diagnostic  significance.  In  some  cases  of  doubt  as  to  the  nature  of  a 
visceral  pain,  functional  rest  of  the  organ,  by  which  relief  is  obtained, 
may  aid  in  determining  its  locality.  Thus,  rest  to  the  eye  may  relieve 
a  headache,  the  nature  of  which  was  obscure  until  this  respite  was 
secured.  Pain  modified  by  temperature  (cold  or  heat  applied  to  the 
spine,  ice  or  hot  water  in  a  sponge)  and  by  electricity  usually  gives 
information  as  to  the  seat  of  the  disease  in  the  spinal  column,  of  which 
the  pain  is  the  external  expression.  Pain  modified  by  climate  is  rheu- 
matic or  neuralgic  ;  if  modified  by  weather  or  season,  it  is  due  to  neu- 
ralgia or  neuritis,  whether  of  gouty  or  traumatic  origin. 

The  patient  may  describe  an  excruciating  pain  in  an  area,  but  not 
exhibit  outward  evidence  or  physiological  change  which  should  accom- 
pany such  suffering.  Thus  the  pain  may  simulate  that  of  peritonitis. 
Such  pain  is  often  modified  and  mollified  by  fixing  the  attention,  of  the 


46  GENERAL  DIAGNOSIS. 

patient  on  some  other  part  or  on  some  extraneous  subject,  when  the 
previously  alleged  tender  area  may  be  pressed  upon  without  causing 
any  evidence  of  suffering.  Similarly,  attention  may  be  called,  by  a 
leading  question,  to  pain  in  some  other  region.  The  admission  of  the 
occurrence  of  such  pain,  and  other  evidences  of  hysteria,  point  to  the 
underlying  causal  factor  in  the  production  of  pain.  A  most  important 
characteristic  of  pain,  and  one  that  serves  to  distinguish  the  pain  of 
organic  disease  from  that  of  hysterical  origin,  is  its  variability  with 
excitement,  or  on  fixation  of  the  attention  of  the  sufferer  on  other 
parts.  Moreover,  the  subject  will  fall  into  the  trap  of  describing  it  as 
having  characters  contrary  to  the  usual  attributes  of  pain  or  being  asso- 
ciated with  phenomena  not  compatible  with  the  pain — if  judicious 
leading  questions  are  put. 

Resume.  Notwithstanding  clinical  investigation  we  may  not  be  able 
from  the  character  and  locality  to  determine  the  real  cause  of  the  pain. 
In  general  it  may  be  borne  in  mind  that  pains  are  due  (1)  to  disease  of 
the  central  nervous  system  or  the  nerve-trunks  ;  (2)  to  inflammations  ; 

(3)  to  intoxications,  as  from  malaria,  lead,  and  other  forms  of  toxaemia  ; 

(4)  to  pressure  on  the  nerve-trunks  ;  (5)  to  reflex  influences.  If  in 
doubt,  therefore,  the  general  symptoms  and  condition  of  the  patient 
must  be  ascertained  in  order  to  determine  the  causal  origin,  and  hence 
the  true  nature  of  the  pain.  In  all  cases  of  pain  the  controlling  motive 
in  diagnosis  should  be  to  determine  the  general  condition  of  the  patient 
and  find  the  cause  of  the  pain. 

Reference  must  be  made  to  the  curious  change  that  takes  place  in 
persons  with  chronic  morphine  intoxication.  Such  persons  are  very 
apt  to  have  functional  pain.  This  form  of  pain  is  usually  paroxysmal 
and  severe,  and  may  simulate  organic  pains.  The  most  common  clini- 
cal form  seen  is  gastralgia.  The  subjects  of  locomotor  ataxia  suffer 
from  pain,  on  account  of  which  they  have  to  take  enormous  doses  of 
morphine.  This  habit  is  soon  acquired,  but  notwithstanding  the  large 
dose  of  the  drug  paroxysmal  pain  continues  ;  in  its  severity  it  simulates 
the  crises  of  the  primary  disease.  It  becomes  a  very  difficult  matter, 
and  is  often  impossible,  to  decide  whether  the  pain  is  due  to  the  mor- 
phine-habit or  to  the  primary  affection.     (See  Source  of  Error,  p.  38.) 

Pain  in  the  Head. 

Pains  in  the  head  may  be  classified,  according  to  location,  into  those 
due  to  affections  of  the  scalp,  those  due  to  affections  of  the  cranium,  and 
those  due  to  intracranial  conditions. 

1.  Affections  of  the  scalp  are  to  be  further  classified  as  those  of 
the  skin,  those  of  the  occipito-frontalis  muscle,  and  those  of  the  nerves. 
The  occurrence  of  itching  and  burning  commonly  indicates  some  local 
condition  of  the  skin  ;  if  the  itching  is  slight,  seborrhcea  should  be 
looked  for  ;  if  more  severe,  eczema  ;  burning  and  itching  of  a  severe 
type  commonly  indicate  dermatitis  venenata  ;  the  pediculus  capitis 
should  not  be  forgotten.  A  feeling  of  tension,  with  soreness,  accom- 
panies the  eruption  of  erysipelas.  Intense  local  irritations  are  caused 
by  burns  and  scalds  ;  the  latter,  however,  are  alone  likely  to  give  rise  to 


THE  DA  TA   OB TAINED  B  Y  INQ  UIB  Y.  47 

error,  because  the  hair  is  not  immediately  destroyed.  A  sore  feeling, 
with  local  tenderness,  limited  to  a  sharply  defined  swelling,  with  a  sen- 
sation of  less  resistance  in  the  centre  and  some  darkening  of  the  skin,  is 
diagnostic  of  a  bruise.  Hyperesthesias  of  the  scalp  frequently  accom- 
pany meningeal  and  cranial  affections,  and  there  are  even  local  changes, 
such  as  the  so-called  puffv  tumor  of  necrosis  of  the  inner  table  of  the 
skull. 

Sharp  pains  in  the  occipital  or  frontal  region,  increased  by  wrinkling 
the  scalp,  or  brief  pressure,  but  generally  relieved  by  firm  and  constant 
pressure,  occurring  with  irregular  periodicity,  and  associated  with 
meteorological  changes,  are  suggestive  of  occipital  myalgia.  The  diag- 
nosis is  confirmed  by  the  presence  of  other  symptoms  of  lithsemia. 

Neuralgia  occurs  in  paroxysms,  accurately  located  in  the  course 
of  one  or  more  of  the  nerve-trunks,  and  presenting  points  of  special 
sensitiveness  where  the  nerve  emerges  from  the  skull  and  where  it 
divides  for  its  cutaneous  distribution.  The  pain  is  usually  relieved 
by  firm  pressure,  but  it  is  to  be  remembered  that  sharply  local- 
ized pressure  on  the  nerve-trunks  against  the  hard  skull  will  cause  a 
traumatic  tenderness.  The  character  of  the  pain  is  variable  ;  it  may 
be  of  the  most  acute  or  rending  form,  or,  but  more  rarely,  a  persistent 
dull  ache  ;  it  may  be  throbbing,  or  occur  in  successive  paroxysms  at 
brief  intervals,  or  it  may  be  regularly  periodic.  There  are  often  asso- 
ciated vasomotor,  secretory,  and  motor  disturbances  ;  local  blushing  or 
sweating  may  be  observed  along  the  course  of  the  nerve,  and  spasms  may 
occur  in  the  muscles  of  the  eyelids,  for  instance,  or  more  general  spasms, 
as  in  the  terrible  tic  douloureux,  distinguished  by  pain  from  tic  convulsif . 
The  commonest  seat  is  the  supraorbital,  the  dental,  the  auricular,  and 
the  occipital  nerves.     In  the  great  majority  of  cases  it  is  unilateral. 

The  sensory  nerves  of  the  scalp  and  face  are  the  trigeminus  and  the 
branches  of  the  cervical  plexus.  The  distribution  is  as  follows  :  the 
ophthalmic  division  of  the  trigeminus  is  distributed  to  the  eyeball, 
lachrymal  gland,  the  mucous  membrane  of  the  nose  and  eyelids,  the 
integument  of  the  nose  and  upper  eyelid,  the  forehead,  and  the  anterior 
half  of  the  hairy  scalp.  The  superior  maxillary  division  supplies  the 
skin  over  the  malar  bone,  and  that  of  the  lower  eyelid,  side  of  the  nose, 
and  upper  lip  ;  the  upper  teeth,  the  upper  part  of  the  pharynx,  the 
antrum  of  Highmore,  and  the  posterior  ethmoidal  cells  ;  the  soft  palate, 
tonsil,  and  uvula,  and  the  glandular  structures  of  the  roof  of  the  mouth. 
The  inferior  maxillary  division  is  distributed  to  the  side  of  the  head, 
the  upper  anterior  portion  of  the  external  ear,  the  external  auditory 
canal,  the  lower  lip,  and  lower  part  of  the  face  ;  the  tongue,  the  mouth, 
the  lower  teeth  and  gums,  the  salivary  glands,  and  the  articulation  of 
the  jaw.  The  great  occipital  is  distributed  to  the  back  of.  the  head,  the 
small  occipital  to  a  narrow  region  just  in  front  of  it,  and  the  greater 
auricular  to  the  skin  of  the  posterior  portion  of  the  pinna  and  the  skin 
over  the  mastoid  and  parotid  gland. 

Pain  simulating  neuralgia  is  frequently  due  to  some  local  irritation  ; 
foreign  bodies  have  been  known  to  cause  paroxysmal  attacks  for  a 
number  of  years,  until  removed  ;  diseases  of  the  bones  are  a  prolific 
source,  especially  in  the  case  of  the  jaws  and  the  cervical  vertebrae. 


48  GENERAL  DIAGNOSIS. 

Enlarged  cervical  glands  occasionally  irritate  the  great  auricular  or 
small  occipital  nerve.  Bilateral  occipital  pain  is  very  characteristic  of 
cancer  of  the  cervical  vertebrse.  In  these  cases  there  is  usually 
pain  on  movement  of  the  head  or  pressure  upon  it,  and  some  stiffness 
of  the  neck.  Intracranial  growths  occasionally  cause  pains,  usually 
paroxysmal,  limited  to  one  of  the  branches  of  the  trigeminus. 

Reflex  Neuralgia.  Certain  of  the  cephalic  nerve-pains  are  symptom- 
atic of  disturbance  in  the  associated  but  distant  nervous  distribution. 
Pain  in  the  region  supplied  by  the  ophthalmic  division  is  very  common 
in  influenza.  It  is  usually  dull,  aching,  and  continuous,  increased  by 
pressure  and  anything  tending  to  increase  congestion.  A  severe,  acute 
attack  of  indigestion  will  produce  ocular  and  supraorbital  pain.  Re- 
fractive lesions  of  the  eye  cause  the  same  kind  of  pains,  which  are, 
however,  increased  by  using  the  eye  and  relieved  by  rest  and  atropine. 
The  use  of  the  latter  is  an  important  diagnostic  procedure.  Pain  in  the 
temporal  region  and  the  external  auditory  meatus  is  often  due  to  intense 
irritation  of  some  of  the  branches  of  the  inferior  dental ;  the  usual  cause 
is  cancer  of  the  tongue,  but  irritable  lingual  ulcer  may  also  produce  it, 
and  even  severe  inflammatory  conditions  of  the  lower  jaw.  The  pain  is 
described  as  sharp,  lancinating,  and  paroxysmal,  liable  to  exacerbations, 
especially  when  the  primary  lesion  is  irritated,  and  relieved  when  it  is 
alleviated.  Pain  may  be  caused  in  the  ear  alone  when  there  is  irrita- 
tion of  the  teeth. 

Systemic  Neuralgia.  Perhaps  in  the  majority  of  cases  of  cephalic 
neuralgias  the  cause  is  to  be  found  in  some  systemic  disturbance.  If 
the  attack  is  preceded  by  a  desire  to  sleep,  occurs  when  the  dew-point  is 
high,  and  is  associated  with  increase  of  urates  in  the  urine,  it  is  prob- 
ably lithcemic  ;  the  pure  gouty  forms  are  most  apt  to  succeed  indulgence 
in  rich  food  or  red  meat,  and  there  is  ordinarily  irritability  of  temper. 
Diabetic  neuralgias  are  invariably  worse  as  the  amount  of  sugar  excreted 
is  increased,  and  there  are  usually  similar  affections  of  the  nerves  in 
other  parts  of  the  body.  Regularly  periodic  pains,  worse  in  the  spring 
and  fall,  occasionally  preceded  by  a  slight  chill  or  malaise,  suggest 
chronic  malaria.  The  diagnosis  can  readily  be  confirmed  by  exam- 
ination of  the  blood  and  by  the  detection  of  enlargement  of  the  spleen. 
Syphilitic  neuralgias  are  usually  worse  at  night ;  the  pain  is  described 
as  boring,  and  may  be  periodical.  There  is  likely  to  be  some  thicken- 
ing of  the  bones,  and  perhaps  a  diminution  of  elasticity  of  the  tissues, 
and  almost  always  local  tenderness.  The  pain  is  almost  immediately 
relieved  by  iodide  of  potassium.  In  ancemic  neuralgias  the  pain  is  not 
characteristic,  but  it  is  temporarily  improved  by  the  recumbent  posture 
and  stimulants,  and  is  worse  during  menstruation.  The  general  appear- 
ance of  the  patient  and  an  examination  of  the  blood  readily  suggest  the 
cause.  In  locomotor  ataxia  there  are  occasionally  cephalic  crises  of  a 
neuralgic  nature  ;  these  come  on  suddenly  and  are  exceedingly  severe, 
but  usually  occur  only  at  long  intervals  ;  the  pain  is  shooting  or  stab- 
bing, and  does  not  remain  located  in  one  nerve-trunk.  Chronic  lead- 
and  alcohol-poisoning  also  cause  neuralgias,  but  they  are  not  of  them- 
selves characteristic,  and  never  occur  as  isolated  symptoms,  being 
frequently  associated  with  peripheral  neuritis. 


THE  DATA  OBTAINED  BY  INQUIRY.  49 

Secondary  Neuralgia.  Dull,  burning  pains,  commencing  perhaps 
with  a  chill,  and  accompanied  by  febrile  symptoms,  indicate  inflamma- 
tions of  the  mucous  membranes  of  the  head.  A  dull,  persistent  head- 
ache located  just  beneath  the  eyebrows  often  accompanies  coiyza,  and 
indicates  extension  to  the  frontal  sinuses  ;  if  the  nose  alone  is  involved, 
there  is  a  feeling  of  fulness  and  occasional  sharp  pains  or  tickling  sen- 
sations. A  feeling  of  dryness  and  some  discomfort  on  swallowing 
accompanies  the  various  forms  of  stomatitis  and  pharyngitis ;  in  the 
latter  there  is  also  a  sensation  of  tickling  and  fulness  in  the  ear,  due  to 
extension  along  the  Eustachian  tube.  Pain  at  the  angle  of  the  jaw, 
with  tenderness,  and  increased  on  swallowing,  almost  invariably  unilat- 
eral and  associated  with  swelling  of  the  parotid,  is  unmistakably  due  to 
parotitis.  The  neuralgias  and  inflammations  of  the  middle  ear  are 
exceedingly  painful ;  they  may  consist  of  a  sharp  continuous  pain,  or  a 
series  of  regular  exacerbations  and  remissions,  or  a  throbbing  sensation  ; 
pain  often  radiates  to  the  jaws  and  side  of  the  face.  As  suppuration 
occurs,  the  feeling  becomes  one  of  extreme  tension  until  the  membrane 
is  perforated,  when  there  is  immediate  relief.  Tinnitus  throughout  the 
whole  course  of  the  case  is  very  common.  The  inflammations  of  the 
eye  produce  local  pain,  usually  causing  the  sensation  of  a  rough  foreign 
body.  Usually  there  is  a  slight  supraorbital  tenderness,  and,  in  iritis, 
sharp  pains  radiate  over  the  whole  area  of  distribution  of  the  two  upper 
branches  of  the  fifth.  Certain  ulcers  of  the  mouth  are  comparatively 
painless,  noma  often  developing  insidiously.  Syphilitic  ulcers  are  to 
be  distinguished  by  their  painlessness  from  simple  and  tubercular  ulcers, 
which  are  very  irritable,  and  carcinomata,  which  are  liable  to  paroxysms 
of  pain  even  when  not  irritated. 

It  may  not  be  out  of  place  to  mention  the  value  of  certain  anaesthesias 
as  diagnostic  signs  ;  thus  in  neuritis  of  branches  of  the  fifth  there  may 
be  cutaneous  anaesthesia  while  there  is  tenderness  over  the  nerve-trunk. 

2.  Affections  of  the  Cranium.  A  dull,  constant  headache,  limited 
to  a  small  area,  later  increasing  in  severity,  and  the  pain  assuming, 
perhaps,  a  boring  character  ;  tenderness,  often  very  severe,  over  the 
affected  area,  and  probably  slight  oedema  of  the  scalp,  with  some 
rigidity  of  the  muscles  of  the  neck,  and  the  ordinary  signs  of  the  in- 
flammatory process,  indicate  inflammation  of  the  cranial  hones.  In  the 
simple  cases  there  will  usually  be  some  history  of  injury,  the  pains  will 
not  be  especially  periodic,  and  the  fever  will  be  irregular.  In  the 
syphilitic  cases  there  will  be  the  history  and  symptoms  of  infection, 
the  pain  will  become  worse  at  night,  and  usually  there  will  be  concom- 
itant rise  of  temperature.  The  pains  will  also  be  controlled  by  iodide 
of  potassium,  but  as  it  often  requires  enormous  doses  to  accomplish 
this  result,  the  failure  of  a  moderate  dose  should  not  be  considered  as 
excluding  syphilis. 

3.  Intracranial  Headaches.  Intracranial  headaches  are  functional 
or  organic.  Both  forms  may  be  acute  or  chronic.  The  typical  acute 
functional  headache  is  seen  in  the  more  or  less  common  type  known  as 
migraine  or  hemicrania. 

Migraine  is  a  periodical  neurosis  characterized  by  pain  in  the  tri- 
geminus and  other  cranial  nerves.     The  headache  is  usually  unilateral, 

4 


50  GENERAL  DIAGNOSIS. 

and,  as  it  is  probably  due  to  vasomotor  disturbances,  is  always  associated 
with  vasomotor  symptoms.  It  occurs  more  particularly  in  women, 
frequently  begins  in  early  childhood,  and  continues  throughout  adoles- 
cence. It  is  often  hereditary.  It  occurs  most  frequently  in  women 
who  suffer  from  anaemia  or  from  menstrual  difficulties.  It  sometimes 
occurs  in  the  early  stages  of  secondary  syphilis.  The  habit  which  pre- 
disposes to  the  headache  may  develop  after  long  physical  or  mental 
over-exertion.  The  attacks,  however,  are  excited  by  over-exertion, 
mental  excitement,  or  disturbances  of  digestion.  Pain  of  migraine  is 
possibly  situated  in  the  pia  and  dura  mater. 

Symptoms.  The  attack  develops  with  or  without  premonitions. 
In  each  individual  different  prodromal  symptoms  are  recognized  as  in- 
dicating the  approach  of  an  attack.  Undue  nervousness,  a  general  sense 
of  discomfort,  pressure  or  heat  in  the  head,  vertigo,  tinnitus,  spots  before 
the  eyes,  excessive  yawning,  and  repeated  chilliness  are  the  most  common. 

Premonitory  Symptoms.  The  pain  is  most  frequently  felt  on  the 
left  side  of  the  head  first.  It  is  seated  in  the  anterior  frontal,  the 
temporal,  or  parietal  region.  The  pain  is  continuous,  and  increases  in 
intensity  to  the  height  of  a  paroxysm.  Painful  points  are  not  usually 
detected,  although  the  whole  skin  may  be  hypersesthetic.  The  patient 
is  sensitive  to  light  and  sound,  intolerable  nausea  intervenes,  and  vomit- 
ing may  occur  at  the  height  of  an  attack.  The  eye-symptoms  are  very 
pronounced.  Flashes  before  the  eyes,  scintillating  scotoma,  or  hemian- 
opia  may  occur. 

The  vasomotor  symptoms  that  attend  the  attack  are  of  two  varieties, 
dividing  the  disease  into  the  spastic  and  angioparalytic  forms.  In 
spastic  migraine  the  skin  on  the  affected  side  is  cool,  the  forehead  and 
ear  pale,  the  temporal  artery  is  contracted,  the  pupil  is  dilated,  and  the 
flow  of  saliva  increased.  In  the  paralytic  form  there  is  redness  of  the 
face  on  the  affected  side.  The  temporal  arteries  are  dilated  and  pulsate 
strongly.  The  face  is  hot,  the  pupils  contracted,  and  there  is  often 
unilateral  sweating. 

Chronic  Headaches.  Chronic  functional  headaches  are  usually 
habitual  in  the  sense  that  the  attacks  are  constant,  but  there  may  be 
longer  or  shorter  intervals  of  freedom  from  pain.  The  nerves  affected 
are  the  trigeminus,  and  the  four  upper  cervical  and  sensory  branches 
of  the  vagus  to  the  posterior  fossa  of  the  skull.  Three  types  of  such 
head-pains  are  seen  :  ordinary  headache,  migraine,  and  neuralgia. 
Headaches  are  caused,  as  a  rule,  by  diffuse  irritations  located  in  or 
referred  to  the  peripheral  ends  of  the  nerve-tracts  above  referred  to. 
Neuralgias,  on  the  other  hand,  are  caused  by  irritations  of  the  trunks  of 
these  nerves. 

Causes.  1.  Hsemic.  (a)  Anaemia;  (6)  diathetic  states  (gout,  rheu- 
matism, diabetes) ;  (c)  infections  (malaria,  syphilis,  specific  fevers).  2. 
Toxic  (lead,  and  other  mineral  poisons,  alcohol,  the  poison  of  uraemia, 
tobacco).  3.  Neuropathic  states  (epilepsy,  neurasthenia,  chorea,  hyste- 
ria, neuritis).  4.  Reflex  causes  (ocular,  nasopharyngeal,  auditory, 
gastric,  sexual,  uterine).     5.  Organic  disease. 

Headaches  are  divided  according  to  their  situation  into  frontal,  occip- 
ital, parietal,  vertical,  diffuse,  and  combinations  of  both.     The  most 


THE  DATA  OBTAINED  BY  INQUIRY. 


51 


common  forms  are  the  frontal,  the  frontal-occipital,  and  the  diffuse. 
Ocular  headaches  are  usually  frontal  when  due  to  errors  of  refraction. 
When  due  to  muscular  insufficiencies  they  are  occipital  and  cervical. 
Nasopharyngeal  headaches  are  dull,  frontal,  or  diffuse.  When  the 
pharyngeal  tonsil  is  enlarged  the  headache  may  be  dull,  frequently 
recurring,  and  seated  in  the  occipital  region.  In  follicular  tonsillitis 
and  in  obstruction  of  the  Eustachian  tubes  the  headaches  are  diffuse. 
In  disease  of  the  middle  ear  they  are  temporal  and  occipital.  Gastric 
or  dyspeptic  headaches  without  constipation  are  often  occipital,  some- 
times frontal.  With  constipation  and  intestinal  irritation  they  are  diffuse 
and  frontal.  Uterine  and  ovarian  headaches  are  occipital  and  vertical. 
Neuropathic  headaches  are  seated  on  the  top  of  the  head,  as  in  clavus, 
or  they  are  associated  with  spinal  irritation.  Neurasthenic  headaches 
are  usually  associated  with  a  sense  of  pressure  or  weight,  and  are  seated 
in  the  frontal  and  vertical  regions.  In  spinal  irritation  the  pain  is  of 
a  boring  character  in  the  occipital  region.  The  earliest  symptom  of  the 
neurasthenic  headache  is  neck-weariness  and  pain  in  the  neck.     The 

Fig.  1. 
Anaemia. 
Endometritis. 
Bladder. 


Constipation  ;  caries  of  incisor  ^s 

Error  of  eye-refraction  _v       N' 
Gastric  dyspepsia --: 


^^  Eye. 
—/---/  Decayed  teeth. 
*~P'~~~^r  Pharyngitis ;  otitis  media. 


Uterine. 
Spinal  irritation. 


Showing  the  location  of  pain  in  various  headaches.    (After  Dana.) 


neurasthenic  headaches  occur  in  brain-workers  when  the  brain  and  eyes 
are  overtaxed.  Headaches  in  epliepsy  are  severe,  and  are  confined  to 
the  vertical  or  occipital  region. 

Organic  headaches  are  usually  violent,  associated  with  fulness  and 
throbbing.  They  may  be  remittent,  becoming  more  intense  with  each 
exacerbation.  The  organic  headaches  may  be  due  to  inflammation,  to 
abscess  and  softening,  to  tumor,  to  congestion  of  the  brain,  and  to 
inflammations  in  the  meninges.  Anything  which  increases  the  blood 
will  increase  the  pain  in  organic  headaches.  In  acute  inflammation 
of  the  brain  the  pain  is  agonizing,  continuous,  associated  with  vomit- 
ing and  fever,  and  sometimes  delirium.  In  abscess  of  the  brain  the 
pain  is  less  violent.  It  is  occasionally  paroxysmal  and  attended  by 
paralysis  and  disturbed  intellection.  In  tumor  of  the  brain  the  head- 
ache is  severe  and  paroxysmal.  In  congestion  the  pain  is  dull,  increased 
by  stooping,  by  sleep,  and  by  bodily  or  mental  fatigue.  Some  conges- 
tive headaches  are  due  to  violent  exercise,  and  are  relieved  by  bleed- 
ing at  the  nose.  In  all  congestive  headaches  the  face  is  flushed,  the 
bloodvessels   are  turgid,  and   the  vessels  in  the  eye-ground  will   be 


52  GENERAL  DIAGNOSIS. 

found  to  be  overfilled.  In  meningitis  the  pain  is  constant,  is  more  or 
less  fixed,  and  sometimes  very  sharp.  Syphilitic  headaches  are  frontal 
or  temporal,  worse  at  night,  and  often  periodic. 

Headaches  are  divided  according  to  the  character  of  the  pain  :  1. 
Pulsating  and  throbbing.  2.  Dull  and  heavy.  3.  With  constriction, 
squeezing,  or  pressing.  4.  Hot  and  burning.  5.  Sharp  and  boring. 
The  headaches  of  the  first  class  are  usually  associated  with  vasomotor 
disturbances,  as  in  migraine.  To  the  second  class  belong  the  toxic  and 
dyspeptic  headaches ;  to  the  third,  the  neurotic  and  neurasthenic ;  to 
the  fourth,  rheumatic  and  anemic ;  to  the  fifth,  hysterical,  neurotic, 
and  epileptic.  Vertigo  is  a  common  accompaniment  of  the  dyspeptic 
type  of  headache  situated  in  the  frontal  regions.  /Somnolence  is  more 
marked  in  the  syphilitic,  anemic,  and  malarial  headaches.  Nausea  is 
more  common  in  occipital  forms  of  headache. 

Duration.  Eye-strain  causes  occipital  pain,  which  is  rarely  per- 
sistent, but  comes  on  after  prolonged  use  of  the  eyes.  It  may  be  asso- 
ciated with  headache  in  other  parts,  due  to  other  causes.  In  chronic 
meningitis  the  headache  is  persistent  and  located  in  the  vertex  or  the 
parietal  regions.  When  thickening  of  the  meninges,  with  adhesions, 
takes  place  from  trauma,  there  is  constant  pain  with  frequent  exacer- 
bations, sensitiveness  of  the  head,  incapacity  for  study.  Uremic  head- 
ache is  not  constant.  Persistent  headache  may  be  present  in  the  latter 
stages  of  Bright' s  disease  and  in  diabetes.  In  atheroma  pain  in  a  part 
or  the  whole  of  the  head  is  common.  It  may  be  persistent,  though 
subject  to  exacerbations  in  case  of  excitement  or  violent  exercise. 
Headache  following  study,  in  children,  is  due  to  brain-strain,  to  eye- 
strain, or  to  indigestion.  Persistent  headache  is  sometimes  due  .  to 
asthma.  In  rare  instances  headache  is  said  to  be  idiopathic.  Neu- 
ralgic headaches  are  usually  periodic,  and  may  be  associated  with 
throbbings  or  pulsations.  They  are  associated  with  vasomotor  signs. 
Hysterical  headaches  are  irregular  and  shifting ;  they  persist  after  all 
causes  are  removed ;  they  are  replaced  by  pain  in  other  parts  of  the 
body.     They  are  usually  associated  with  other  manifestations  of  hysteria. 

Neuralgia. 

Neuralgia  is  characterized  by  pain  in  the  course  of  distribution  of  the 
affected  nerve.  The  pain  is  of  pronounced  severity,  and  occurs  in  re- 
missions and  intermissions.  The  symptoms  of  a  neuralgic  paroxysm 
may  be  preceded  by  hyperesthesia  over  the  part  subsequently  affected. 
The  pain  is  of  a  burning  or  shooting  character.  It  is  usually  limited 
to  the  distribution  of  the  affected  nerve,  but  may  extend  into  other 
regions.  It  may  be  excited  by  external  irritants,  by  mental  excite- 
ment, and  often  by  movement  of  the  part.  On  examination  the  area 
of  distribution  of  the  affected  nerve  may  be  found  to  be  anesthetic, 
but  usually  there  is  a  hyperesthesia  of  the  skin.  Wherever  the 
affected  nerve  is  accessible  to  pressure  pain  can  be  elicited.  The  nerve- 
trunk  may  be  tender  during  the  attack,  as  well  as  during  the  intervals. 
In  neuralgia  there  is  often  some  spasm  of  the  muscles  supplied  by  the 
nerve- 


THE  DA  TA  OB  TAINED  B  Y  INQ  UIR  Y.  53 

Vasomotor  symptoms  are  common.  The  skin  may  be  pale  or  red- 
dened. When  the  trigeminal  nerve  is  affected  the  skin  and  conjunc- 
tivae are  both  reddened.  The  secretions,  as  the  tears,  may  be  modified. 
Eruptions  like  urticaria  or  herpes  may  develop  along  the  course  of  the 
nerves.  Prolonged  neuralgia  may  cause  marked  nutritive  disturb- 
ances. 

General  Conditions.  A  patient  who  is  subject  to  neuralgia  may 
be  in  apparent  good  health.  The  neuralgia  may  be  due  to  constitu- 
tional causes,  as  rheumatism  or  gout ;  to  some  form  of  toxaemia,  as 
malaria  ;  to  some  condition  of  the  blood,  as  anaemia  ;  and  may  be  due 
to  trauma  or  to  cold. 

The  following  individual  forms  of  neuralgia  are  seen  :  1.  Neuralgia 
of  the  trigeminus,  or  tie  douloureux.  The  entire  fifth  nerve  or  some 
of  its  branches  are  affected.  The  pain  is  often  severe  and  may  be  asso- 
ciated with  twitchings,  with  vasomotor  disturbances,  with  eruptions, 
and  with  changes  in  the  secretions.  Trophic  changes,  as  the  hair  turn- 
ing gray,  or  ulceration  of  the  cornea  may  follow.  Usually  a  single 
branch  is  affected,  either  the  first  branch  (ophthalmic),  the  second 
branch  (supramaxillary),  or  the  third  branch  (inframaxillary).  Points 
of  pressure  are,  as  a  rule,  readily  detected  at  the  foramina  for  the  exit 
of  the  nerves.  2.  Occipital  neuralgia.  3.  Neuralgia  of  the  brachial 
plexus.  4.  Intercostal  neuralgia.  5.  Neuralgia  of  the  lumbar  plexus, 
of  which  we  have  lumbo-abdominal,  crural,  and  obturator  neuralgia. 
This  form  of  neuralgia  (lumbar  plexus)  must  not  be  confounded  with 
bone  and  joint  disease,  with  lumbago,  renal  colic,  appendicitis,  and  uterine 
affections.     6.  Sciatica.     7.  Genital  and  rectal  neuralgia. 

Trigeminal  neuralgia  must  be  distinguished  from  headache  due  to 
other  causes,  affections  of  the  bones  and  periosteum,  and  affections  of 
the  teeth.  The  distribution  and  paroxysmal  character  of  the  pain  and 
the  points  of  tenderness  assist  in  the  diagnosis. 

Pain  in  the  Legs  and  Feet. 

Paroxysmal  Pain.  Pain  in  one  leg  may  be  due  (1)  to  sciatic 
neuralgia  or  (2)  to  neuritis.  The  former  does  not  exhibit  localized 
tenderness  and  is  not  aggravated  by  movement.  The  latter,  also 
called  sciatica,  is  recognized  by  tenderness  in  the  course  of  the  sciatic 
nerve  or  at  its  exit  from  the  pelvis,  and  by  increase  in  the  pain  when 
the  limb  is  extended  by  forced  movement.  The  pain  is  constant,  worse 
at  night,  and  characterized  by  agonizing  paroxysms.  It  follows  ex- 
posure to  cold  or  may  be  caused  by  rheumatism.  One  of  the  many 
branches  of  the  sciatic  may  be  affected,  exhibiting  tenderness  in  its 
course.  If  the  sciatica  persists,  wasting  of  the  muscles,  herpetic  erup- 
tions, and  areas  of  anaesthesia  over  the  affected  leg  may  be  found. 
Such  neuritis  is  usually  traumatic  (cold),  alcoholic,  rheumatic,  gouty, 
or  syphilitic ;  the  exact  cause  in  each  case  must  be  ascertained  by  the 
associate  phenomena  and  by  the  exclusion  of  other  causes.  Pain  in 
the  leg  may  also  be  due  to  (3)  pressure  on  the  sciatic  nerve  by  a  pelvic 
growth,  (4)  neuroma,  (5)  rheumatism,  (6)  syphilis  of  bone  or  a  syphilitic 
gumma  of  muscle  or  connective  tissue. 


54  GENERAL  DIAGNOSIS. 

Fixed  pain  in  the  leg,  in  contradistinction  to  the  mobile  pains  of 
neuritis,  is  usually  situated  in  the  fasciae  or  muscles  or  in  the  bones. 
It  may  be  due  to  rheumatism,  when  the  pain  is  diffused  and  the 
nerve  points  of  tenderness  are  wanting.  It  may  be  the  result  of 
strain  or  injury,  a  history  of  which  must  be  carefully  inquired  for. 
The  latter  may  be  the  exciting  cause  only,  in  a  person  of  rheumatic 
diathesis,  the  fixed  pain  at  the  situation  of  the  injury  being  due  to 
rheumatism.  Fixed  traumatic  pains  are  usually  accompanied  by  ten- 
derness on  pressure,  and  aggravated  by  movement  both  active  and 
passive,  the  tenderness  on  pressure  not  necessarily  being  in  the  nerve- 
trunk.  In  malignant  disease  of  the  long  bones,  mobile  neuralgic-like 
pains  may  precede  for  some  time  the  fixed  pain  of  the  permanent  pro- 
cess.    (See  "  A  Case  of  Carcinoma  of  the  Bones,"  J.  H.  M.) 

Bilateral  pains  in  the  extremities  are  often  of  central  origin,  and 
may  be  due  to  spinal  sclerosis  ;  to  malignant  disease  of  the  vertebra 
pressing  on  the  cord  ;  to  pelvic  growth,  or  lumbar  abscess,  causing 
pressure  on  both  nerve-trunks  in  the  pelvis. 

Pains  of  the  feet  not  due  to  affections  of  the  large  nerve-trunks  are  : 

1.  Pain  in  the  Articulations  due  to  Flat-foot.  This  may 
be  in  the  tarsus  or  at  the  metatarsal  articulations.  It  is  a  common 
cause  of  pain  in  the  extremities,  and  may  be  unilateral  or  bilateral. 
Flat-foot  from  breaking  of  the  arch  can  readily  be  recognized  ;  pressure 
on  the  sole  of  the  foot  may  increase  the  pain. 

2.  Pain  in  the  Heel.  This  is  often  of  gouty  origin,  and  is  a  per- 
sistent source  of  complaint  in  many  instances. 

3.  Pain  in  the  Interosseous  Spaces  Between  Distal  Ends 
of  the  Third  and  Fourth  Metatarsal  Bones  (Morton's  painful 
affection  of  the  foot).  It  occurs  in  people  who  are  on  their  feet  a  great 
deal,  is  relieved  by  a  night's  rest,  increases  as  the  day  goes  on,  and  is 
increased  by  pressure  or  by  wearing  a  tight  shoe.  It  is  worse  in  wet 
and  cold  weather.  Localized  pressure  at  the  point  on  the  sole  indicated 
above  causes  extreme  pain. 

We  cannot  leave  the  extremities  without  a  word  regarding  pains  in 
the  extremities  of  distinctly  central  origin — the  forerunners  of  hemor- 
rhage into  the  brain.  Mitchell  has  called  attention  to  these  pains. 
They  occur  suddenly  without  evidence  of  local  disease ;  they  are 
located  in  one  of  the  extremities,  usually  the  leg,  are  excruciating, 
and  not  influenced  by  position,  local  applications,  or  pressure.  In 
a  patient  with  hard  arteries  and  high  pulse-tension  they  should  be 
looked  upon  with  suspicion. 

Pain  in  the  Arms. 

Unilateral  Pain.  It  may  be  due  (1)  to  neuritis  associated  with 
tenderness  of  the  nerve-trunk  ;  (2)  to  neuroma,  as,  indeed,  any  peripheral 
nerve  may  be  affected ;  (3)  to  simple  neuralgia  or  neuralgia  from  the 
pressure  of  enlarged  axillary  lymphatic  glands ;  of  a  morbid  growth 
of  an  aneurism  on  the  nerves ;  (4)  to  rheumatism  or  myalgia  ;  (5)  to 
bone  disease. 

Bilateral  pain  in  the  arms  is  of  central  origin,  due  to  diseases  of  the 


THE  DATA  OB  TAIN  ED  B  Y  INQ  UIR  Y.  55 

vertebra  or  of  the  spinal  cord,  or  neuralgic,  clue  to  anaemia  or  toxaemia 
of  some  form. 

Pains  of  the  Thorax. 

Painful  diseases  of  the  muscles  and  of  the  viscera  will  be  considered 
in  the  chapters  on  Diseases  of  the  Heart  and  Lungs.  Pains  of  reflex 
origin  will  be  referred  to.  They  are  usually  seated  in  the  shoulder  or 
the  back,  and  are  due  to  liver  or  gastric  disease.  The  pain  of  liver 
disease  is  referred  to  the  right  shoulder  ;  of  ulcer  of  the  stomach,  to 
the  interscapular  region  and  the  lumbar  region,  or  to  the  top  of  the 
shoulder,  as  in  a  case  observed  by  Wood. 

Pain  behind  the  sternum  is  often  a  reflex  neurosis  from  gastric  dis- 
order. It  may  occur  in  bronchitis.  It  may  also  be  due  to  cancer  of 
the  mediastinum,  to  aneurism,  or  angina.  Pain  in  the  sternum  or  ribs 
is  syphilitic  or  due  to  periostitis  or  necrosis  following  typhoid  fever, 
rarely  to  cancer.  Chronic  fibrous  inflammation  of  one  or  more  of  the 
attachments  of  the  muscles  is  of  common  occurrence.  The  pain  lasts 
for  years.  It  is  persistent,  sometimes  associated  with  stiffness  ;  it  is 
increased  by  movement,  and  there  may  be  extreme  aching  pains  in  the 
parts.  The  pain  of  vertebral  caries  transmitted  along  the  course  of 
the  nerve  has  been  referred  to. 

Girdle-pain.  This  is  a  peculiar  pain  or  sensation  in  the  trunk,  due 
to  disease  of  the  spinal  cord.  It  is  described  as  the  sensation  of  a  band 
drawn  tightly  around  the  body.  It  varies  from  a  simple  drawing 
sensation  to  extreme  pain  which  encircles  the  trunk.  It  is  situated 
above  the  level  of  the  umbilicus.  In  milder  forms  it  is  due  to  chronic 
myelitis  or  spinal  sclerosis  ;  in  severe  forms  to  inflammation  of  the 
nerve-roots,  or  to  cancerous,  syphilitic,  or  tubercular  disease  of  the 
meninges. 

Pain  in  the  Spine. 

Pain  in  the  spine  is  due  less  frequently  to  organic  disease  of  the  cord 
than  to  acute  or  chronic  inflammation  of  the  meninges,  to  disease  of  the 
bones  of  the  vertebral  column,  or  to  curvature  of  various  forms  from 
muscle-weakness.  FJiachialgia  and  tenderness  in  the  course  of  the 
spine  occur  after  concussion. 

I.  Disease  of  the  Spinal  Cord.  In  organic  disease  of  the 
cord  pain  may  be  referred  to  the  loins,  the  sacrum,  or  to  the  parts  about 
the  spine,  but  not  to  the  spinal  column  itself.  In  the  same  disease  of 
the  cord  we  may  have  also  the  eccentric  or  radiating  pains,  of  which 
mention  has  been  previously  made,  due  to  irritation  of  posterior  nerve- 
roots.  They  may  be  dull,  resembling  those  of  rheumatism.  In  acute 
cases  the  pains  are  accompanied  by  febrile  symptoms,  which  may  simu- 
late rheumatism,  especially  when  the  other  spinal  symptoms  are  in 
abeyance.  In  chronic  cases  these  peripheral  spinal  pains  are  influenced 
by  the  weather,  and  this  likewise  makes  it  difficult  to  distinguish  them 
from  rheumatism.  Rheumatic  pains  in  the  limbs  occurring  after  middle 
life,  with  or  without  joint-changes,  should  suggest  locomotor  ataxia. 


56  GENERAL  DIAGNOSIS. 

In  this  affection  sharp  and  darting  pains,  '  *  pain  crises,"  and  girdle 
sensations  occur. 

II.  Disease  of  Vertebrae.  Fixed  localized  pain  at  some  point 
in  the  vertebrae  points  to  traumatic,  syphilitic,  or  tubercular  caries,  or 
to  pressure  necrosis,  as  by  an  aneurism.  Pain  due  to  vertebral  dis- 
ease is  both  local  and  radiating.  It  is  increased  by  pressure  directly 
on  the  spinal  column  (on  the  head),  by  heat  or  by  cold,  or  by  electricity, 
applied  over  the  part.  It  is  relieved  by  removing  the  pressure  of  the 
weight  above,  as  by  raising  the  head  or  shoulders.  It  is  relieved  by 
the  absolutely  recumbent  posture.  With  this  pain  the  movements 
(flexibility)  of  the  spine  are  interfered  with,  because  of  spasm  of  the 
muscles  or  anchylosis  ;  there  may  be  deformity.  When  the  patient  is 
placed  upon  a  flat  surface  the  normal  lumbar  arch  is  changed. 

III.  Disease  of  Meninges.  Pain  due  to  meningeal  disease  is  local 
and  radiating.  It  is  associated  with  muscular  spasm  and  stiffness  of 
the  spinal  column. 

IV.  Spinal  Curvature.  The  pain  of  curvature  from  muscular 
weakness  extends  along  the  nerves.  The  patient  is  afebrile.  The  signs 
of  organic  disease  above  mentioned  are  absent,  but  muscle-weakness  and 
general  signs  of  debility  are  present.  Pain  in  the  spine  frequently  attends 
scurvy  and  rhachitis.  It  may  be  accompanied  by  paresis  of  the  muscles 
and  closely  simulate  an  organic  brain  or  cord  disease. 

Pain  in  the  Side. 

Pain  in  the  left  side — the  so-called  inframammary  pain — is  one  of 
the  most  frequent  complaints  heard  by  the  practitioner.  By  discussion 
of  it  we  can  show  how  the  symptom  pain,  wherever  situated,  must  be 
investigated  in  order  to  determine  the  tissue  affected  and  the  nature  of 
the  disease.  The  tests  used  in  the  study  of  nerve  affections  (q.  v.)  are 
not  given.  It  may  be  due  to  many  causes,  to  exclude  any  one  of  which 
inquiry  as  to  the  mode  of  onset,  duration,  and  character  of  the  pain 
must  be  made.  Then  the  structures  underneath  and  about  the  seat  of 
pain  must  be  examined.  1 .  The  skin :  to  exclude  any  swelling  or 
tumor  or  herpes  zoster,  and  to  determine  the  tender  nerve-points.  2. 
The  muscle  :  to  exclude  myalgia  or  pleurodynia.  Examine  for  tender- 
ness ;  note  the  effect  of  movement ;  does  full  breathing  increase  the 
pain  ?  Palpate  with  the  fingers  and  with  the  whole  hand.  Negative 
results  exclude  any  muscular  affection.  3.  The  nerves,  (a)  Tender 
points  ;  (6)  herpes  ;  (o)  the  vasomotor  appearance.  The  presence  of 
anaemia,  other  neuroses  and  neurasthenic  phenomena,  or  toxic  condi- 
tions, as  malaria,  lead,  or  gout,  lend  color  to  the  view  that  the  pain  is 
neuralgic.  4.  The  pleura.  Auscultate  for  friction  if  pleuritis.  In- 
quire for  cough.  Note  the  character  and  effect  of  breathing.  5.  The 
pericardium.  Note  friction  of  pericarditis  or  thrill  by  palpation.  Is 
the  heart  disturbed  in  function  '?  6.  The  heart.  It  is  rare  that  disease 
of  this  organ  causes  pain,  although  it  may  be  present  in  dilatation.  Is  it 
affected  in  a  reflex  manner,  causing  palpitation  or  irregularity  ?  Look 
for  distant  disease.     Angina  or  pseudo-angina  pectoris  may  be  present 


THE  DATA   OBTAINED  BY  INQUIRY.  57 

7.1  The  stomach  and  colon.  A  dilated  stomach  or  loaded  colon  may 
cause  pain  by  pressure  upward.  Gastralgia  may  also  be  the  cause.  8. 
The  spine.  Determine  if  it  is  diseased  or  if  there  is  pressure  by  an 
aneurism  or  a  mediastinal  growth.  If  a  local  cause  is  not  ascertained, 
look  for  a  central  or  reflex  disorder. 

Although  any  one  of  the  above  conditions  may  cause  pain  in  the 
side,  it  is  usually  (1)  a  reflex  pain  from  gastric  disorder ;  (2)  pain  from 
neuritis ;  (3)  a  true  neuralgia  from  anaemia ;  (4)  a  neuralgia  from  heart- 
fatigue.     (Hilton.) 

It  is  to  be  observed  that  every  local  tissue  must  be  examined,  and 
questions  asked  as  to  the  various  attributes  of  the  pain. 

Pain  in  the  Loins. 

When  acute,  without  fever,  pain  in  the  loins  may  be  due  to  lum- 
bago, to  a  sudden  uterine  retroversion,  to  a  suddenly  moved  kidney,  or 
to  calculus  of  the  kidney ;  with  fever,  acute  Bright's  disease,  smallpox, 
muscular  rheumatism,  tonsillitis,  influenza,  dengue,  or  spinal  meningitis 
must  be  looked  for. 

Chronic  Pain  in  the  Back  ;  Backache.  Backache  may  be  due  to 
many  causes.  When  in  the  region  of  the  kidneys,  they  may  be  at 
fault.  Organic  disease  (Bright's)  may  be  associated  with  backache ; 
more  frequently,  pain,  if  in  one  kidney,  is  due  to  a  calculus  or  to  accu- 
mulation of  uric-acid  gravel.  Pressure  over  the  kidney  or  a  sudden 
jar  from  a  false  step  will  usually  excite  the  pain.  It  may  be  constant 
in  moved  or  movable  kidney.  When  low  down,  just  above  or  over 
the  sacrum,  it  is  due  to  disturbance  of  the  pelvic  viscera.  The  uterus, 
the  colon,  and  rectum  (impacted,  cancerous)  must  be  examined 

Otherwise  we  may  have — (a)  Pain  due  to  affections  of  the  muscles. 
1,  Myalgia  of  rheumatic  origin.  Increased  by  movement,  by  damp- 
ness, by  pressure.  Often  relieved  by  warmth,  by  the  recumbent 
posture,  or  rest.  It  is  associated  with  symptoms  of  lithsemia  and  with 
the  passage  of  red  sand  in  the  urine.  When  the  fascia  or  the  ligaments 
of  the  vertebra?  are  affected,  the  upright  position  and  pressure  in  small 
areas  increase  the  pain  ;  other  muscles  may  be  affected  alternately.  2. 
Myalgia  from  sprain.  A  history  of  injury  is  obtained.  Usually  one  side 
is  larger  than  the  other.  Tenderness  is  present  and  movement  in- 
creases the  pain.  There  may  be  increased  swelling,  vasomotor  disturb- 
ance, or  ecchymoses.     A  neurosis  of  the  so-called  spinal  or  traumatic 

1  Shoulder-tip  pain,  due  to  anastomosis  of  phrenic  nerve  with  3d  and  4th  cervical 
and  to  parts  of  liver  and  round  ligament  i  Hilton )  ;  or  of  phrenic  nerve  and  subclavius 
(Rolleston)  ;  or  of  vagus  with  spinal  accessory,  which  communicates  with  3d  and  4th 
cervical.     The  v.  and  s.  a.  are  sensitive  to  pressure.      (Embleton.  ) 

Inframammary  pain  (6th,  7th,  and  8th  intercostal  spaces).  The  aorta  at  left  side, 
3d  dorsal  vertebra,  is  in  relation  with  the  4th,  5th,  and  6th  intercostal  nerves  through 
the  sympathetic  ganglia,  through  which  also  the  heart  ^ympathetics  are  in  anasto- 
mosis The  4th,  5th,  and  6th  intercostal  nerves  supply  cutaneous  branches  to  the 
6th,  7th,  and  8th  intercostal  spaces.  The  inframammary  pain  is  a  reflex  neuralgia 
expressive  of  some  heart-distress.  The  latter  is  brought  about  by  exhaustion  of  the 
medullary  and  vasomotor  centres,  from  worry  or  overwork,  or  from  long-continued 
irritation  of  the  uterine  nerves.  In  leucorrhoea  this  pain  is  most  common.  (Jacob- 
son :  Hilton  on  "Rest  and  Pain.") 


58  GENERAL  DIAGNOSIS. 

type  (hysteria)  attends  the  pain.  3.  Myalgia  from  fatigue.  Not  only 
acute  fatigue  after  exertion,  but  chronic  muscle-tire  (and  nerve-tire). 
The  pain  is  increased  on  exertion,  after  mental,  physical,  or  emotional 
effort.  Neurasthenia,  ancemia,  or  local  exhaustive  disease  (uterine, 
gastro-intestinal,  etc.)  are  present.  The  muscles  are  usually  flabby, 
and  the  vertebral  column  is  not  supported.  The  patient  lounges  or 
supports  the  back.     Spinal  curvatures  are  observed. 

(6)  Pain  due  to  affections  of  the  nerves.  Nerve-pain  is  recognized 
by  the  tender  points  ;  by  vasomotor  phenomena. 

(o)  Pain  due  to  disease  of  the  spine,  the  membranes,  or  the  cord. 
(See  above.) 


CHAPTER    V. 

THE  DATA  OBTAINED  BY  OBSERVATION. 

The  objective  symptoms  correspond  to  phenomena  in  nature.  Method  of  procedure; 
method  of  the  observer.  Inspection,  palpation,  percussion.  The  instruments 
required. 

The  Objective  Symptoms. 

The  objective  symptoms  of  disease  are  the  most  important  to  ascer- 
tain. They  are  the  "  handwriting  on  the  wall."  The  impress  of 
forces  for  good  or  evil  is  observed.  In  determining  them  we  deter- 
mine the  physical,  chemical,  and  vital  condition  of  the  organism  ;  its 
state  after  the  action  of  the  forces  of  its  environment.  The  physical 
and  mental  status  of  the  patient  is  measured.  He  is  individualized. 
The  objective  symptoms  are  data  by  which  a  complete  diagnosis  is 
made.  Without  such  data  the  diagnosis  is  mere  guesswork — one  of 
probability.  With  such  data  alone,  if  accurately  and  precisely  col- 
lected, a  positive  diagnosis  can  very  frequently  be  made.  A  correct 
diagnosis  depends  upon  the  skill  and  thoroughness  of  the  physician  and 
his  ability  to  interpret  the  data  secured,  always  provided  that  clear, 
succinct  data  can  be  obtained 

The  data  obtained  by  inquiry  are  carefully  recorded,  after  which  the 
following  procedure  is  conducted.  A  physical  examination  of  the 
patient  is  made,  followed  by  an  immediate  study,  or,  if  time  permits,  a 
study  at  leisure  of  the  fluids  of  the  body — microscopically,  chemically, 
and  bacteriologically.  In  the  physical  examination  we  make  a  general 
survey  of  the  individual,  and  form  an  estimate  of  his  height  and  weight. 
The  various  organs  and  tissues  are  interrogated  by  the  senses  appli- 
cable to  the  investigation  of  each,  aided  by  special  instruments.  The 
natural  secretions  and  discharges,  abnormal  discharges,  all  exudations 
or  transudations,  and  cystic  fluids  are  passed  upon. 

The  student  will  soon  learn  that  the  process  of  ascertaining  the  ob- 
jective signs  of  disease  is  in  no  respect  different  from,  that  which  obtains 
in  the  study  of  any  object  in  nature  or  any  like  phenomena.  The 
chemist  notices  the  form,  the  color,  the  density,  etc.,  of  the  object 
under  examination  ;  the  effects  of  heat  and  cold,  of  various  reagents 
upon  its  structure  ;  he  determines  its  component  parts  and  ascertains 
its  relation  to  other  objects  in  nature.  From  data  thus  obtained  by 
the  use  of  all  his  senses  he  classifies  the  object.  The  biologist  notes 
not  only  the  physical  appearance  of  a  given  form  of  life,  but  also  the 
phenomena  of  the  living,  sentient  matter  under  all  conditions  in  a 
varied  environment.  By  comparison  and  analysis  the  living  being  is 
classified. 


60  GENERAL  DIAGNOSIS. 

By  the  same  powers  of  observation  and  the  same  analytical  process, 
the  departures  from  health  are  recognized  and  classified.  Is  it  not, 
therefore,  a  wonderful  aid  to  the  diagnostician  to  possess  faculties 
which  have  been  trained  to  minute  observation  by  previous  studies  in 
sciences  allied  to  medicine  "? 

W  hat  has  been  thus  imperfectly  said  is  intended  to  emphasize  the 
fact  that  no  mystery  attends  the  recognition  of  the  objective  signs  of 
disease.  Abundant  opportunities  of  observing  disease  at  the  bedside, 
patient  training,  skill  in  technique,  and  a  systematic  procedure  are 
essential. 

Method  of  Procedure. 

The  method  by  which  the  data  ascertained  by  observation  are  secured 
is  modified  by  the  circumstances  under  which  the  patient  is  seen.  It 
is  obvious  that  the  patient  who  comes  to  the  office,  or  is  not  sufficientlv 
ill  to  be  in  bed,  has  sufficient  strength  to  stand,'  and  should  be  given 
an  exhaustive  examination.  Moreover,  we  can  inquire  into  certain 
abnormalities,  as  the  gait,  not  visible  in  bed.  On  the  other  hand,  in 
the  case  of  a  bed  patient,  we  learn  the  position  he  assumes  when  lying 
down,  and  have  better  opportunities  for  thorough  examination  of  the 
various  organs.  Often  the  objective  examination  must  be  very  brief, 
on  account  of  the  patient's  extreme  illness.  It  may  be  advisable, 
although  unfortunate,  to  exclude  one  or  more  methods,  as  percussion, 
if  there  is  pain,  or  auscultation,  if  there  is  great  restlessness  or  orthopnoea. 

If  a  complete  examination  is  made,  it  is  well  to  begin  with  the 
exterior.  After  the  external  examination  is  made,  the  internal  exami- 
nation is  conducted,  by  grouping  together  and  examining  organs  func- 
tionally related,  as  the  heart  and  bloodvessels,  in  diseases  of  the  heart  ; 
the  nose,  larynx,  and  lungs,  in  diseases  of  the  latter.  The  student  will 
do  well  to  begin  at  the  head  and  take  up  the  organs  in  their  continuitv. 

Compaeisox.  The  results  obtained  by  observation  are  based  upon 
comparison  ;  the  student  must  bear  this  constantly  in  mind.  AVe 
compare  the  body  as  a  whole  with  our  conception  of  the  normal  indi- 
vidual, formed  by  a  study  of  a  large  number  of  persons.  We  compare 
symmetrical  parts— the  right  side  of  the  chest  with  the  left,  the  arm 
suspected  to  be  the  seat  of  the  disease  witli  the  healthy  arm,  etc.  The 
cardinal  rule  in  an  examination  ls  to  base  the  significance  of  ascertained 
facts  upon  comparison  with  known  normal  conditions. 

Methods  of  Observation. 

Securing1  the  Data.  To  accomplish  these  ends,  examination  is 
made  by  the  sense  of  sight  (inspection)  ;  by  the  sense  of  touch  (palpa- 
tion) ;  by  the  sense  of  hearing  (auscultation)  ;  and  by  the  sense  of  hear- 
ing applied  to  the  discrimination  of  sounds  developed  by  percussion. 
By  percussion  or  tapping  the  part  we  also  elicit  the  peculiar  phenom- 
ena known  as  reflexes. 

The  sense  of  taste  is  not  used  to  determine  the  objective  phenomena 
of  disease.  Some  data,  such  as  the  odor  of  the  exhalations  and  dis- 
charges, are  obtained  by  the  sense  of  smell. 


THE  DATA  OBTAINED  BY  OBSERVATION.  61 

Inspection.  By  inspection  we  judge  of  the  physical  condition  of 
the  whole  or  a  part  of  the  body,  as  seen  in  the  shape  and  size  and  in 
the  color ;  of  the  vital  condition,  by  the  expression  of  countenance,  by 
the  character  of  the  movements  of  the  body  as  a  whole  or  in  part,  by 
the  position  in  bed,  and  by  the  gait.  The  appearance  of  fluids  (blood) 
and  of  discharges  is  also  observed.  The  results  of  inspection  as  to  size 
are  confirmed  by  actual  weighing. 

In  order  that  the  data  obtained  by  inspection  may  be  complete  and 
accurate,  every  portion  of  the  body,  and  of  its  internal  cavities  which 
can  be  seen  by  the  unaided  or  aided  eye,  should  be  inspected.  The 
clothing  should  be  removed,  and,  bearing  in  mind  the  proprieties,  the 
whole  body  should  be  examined.  For  this  purpose  the  patient  should 
be  under  a  good  light.  The  light  should  always  fall  directly  on  the 
surface.  The  entire  surface,  of  course,  need  not  be  exposed  at  once, 
and  circumstances  may  be  such  that  only  one  portion  need  be  exam- 
ined. Nevertheless,  the  fact  must  be  insisted  upon  that  patients  who 
have  been  ill  for  a  considerable  time,  as  well  as  all  grave  cases,  should 
be  examined  all  over.  It  is  even  more  important  to  do  this  if  the 
patient  is  comatose.  A  node  on  the  tibia,  undue  prominence  of  the 
vertebrae,  a  special  rash  about  the  anus,  may  afford  information  which 
could  not  be  obtained  in  any  other  way.  It  is  assumed  that  the  patient 
has  been  examined  lying  down.  In  nervous  diseases  and  diseases 
affecting  the  muscles  and  bones,  the  patient's  gait,  his  ability  to  stand, 
the  method  of  rising  or  assuming  a  sitting  posture,  and  the  performance 
of  other  customary  physiological  acts  should  be  observed.  For  this 
purpose,  as  above  mentioned,  portions  of  the  body  can  be  covered,  or  a 
light  gown  thrown  over  the  patient  from  head  to  foot. 

Method  of  the  Observer.  In  order  to  secure  the  data  in  full, 
the  student  should  teach  himself  a  method  of  observation  by  which  all 
the  facts  are  collated  in  regular  systematic  order.  AVhether  the  exam- 
ination is  general  or  local,  whether  the  whole  of  the  body  is  referred  to 
or  only  a  part,  as,  for  instance,  the  nose,  the  student  should  accustom 
himself  to  make  observations  in  the  following  order  :  First,  the  shape 
or  contour  (expression) ;  second,  the  size  ;  third,  the  color  ;  fourth,  the 
movability  and  the  physiological  condition  of  the  part  on  movement. 
If  this  plan  is  pursued,  little,  if  anything,  will  be  overlooked.  A  simi- 
lar order  should  be  followed  in  the  investigation  of  the  character  of  the 
secretions  and  excretions  of  the  body. 

Inspection  of  Special  Regions.  In  the  inspection  of  special 
regions  artificial  light  and  special  instruments  are  also  required.  The 
artificial  light  should  be  secured  from  an  Argand  or  TTelsbach  burner, 
or  from  a  gas-jet  with  a  reflector,  or  from  electricity.  To  facilitate  the 
examination  the  room  should  be  darkened  and  head-mirrors  used  as 
reflectors.  A  number  of  these  have  been  devised,  any  one  of  which  is 
suitable  if  it  fits  the  head  well  and  can  be  adjusted  with  comfort,  so  that 
the  observer  can  throw  the  light  on  the  part  he  wishes  to  examine,  and, 
at  the  same  time,  peer  through  the  centre  of  the  mirror.  A  special 
arrangement  of  the  patient  and  the  light  is  required.  The  patient 
should  sit  in  an  easy,  comfortable,  erect  position,  with  the  light  on  a 
level  with  the  part  to  be  examined,  a  little  behind,  and  to  his  right  or 


62  GENERAL  DIAGNOSIS. 

left,  according  to  the  convenience  of  the  examiner.  Special  apparatus 
is  required  for  the  examination  of  each  cavity  :  mirror,  tongue- 
depressor,  and  specula  for  the  throat,  an  ophthalmoscope  for  the  eye, 
etc.     (See  respective  sections.) 

Palpation.  The  results  of  inspection  are  confirmed,  when  possible, 
by  palpation,  and  the  sense  of  touch  supplies  additional  data.  The 
nutrition  of  the  parts  is  ascertained.  The  density,  the  resistance,  the 
special  character  of  the  part,  whether  solid  or  liquid,  are  determined  by 
this  method  of  examination.  On  examination  of  the  skin,  the  degree 
of  dryness  or  moisture,  the  character  of  the  skin,  whether  smooth  or 
rough,  the  density  of  the  part — as  to  degree  of  thickness  and  resist- 
ance— are  all  ascertained  by  means  of  the  sense  of  touch.  The  pres- 
ence or  absence  of  pitting  is  observed,  and  the  nature  of  swellings 
ascertained.  In  a  similar  manner  local  areas  are  examined.  The 
same  routine  method  should  become  habitual  with  the  student.  First, 
the  shape  and  contour  ;  second,  the  size  ;  third,  the  color,  its  change 
on  pressure,  etc.  ;  fourth,  the  movability  of  the  part,  and  the  character 
of  the  normal  movements,  as  when  a  joint  is  under  observation  ;  fifth, 
the  resistance  and  density  of  the  part  examined,  or  special  characteris- 
tics revealed  by  touch — the  elasticity  of  the  skin,  firmness  of  muscles, 
and,  in  swellings,  the  presence  or  absence  of  fluctuation.  Other  phe- 
nomena are  detected,  which  are  vital,  in  contrast  to  the  above,  which 
are  physical.  By  palpation,  alone  or  with  instruments,  we  determine 
the  sensibility  of  the  part,  the  presence  or  absence  of  tenderness,  the 
temperature,  and  the  degree  of  moisture.  In  the  examination  of  special 
regions  by  means  of  palpation  some  phenomena  are  determined  pecu- 
liar to  the  system  under  examination,  and  dependent  upon  its  physio- 
logical or  functional  action.  Thus,  in  palpation  of  the  chest,  in  addi- 
tion to  its  movement,  we  note  the  vibrations  transmitted  to  the  hand 
when  the  patient  is  asked  to  speak,  or  detect  abnormal  vibrations  from 
the  friction  of  two  rough  surfaces  together  (pleura),  or  from  the  throw- 
ing of  fluids  into  agitation  :  fremitus,  friction,  and  rales  are  thus  trans- 
mitted. 

Knowledge  of  the  action  of  the  heart  and  of  its  position  is  obtained 
by  palpation ;  thrills  are  detected,  abnormal  impulses  felt.  (For 
method  of  procedure,  see  respective  organs.) 

Auscultation.  By  auscultation  we  hear  and  analyze  the  sounds 
that  attend  respiration,  the  movements  of  the  heart  and  of  the  blood  in 
the  bloodvessels.  Abnormal  sounds  may  be  created  in  the  pleura  and 
pericardium — and  in  hollow  viscera,  as  the  oesophagus,  stomach,  and 
intestines — and  their  presence  is  likewise  ascertained  by  auscultation. 
(See  Diseases  of  the  Lungs  and  Heart.)  The  character  of  the  voice  as 
to  the  quality  and  degree  of  loudness  is  studied  to  determine  abnormal- 
ities in  the  respiratory  tract  or  any  speech  defects  of  central  or  periph- 
eral origin. 

Percussion.  By  percussion,  sounds  are  elicited  which  indicate  the 
physical  condition  of  the  part  percussed.     In  health  the  lungs  and  the 


THE  DATA  OBTAINED  BY  OBSERVATION.  63 

gastrointestinal  tract  contain  air  in  certain  proportions,  and  therefore 
the  sounds  yielded  by  percussion  are  always  of  a  known  character. 
Any  change  from  the  normal  sound  is  indicative  of  disease,  of  abnor- 
mal structure,  or  of  alterations  in  the  normal  relations  of  the  parts. 
Percussion  determines  these  changes,  and,  in  addition,  enables  us  to 
estimate  the  size  of  organs.  It  is  possible  to  determine  the  size  of  the 
liver,  the  heart,  or  the  spleen,  because  of  the  relationship  of  these 
airless,  non-resonant  bodies  to  the  air-containing  structures  around 
them.  As  this  method  of  securing  data  is  of  the  greatest  use  in  pul- 
monary and  abdominal  diseases,  the  mode  of  procedure  will  be  described 
in  the  chapters  on  Diseases  of  the  Lungs  and  Abdomen. 

Other  Methods  to  Secure  Data.  In  addition  to  the  data  obtained 
by  the  above  methods,  valuable  and  essential  data  are  obtained  by 
chemical,  microscopical,  and  bacteriological  examinations  of  the  fluids, 
discharges,  exudations,  and  transudations,  and  by  aspiration  and  special 
examination  of  the  fluids  obtained  from  the  natural  cavities,  or  from 
cysts  of  the  body.  Bacteriological  diagnosis  and  exploratory  puncture 
will  be  considered  in  a  special  chapter. 


CHAPTER    VI. 

THE  DATA  OBTAINED  BY  OBSERVATION— (Continued). 

The  first  sight  impressions.  General  abnormal  vital  conditions.  Fits  or  seizures. 
Coma.  Collapse.  Shock.  1.  The  personal  appearance.  2.  The  apparent  age. 
3.  The  temperament  and  constitution.  4.  The  attitude  and  gait.  5.  The  general 
form  and  nutrition.     The  size — enlargement,  diminution.     The  weight. 

GENERAL  EXAMINATION  OF  THE  EXTERIOR. 

The  general  appearance  of  the  patient  affords  an  idea  of  the  ability 
he  has  to  cope  with  the  antagonistic  forces  of  his  environment,  or  to 
overcome  the  deleterious  effects  of  his  occupation.  It  indicates  the 
effect  of  present  or  past  disease  or  of  inherited  disease.  The  first  sight, 
striking  impression,  is  always  to  be  noted.  "  Very  sick,"  '.'  coma- 
tose," "  collapsed,"  etc.,  or  "  robust,"  "  cyanosed,"  etc.,  are  speaking 
memoranda.  To  the  experienced  practitioner,  the  opinion  formed  at 
first  glance  is  often  of  great  diagnostic  significance.  It  may  happen 
that  the  patient  is  suffering  from  some  unusually  abnormal  vital  con- 
dition, a  study  of  which  must  be  made  before  the  exhaustive  survey  of 
the  case  we  are  about  to  enter  upon  is  conducted. 

General  Abnormal  Vital  Conditions.  Impairment  of  conscious- 
ness and  fits  are  readily  recognized.  The  two  often  go  hand-in-hand, 
but  in  some  instances,  as  in  fainting-fits,  consciousness  is  not  lost. 
The  following  list  includes  the  various  forms  with  their  associate  phe- 
nomena. Only  those  are  mentioned  which  occur  instantaneously.  For 
their  symptomatology  and  diagnosis  the  appropriate  sections  on  special 
diagnosis  must  be  consulted. 

1.  Unconsciousness,  a.  Syncope.  The  face  is  pale  but  calm,  the 
pulse  feeble  or  imperceptible,  the  extremities  cool  ;  nausea  or  hurried 
breathing  may  precede.  The  breathing  is  quiet  in  the  attack.  The 
pupils  respond  to  light.     Xo  pain.     (See  Heart  Disease.) 

b.  Cekebbal  Disease.  (Spasm  is  sometimes  associated.)  Head- 
pain,  congested  face,  hemiplegia,  facial  palsies,  pupils  irregular  and 
irresponsive,  cornea  not  sensitive,  incontinence  of  urine. 

c.  Intoxications.  Alcohol,  opium,  and  other  narcotics ;  uraemia, 
diabetes,  toxsemia  from  infections,  sunstroke. 

2.  Fits.  a.  Epilepsy.  (1)  "Hautmal:"  aura,  convulsions  ;  (a) 
tonic,  respiratory  muscles  affected,  face  livid,  stupor  afterward  ;  (6) 
clonic,  tongue  bitten,  stupor  follows.  (2)  "  Petit  mal  :"  pallor  sudden, 
no  convulsions. 

b.  Infantile  Convulsions.  Usually  reflex  from  indigestion ; 
may  be  the  onset  of  a  specific  fever  or  due  to  high  temperature. 


THE  DATA  OBTAINED  BY  OBSERVATION.  65 

c.  Puerperal  Convulsions.  Headache,  amaurosis,  oedema,  sup- 
pressed and  albuminous  urine  ;  clonic  convulsions,  tongue  bitten,  com- 
plete coma.     (See  Uraemia.) 

d.  Uraemia.  Unilateral  or  bilateral  clonic  convulsions. .  (See  Renal 
Disease.) 

e.  Alcoholism  and  Sunstroke. 

/.  Organic  Brain  Diseases  (syphilis,  tumor,  softening,  etc.). 

g.  Fits  with  Partial  or  no  Loss  of  Consciousness.  Hystero- 
epilepsy,  focal  or  Jacksonian  epilepsy,  hysteria,  cerebral  embolism, 
thrombosis,  or  hemorrhage,  spasms  of  various  kinds. 

h.  Fits  with  Vertiginous  Movement.  The  forms  of  vertigo  are 
gastric,  aural,  and  labyrinthine  (Meniere's,  also  paroxysmal),  ocular, 
cerebellar,  from  congestion  of  the  brain  (reflex),  epileptic. 

3.  Collapse.  Collapse  may  occur  in  a  person  in  apparent  health 
and  be  the  first  indication  of  disease,  as  in  rupture  of  a  large  blood- 
vessel causing  internal  hemorrhage.  Or  it  may  occur  in  the  course  of 
disease,  as  typhoid  fever,  when  intestinal  hemorrhage  takes  place. 

The  symptoms  are  those  of  prostration,  with  partial  loss  of  con- 
sciousness, or  the  mind  is  perfectly  clear.  The  face  is  pale,  pinched, 
and  bathed  with  perspiration.  (See  Hippocratic  Facies.)  The  skin  i;j 
cool  and  clammy.  The  hands  are  cold.  The  skin  is  wrinkled.  The 
eyes  are  sunken  and  encircled  by  dark  rings.  The  voice  is  weak  or  sup- 
pressed. The  pulse  is  rapid  and  thready,  or  may  be  absent  at  the 
wrists.  The  heart-sounds  are  indistinct.  The  temperature  falls.  The 
respiration  may  be  hurried  or  shallow,  sighing  and  gasping.  The 
urine  is  scanty  or  may  be  absent.  Collapse  is  due  to  hemorrhage,  ex- 
ternal or  internal ;  to  perforation  of  abdominal  viscera ;  to  peritonitis ; 
to  excessive  watery  discharge,  as  in  cholera  or  serous  purging.  It  may 
be  due  to  pernicious  malarial  fever.     Coma  attends  this  form. 

4.  Shock  is  a  condition  in  which  the  vital  powers  are  blunted  or 
stunned,  with  or  without  mental  terror  or  anxiety.  It  is  likely  to  be 
seen  in  injury,  surgical  operation,  hemorrhage,  angina  pectoris,  severe 
pain  from  any  cause,  any  sudden  cerebral  or  spinal  lesion,  undue 
mental  and  emotional  strain.  Its  presence  points  to  a  grave  ante- 
cedent condition,  near  or  remote.     The  symptoms  are  those  of  collapse. 

Location  of  Disease.  A  general  view  of  the  exterior  will  often 
indicate  which  system  is  the  probable  seat  of  the  disease.  For  instance, 
violent  respiratory  action  points  to  the  lungs  ;  paralysis,  to  the  nervous 
system ;  the  enlarged  abdomen,  to  disease  of  the  viscera  in  that  region. 
The  apparently  hasty  view  has  already  given  the  practitioner  much 
information. 

We  then  note  with  more  deliberation  (1)  the  personal  appearance  ; 
(2)  the  apparent  age  ;  (3)  the  temperament  and  constitution  of  the 
patient  or  the  evidence  of  any  diathesis  or  cachexia  ;  (4)  the  position 
assumed  in  standing,  walking,  or  in  bed  ;  (5)  the  general  form  and 
nutrition. 

1.  The  Personal  Appearance. 

From  the  general  appearance,  the  patient's  habits  as  to  industry, 
neatness,  or  care  of  dress  may  be  observed  ;  these  habits  are  of  diag- 


66  GENERAL  DIAGNOSIS. 

nostic  importance,  particularly  in  brain  affections.  The  appearance 
also  shows  frequently  whether  the  patient  is  addicted  to  alcohol  or  to 
the  use  of  narcotics.  Moreover,  the  slit -boot,  to  relieve  the  swelling  of 
gout,  the  loosely  fastened  boots  from  swollen  ankles,  the  unduly  worn 
sole  as  in  spastic  paralysis,  the  unbuttoned  waist-band  because  of  dropsy 
or  increased  weight,  the  stained  trousers  from  drops  of  urine,  are  seem- 
ing trifles,  but  of  diagnostic  value. 

The  occupation  of  the  patient  is  often  important  in  throwing  light 
upon  his  disease  ;  the  brown,  weather-beaten  face  of  the  farm  laborer, 
sailor,  or  driver  contrasts  strongly  with  that  of  the  merchant,  clergy- 
man, or  clerk.  A  machinist  can  often  be  recognized  by  his  grimy,  oily 
hands.  All  this  information  can  be  obtained  at  a  glance,  and  many 
details  can  be  added  before  the  patient  has  taken  his  seat  in  the  con- 
sulting-room. 

2.   The  Apparent  Age. 

The  apparent  age  of  the  patient  should  be  estimated  from  his  appear- 
ance, and  compared  with  the  exact  age  when  this  is  learned  later.  In 
this  way  the  physician  will  be  able  to  judge  whether  the  patient  is 
aging  too  rapidly  or  bearing  his  age  well.  An  obvious  advantage  of 
noting  the  patient's  age  is  that  it  enables  us  at  once  to  exclude  a  large 
number  of  diseases  which  are  not  found  in  the  period  of  life  to  which 
the  patient  belongs.  For  example,  if  the  patient  is  a  child,  we  need 
not  consider  the  chronic  degenerations  and  the  visceral  cirrhoses  which 
appear  in  middle  and  later  life.  Conversely,  in  an  old  person  we  do 
not  expect  to  meet  with  the  exanthemata  which  affect  children  almost 
exclusively.  So,  too,  typhoid  fever  and  pulmonary  tuberculosis  are 
more  common  in  adolescence  and  early  manhood  than  in  childhood  and 
old  age.  Again,  in  very  young  girls,  the  question  of  menstruation  and 
its  difficulties  never  have  to  be  considered.  Gray  hair  in  a  person 
under  thirty-five  generally  indicates  a  feeble  constitution  and  prema- 
ture age.  Loss  of  hair  is  not  significant,  for,  apart  from  a  tendency  to 
baldness  which  is  very  marked  in  some  families,  professional  men  who 
do  much  brain-work,  especially  in  hot,  close  rooms,  are  apt  to  become 
bald  much  sooner  than  other  men.  The  presence  of  icrinkles  at  the 
corners  of  the  eyes  and  of  "  crow's  feet,"  and  of  dull,  dry,  lustreless 
eyebrows,  should  be  noted  as  indicating  aging,  whether  the  person  has 
lived  long  or  not.  In  women  approaching  forty,  who  do  not  gam  in 
flesh,  there  is  often  a  suggestive  prominence  of  the  angles  of  the  jaw 
and  sternomastoid  muscles,  with  a  certain  loss  of  roundness  and  elas- 
ticity of  the  cheeks.  The  latter  appearance,  however,  may  be  due  to 
loss  of  molar  teeth. 

3.  The  Temperament  and  Constitution  of  the  Patient. 

In  former  times  emphasis  was  laid  upon  appearances  which  pointed 
to  a  particular  diathesis  or  type  of  inherited  constitution.  Five  varie- 
ties of  diathesis  were  described  to  which  general  appearances  pointed. 
They  were  the  gouty  or  sanguine-arthritic,  the  strumous,  the  nervous, 
the  bilious,  and  the  lymphatic.    While  certain  appearances  point  to  the 


THE  DATA  OBTAINED  BY  OBSERVATION.  67 

occurrence  of  groups  of  individuals  who  may  be  classified  under  one  of 
these  diatheses,  it  is  well  not  to  lay  too  much  stress  upon  them  for 
diagnostic  purposes.  As  pointed  out  by  Gairdner,  it  is  not  proper  to 
designate  the  diathesis  off-hand.  Individual  appearances  should  be 
carefully  noted,  so  that  only  after  the  completed  examination  a  final 
conclusion  as  to  the  diathesis  can  be  drawn. 

In  the  gouty  or  sanguine  diathesis  the  osseous  system  and  muscles 
are  well  developed,  the  nutrition  active,  and  the  patient  usually  robust 
in  appearance.  The  digestion  is  good,  respirations  deep,  the  circula- 
tion is  well  carried  on  (as  shown  by  the  florid  skin  and  the  large  heart), 
the  pulse  is  firm  and  steady,  and  the  pressure  in  the  arteries  is  high. 
The  head  is  large  and  the  jaw  prominent,  the  teeth  good.  The  hair  is 
of  strong  growth.  The  individual  with  such  diathesis  is  predisposed 
to  the  arterial  changes  of  advancing  age.  Apoplexy,  aneurism,  and 
angina  pectoris,  or  complications  resulting  from  the  senile  changes  in 
the  heart  and  arteries,  develop. 

In  the  strumous  diathesis  the  bones  and  the  glandular  system  are 
changed  and  the  appearance  of  the  face  is  expressive  ;  the  bones  of 
the  chest  are  small ;  the  long  bones  are  slender,  while  their  epiphyses 
are  large  ;  the  forehead  is  broad  and  prominent,  the  lips  full,  the  ala? 
nasi  thick,  the  teeth  are  carious,  the  lower  jaw  light  and  thin,  the  hair 
is  fine  and  often  of  a  light  hue,  the  eyelashes  long,  the  eyebrows  arched, 
often  heavy.  In  this  diathesis  the  nutritive  changes  are  poor,  inflam- 
mations are  usually  sluggish  ;  disease  of  the  bones,  of  the  glands,  and 
forms  of  tuberculosis  are  apt  to  be  more  severe. 

In  the  nervous  diathesis  we  see  small,  active,  restless  beings,  with 
small  bones  and  large  muscles.  They  are  full  of  energy,  and  carry  on 
large  business  or  mental  operations.  The  features  are  well  formed,  the 
eyes  active.  Such  types  readily  become  the  victims  of  overwork  and  of 
early  breaking-down  of  the  nervous  system  and  of  dyspepsia.  They 
possess  idiosyncrasies  toward  drugs,  particularly  opiates. 

In  persons  of  the  bilious  diathesis  we  find  a  dark  skin,  dark  hair, 
muddy  conjunctiva?.  They  are  usually  not  well  nourished.  Their 
digestion  is  poor,  and  they  are  subject  to  attacks  of  so-called  bilious- 
ness.    Sick  headaches  are  common.     Fatigue  is  not  borne  well. 

In  the  lymphatic  diathesis  there  is  lack  of  energy  and  sluggishness  of 
nutritive  processes  ;  such  persons  are  unable  to  keep  up  in  the  wear 
and  tear  of  life.     They  are  usually  pallid  and  have  soft  muscles. 

In  addition  to  diathesis,  cachexke  are  also  noted.  Cachexia?  arise 
from  the  ravages  of  disease,  especially  when  the  number  of  the  red 
cells  of  the  blood  is  reduced  and  the  haemoglobin  diminished.  Cachexia? 
are  caused  especially  by  syphilis,  gout,  and  chronic  malarial  poisoning. 
In  cancer  of  some  part  of  the  digestive  apparatus — and,  indeed,  in  all 
forms  of  chronic  disease  of  the  digestive  tract — a  cachexia  is  seen. 
The  anaemia  from  poisoning  with  lead,  arsenic,  and  other  metallic 
poisons  produces  an  appearance  to  which  the  term  cachexia  has  been 
applied,  although  in  truth  it  only  resembles  one.  Each  form  of 
cachexia  takes  its  name  from  its  cause,  as  the  syphilitic  or  the  cancer- 
ous cachexia. 


68  GENERAL  DIAGNOSIS. 

4.  The  Attitude  and  Gait  of  the  Patient. 

The  attitude  of  the  patient  gives  information  as  to  his  physical  vigor, 
and,  to  a  certain  extent,  of  his  alertness  of  mind.  A  man  vigorous  of 
mind  and  body  will  stand  firmly  upon  both  feet,  with  back  straight, 
shoulders  square,  and  head  erect.  When  one  is  depressed  by  care -or 
disease  the  shoulders  have  a  tendency  to  droop  and  the  head  to  fall 
forward.  Indecision  and  a  vacillating  disposition  are  sometimes  indi- 
cated by  the  patient  standing  first  on  one  foot  and  then  upon  the  other 
while  talking,  or  by  an  unsteady  look  from  the  eye. 

When  one  shoulder  is  lower  than  the  other  and  the  patient  is  of 
phthisical  build,  pale,  and  emaciated,  the  attitude  is  strongly  suggestive 
of  phthisis  or  chronic  pleurisy  on  the  side  on  which  the  shoulder  is 
depressed.  Sometimes,  in  acute  pleurisy,  the  patient  will  walk  with 
the  shoulder  depressed  and  the  arm  firmly  pressed  against  the  affected 
side,  so  as  to  restrict  its  movements  as  much  as  possible. 

Decubitus.  The  attitude  of  the  patient  in  bed  is  often  significant. 
He  may  assume  the  active  dorsal,  or  the  side  j^osition,  with  the  body 
arranged  so  that  it  is  comfortable  and  unconstrained.  Then  slight  in- 
disposition only  is  present.  On  the  other  hand,  the  side  position,  the 
dorsal  position,  or  the  upright  or  semi-upright  position  may  be  assumed. 

To  the  close  observer  the  attitude  of  a  patient  in  bed  is  sometimes 
reassuring.  He  lies  easily  upon  his  back,  or  turned  slightly  to  one 
side  with  the  arms  uncovered,  and  may  even  turn  or  sit  up  to  meet 
the  physician  as  he  enters  the  room — all  these  signs  point  to  moderate 
illness  or  to  the  approach  of  convalescence. 

Side  Position.  A  patient  with  acute  pleurisy  or  pneumonia  will 
lie  on  the  affected  side  so  as  to  limit  its  motion  as  much  as  possible. 
The  breathing  will  be  shallow  and  frequent,  the  expression  of  the  face 
anxious,  and  occasionally  a  spasm  of  pain  contracts  it  as  the  patient 
coughs  or  is  obliged  to  take  a  full  breath.  He  usually  lies  on  the 
affected  side  because  fixation  is  thus  secured  and  pain  on  inspiration  is 
diminished,  and  also  because  there  is  a  greater  liberty  for  expansion  of 
the  free,  healthy  side.  If  effusions  are  present,  by  lying  on  the  side  of 
the  effusion  pressure  is  removed  from  the  heart  and  the  unaffected 
lung,  an  obvious  advantage. 

At  times,  in  case  of  thoracic  aneurism,  if  situated  on  one  side,  or  of 
movable  thoracic  tumors,  the  patient  will  lie  on  the  side  which  is  the 
seat  of  the  disease. 

The  dorsal  position,  as  assumed  in  health  or  slight  disease,  has 
been  referred  to.  When  the  position  is  assumed  in  grave  disease  it  is 
called  passive  dorsal,  because  it  is  often  assumed  without  volition  of 
the  patient. 

In  grave  cases  of  typhoid  or  other  low  fevers  the  patient  lies  upon 
the  back  and  shows  a  marked  tendency  to  slip  down  in  the  bed.  The 
expression  of  the  face  is  heavy  or  vacant.  The  lips  and  teeth  require 
constant  cleansing  to  keep  them  from  sordes  ;  the  tongue  is  dry  and 
glazed  or  covered  with  sordes  ;  the  tendons  of  the  wrists  twitch  convul- 
sively, and  the  patient  lies  with  open  or  half-open  eyes  (coma  vigil),  pick- 
ing at  the  bedclothes  or  at  imaginary  objects  which  float  before  his  eyes. 


THE  DATA  OBTAINED  BY  OBSERVATION.  69 

A  healthy  baby  a  few  months  old  finds  motion  an  almost  ceaseless 
delight.  It  will  lie  on  its  back,  kick  np  its  feet,  play  with  its  toes  or 
some  object  that  attracts  it,  crowing,  wriggling,  squirming.  In  rickets, 
on  the  contrary,  the  little  patient  lies  as  quiet  as  possible,  even  refrain- 
ing from  crying,  because  all  motion  is  painful.  In  cerebrospinal  men- 
ingitis the  head  is  drawn  backward  and  downward  and  the  muscles  at 
the  back  of  the  neck  are  rigidly  contracted. 

In  acute  disease  involving  the  peritoneum  or  neighboring  organs,  such 
as  acute  peritonitis,  appendicitis,  or  endometritis,  the  patient  lies  on  the 
back  with  the  legs  flexed  upon  the  thighs  and  the  thighs  upon  the 
abdomen.  Motion  is  avoided  as  much  as  possible,  and  so  is  any  press- 
ure upon  the  abdomen. 

The  lateral  or  dorsal  position,  with  legs  drawn  up  and  trunk 
and  head  drawn  down  to  meet  them,  occurs  with  groans  of  pain  and 
possibly  involuntary  bearing-down  in  hepatic  and  intestinal  colic  and 
during  the  throes  of  labor. 

The  Semi-upright  or  Upright  Sitting  Position.  In  an  acute 
attack  of  asthma  the  patient  is  found  sitting  up  in  bed,  or  in  a  chair, 
possibly  by  an  open  window.  The  expression  of  the  face  is  anxious, 
the  skin  dusky  or  pale,  and  moist.  The  breathing  is  loud,  noisy,  and 
scraping.  The  demand  for  oxygen  is  imperative,  difficulty  is  experi- 
enced in  inspiration  and  expiration,  not  enough  air  for  physiological  pur- 
poses being  able  to  enter  the  alveoli ;  expiration  is  prolonged  and  labored 
(expiratory  dyspncea).  The  patient  sits  with  the  chin  raised  and  head 
erect,  the  hands  grasping  the  arms  of  a  chair  or  the  bedclothing,  so 
that,  by  fixing  the  chest,  the  accessory  muscles  of  respiration  can  be 
of  the  greatest  assistance  in  supplementing  the  diaphragm.  In  emphy- 
sema, in  its  late  stages,  or  when  complicated  with  bronchitis  and  asthma, 
the  same  position  is  assumed  almost  constantly. 

In  pericarditis  with  effusion,  in  large  pleural  effusions,  and  in  advanced 
heart  disease  with  anasarca,  the  patient  is  unable  to  lie  down  on  account 
of  the  smothering  feeling  which  the  recumbent  position  induces.  In 
pericarditis  the  expression  of  the  face  is  extremely  anxious,  the  patient 
having  a  dread  of  impending  death. 

In  large  pleural  effusion  the  expression  is  not  usually  so  anxious, 
but  the  dyspnoea  may  be  intense.  The  patient  is  propped  up  in  bed, 
leaning  slightly  to  the  affected  side,  and  devotes  all  his  energies  to 
breathing,  avoiding  every  exertion,  such  as  moving,  answering  ques- 
tions, or  coughing,  which  taxes  his  breathing-muscles  still  more.  One 
side  of  his  chest  may  be  observed  to  move  violently  while  the  other  is 
motionless. 

In  heart  disease  and  anasarca  dyspnoea  frequently  amounts  to  orthop- 
nea. The  patient  may  be  found  propped  up  in  bed  or  seated  in  a  large 
rocking-chair,  some  patients  finding  greater  comfort  in  the  latter.  The 
face  is  pale,  livid,  or  jaundiced,  and  may  be  swollen,  while  the  cellular 
tissue  throughout  the  body  is  oedematous,  and  the  cavities,  especially 
the  peritoneum,  are  more  or  less  filled  with  fluid.  In  diaphragmatic 
pleurisy  the  position  assumed  is  very  characteristic — the  erect  sitting 
posture,  with  the  body  leaning  forward  and  laterally,  to  relieve  the 
pain. 


70  GENERAL  DIAGNOSIS. 

The  Prone  Position.  Rarely  the  patient  is  found  lying  upon  the 
abdomen.  He  assumes  this  position  because  it  gives  relief  to  abdominal 
pain  or  to  colic  of  any  form.  Owing  to  the  change  in  the  relative  posi- 
tions of  the  organs  brought  about  by  this  posture,  the  pain  of  an  ulcer  of 
the  stomach,  of  aneurism,  or  of  caries  of  the  vertebra?  may  be  mitigated. 

In  tetanus  opisthotonos  occurs.  The  body  rests  on  the  head  and  heels 
and  the  trunk  is  arched  upward,  because  of  tonic  contraction  of  the 
spinal  muscles.  In  strychnine-poisoning  with  tonic  convulsions  the 
same  position  may  be  assumed. 

JEmprosthotonos,  vaulted  side  position,  is  occasionally  assumed  in 
tetanus  and  also  in  strychnine-poisoning. 

Unclassified  Positions.  Irregular  or  bizarre  positions  are  usually 
assumed  in  affections  of  the  nervous  system,  particularly  in  hysteria. 

Restlessness.  Often  the  patient  is  unable  to  assume  a  position,  or, 
at  least,  to  remain  fixed  in  any  position.  This  may  occur  on  account 
of  pain,  or  because  of  irritation  or  anaemia  of  the  nerve-centres.  In 
cases  of  moderate  cerebral  hemorrhage,  and  of  shock,  there  is  great 
restlessness.  The  patient  is  restless  without  the  appearance  of  agita- 
tion. In  profuse  hemorrhage,  whether  uterine,  intestinal,  or  pulmo- 
nary, ou  account  of  cerebral  anaemia,  there  is  also  restlessness  with 
sighing  and  gasping.  The  pallor,  the  quickened  pulse,  the  great  thirst, 
with  the  history  of  bleeding,  are  sufficient  to  explain  the  restless  state. 
In  chorea  there  is  more  than  restlessness — there  is  constant  twitching 
of  muscles  with  jerking  from  one  side  of  the  body  to  the  other.  The 
patient  does  not  keep  the  covers  on  when  in  bed,  and  by  her  jerky 
movements  often  does  herself  considerable  injury. 

In  cerebral  meningitis  the  patient  tosses  from  side  to  side  or  lies  with 
the  head  retracted  and  pressed  deeply  into  the  pillow.  The  eyes  are 
injected,  the  pupils  contracted,  and  frequent  sharp  cries  are  uttered, 
especially  if  the  patient  be  a  child. 

In  hysterical  convulsions  the  patient,  usually  a  young  woman,  tosses 
wildly  to  and  fro,  screaming,  laughing,  or  crying';  or  coma  may  be 
mimicked.  The  moods  often  change  with  great  suddenness.  The 
appearance  is  very  alarming  at  first  sight ;  but  the  pulse  and  breathing 
are  not  much  accelerated,  there  is  no  fever,  and  the  patient  is  conscious 
enough  not  to  injure  herself  even  to  the  extent  of  biting  the  tongue. 

Gait.  The  gait  is  sometimes  characteristic.  (See  Nervous  Diseases.) 
The  hemiplegia  patient  advances  the  sound  limb,  and  then  brings  the 
other  up  to  it  by  lifting  the  pelvis  and  swinging  the  paralyzed  limb 
around  by  a  movement  of  circumduction.  The  shoe  is  worn  down  at 
the  toe  in  an  irregular  way.  Sometimes  the  shoulder  on  the  sound 
side  is  thrown  outward  and  forward,  so  as  to  facilitate  the  raising  of 
the  pelvis  on  the  paralyzed  side  in  order  that  the  limb  may  be  circum- 
ducted. The  arm  may  be  rigid  or  bent  at  the  elbow,  the  fingers  being 
flexed  upon  the  palm  and  the  thumb  turned  in. 

In  locomotor  ataxia  there  is  uncertainty  in  the  gait,  which  may  only 
be  felt  by  the  patient  or  be  apparent  to  the  observer  also.  There  is 
irregularity  in  the  line  of  progression,  or  the  movements  become  very 
jerky  and  erratic.  As  there  is  very  little  motion  at  the  knee,  because 
it  is  spasmodically  braced,  the  pelvis  is  slightly  tilted  until  the  foot  is 


THE  DATA  OBTAINED  BY  OBSERVATION.  71 

released  ;  the  foot  is  then  raised  unnecessarily  high,  jerked  rapidly 
forward  and  outward  and  brought  down  with  a  sudden  stamp,  or  flail- 
like action,  on  the  heel.  The  patient's  centre  of  gravity  undergoes 
several  changes  at  each  step,  so  that  he  swings  from  side  to  side.  He 
cannot  walk  in  the  dark,  and,  at  a  later  stage,  requires  the  aid  of  canes 
to  prevent  him  from  falling  forward. 

Fig.  2 


Gait  in  a  case  of  locomotor  ataxia  ;  instantaneous  serial  photographs.    (Muybeidge  and  Dercum.) 

In  paralysis  agitans  the  attitude  and  gait  of  the  patient  are  peculiar- 
The  head  and  body  are  thrown  forward  and  fixed  in  that  position  ;  the 
arms  are  slightly  abducted  and  partly  flexed,  the  hands  being  in  the 
position  in  which  a  pen  is  held  or  a  pill  rolled.  The  legs  are  also  bent 
at  the  knees.  Rhythmical  tremors  affect  the  hands  first  and  then  the 
rest  of  the  body,  the  head  and  neck  usually  escaping.  On  attempting 
to  Avalk  the  gait  is  festinating — that  is  to  say,  each  step  becomes  more 
rapid  than  the  preceding,  until  the  patient  is  prevented  from  falling 
only  by  catching  hold  of  something.  The  tremors  cease  during  sleep, 
and  are  independent  of  voluntary  motion.     (See  Fig.  3.) 

In  spastic  paraplegia  the  patient  walks  with  two  sticks.  He  leans 
on  the  left  one,  arches  the  back,  and  then  lifts  the  pelvis  and  the  right 
limb  as  far  from  the  ground  as  possible,  but  cannot  quite  clear  it.  The 
leg  is  rigid  and  the  foot  dragged  around  in  a  semi-circle.  The  toe  has 
a  marked  tendency  to  stick  to  the  ground,  and  is  brought  forward  with 
a  scraping  sound.  The  knees  have  a  tendency  to  interlock,  and  the 
foot  which  is  brought  forward  is  apt  to  cross  in  front  of  the  other. 

In  disseminated  insular  sclerosis  the  gait  is  somewhat  jerky  and  resem- 
bles the  gait  of  ataxia  or  of  tumor  of  the  cerebellum.     Of  course,  the 


72 


GENERAL  DIAGNOSIS. 


disease  that  causes  such  peculiarity  in  gait  cannot  be  established  with- 
out first  observing  the  mental  and  nervous  phenomena  that  attend  such 
affections. 


Fig.  3. 


Fig.  4. 


^ J 


Side  view  of  a  case  ot  paralysis  agitans,  show- 
ing forward  inclination  of  trunk.  Tendency  to 
propulsion.    (Dercum.) 


Spastic  paraplegia,  cross-legged  progression. 
(Deecdm.) 


In  hysterica!  paraplegia  there  is  sometimes  complete  loss  of  power  of 
standing  or  of  walking.  The  patient  falls  if  an  attempt  is  made  to 
compel  her  to  stand.  Or  she  walks  with  the  knees  and  the  hips  semi- 
flexed or  in  awkward  attitudes,  implying  greater  muscular  exertion 
than  necessary  for  the  normal  gait.  It  is  recognized  by  the  fact  of  its 
occurrence  in  young  subjects  in  whom  other  striking  phenomena  of 
hysteria  are  observed.     (See  page  73.) 

Cross-legged  Progression.  This  form  of  gait  is  seen  in  children  with 
spastic  paraplegia,  and  occurs  because  of  contracture  in  the  calf  muscles. 
When  the  child  begins  to  walk,  one  foot  gets  over  in  front  of  the  other. 
Sometimes  a  swinging  oscillation  of  the  body  occurs,  which  may  persist 
throughout  adult  life.     (See  Fig.  4.) 

The  gait  of  pseudo-hypjertrophic  muscular  paralysis  is  known  as  the 
waddling  gait.  This  oscillating  character  is  assumed  in  order  that  the 
body  be  so  inclined  "  as  to  bring  the  centre  of  gravity  over  each  foot 


THE  DATA  OBTAINED  BY  OBSERVATION. 


73 


on  which  the  patient  successively  throws  his  weight,  because  the  weak 
gluteus  meclius  cannot  counteract  the  inclination  toward  the  leg  that  is 
off  the  ground,  unless  the  balance  is  exact "  (Gowers).  The  position 
assumed  in  getting  up  from  the  floor,  as  described  by  Gowers,  is  pathog- 
nomonic.    The  patient  turns  over  in  the  all-fours  position,  raises  the 


Fig.  6. 


^r 


Hysterical  astasia-abasia.    (Lloyd.) 

trunk  with  his  arms,  rests  the  trunk 
upon  the  extended  hands,  then  extends 
the  knees,  pushes  back  with  the  hands 
until  he  can  grasp  one  knee  with  the 
corresponding  hand,  then  grasps  the 
other  knee,  and  pushes  up  the  trunk  by 
gradually  raising  the  point  of  support 
for  the  hand  upon  the  thigh.  (Fig.  5). 
The  swaying  gait,  like  that  of  a 
drunken  man  (cerebellar  titubation),  is 
significant  of  cerebellar  disease.  (See 
Station.) 

Feebleness  of  the  gait  attends  gen- 
eral paresis  and  the  early  stage  of 
chronic  myelitis,  but,  of  course,  is  of 
no  significance  unless  it  is  attended  by  other  symptoms  of  these  affec- 
tions. 


Typical  pseudo-muscular  hypertrophy. 
(Dercdm.) 


74  GENERAL  DIAGNOSIS. 

The  gait  of  paramyoclonus  multiplex  and  of  Thomsen's  disease  is  also 
peculiar.     (See  Muscles.) 

Station.  Astasia  and  abasia  are  terms  employed  to  define  the 
loss  of  power  of  standing  and  of  walking,  respectively,  without  paraly- 
sis.   Both  may  occur.     (See  Fig.  6.)    They  are  usually  due  to  hysteria. 

Ataxic  Astasia  in  Locomotor  Ataxia.  The  inability  to  stand 
is  observed  under  many  circumstances.  Either  with  (1)  the  eyes  closed, 
or  (2)  the  eyes  open  and  the  toes  and  heels  in  contact,  or  (3)  with  the 
eyes  open  and  feet  apart.  The  latter  occurs  in  the  highest  degree  of 
ataxia,  and  may  be  followed  later  by  complete  loss  of  power  of  standing. 

Swaying.  If  a  healthy  person  stands  with  the  eyes  shut  the  body 
will  sway  slightly.  In  a  patient  with  locomotor  ataxia  swaying  is 
seen  in  increased  degree. 

In  pjseudo-hypertrophic  paralysis,  if  the  patient  stands,  there  is  that 
extreme  curvature  of  the  spine  known  as  lordosis.  It  disappears  entirely 
when  the  pelvis  is  supported,  as  in  the  sitting  posture.  In  the  latter 
stages  of  this  affection  there  is  posterior  or  lateral  convexity  of  the 
spine  with  astasia. 

In  the  paroxysms  of  MSniere's  disease  the  loss  of  power  of  standing 
may  be  absolute.  The  patient  may  be  hurled  to  the  ground  and  be 
quite  unable  to  rise  or  sit  up.  The  nature  of  the  paroxysm  is  sus- 
pected on  account  of  the  sudden  onset  and  the  complaint  of  vertigo, 
together  with  the  ear  symptoms  that  attend  this  affection. 

In  disease  of  the  middle  lobe  of  the  cerebellum,  swaying  from  side  to 
side,  or  in  large  waves,  is  observed.  The  appearance  is  like  that  of  a 
drunken  person.  AVhile  the  walk  is  peculiar  the  patient  can  usually 
sit  up. 

5.  General  Form  and  Nutrition. 

The  general  form  and  nutrition  of  the  body  are  estimated  by  the 
color  of  the  skin,  the  amount  of  subcutaneous  fat,  the  degree  of  muscu- 
larity, the  size  and  shape  of  the  osseous  system.  Hence  we  estimate 
the  degree  of  physical  development  of  the  individual  by  the  size,  the 
weight,  and  the  condition  of  the  muscles,  as  well  as  by  the  state  of 
other  tissues.  To  recognize  lack  of  development  is  often  to  be  able  to 
explain  phenomena  of  a  functional  nature  which  otherwise  could  not 
be  accounted  for.  The  color  will  be  considered  under  the  head  of  the 
condition  of  the  skin. 

Importance  of  such  Observation.  It  is  extremely  important 
that  these  observations  should  be  made,  particularly  in  childhood  and 
adolescence.  Xot  only  are  marked  departures  from  the  normal  signifi- 
cant, but  slight  deviations  point  to  the  occurrence  of  processes  which 
modify  nutrition.  Unless  lack  of  development  is  detected,  it  is  fre- 
quently impossible  to  explain  the  occurrence  of  some  functional  disor- 
der, as  neuralgia,  or  of  derangement  of  the  viscera,  or  of  indefinable  ill 
health,  as  the  result  of  which  the  patient  shows  inaptitude  for  exertion 
or  inability  to  conduct  the  usual  affairs  of  life.  The  recognition  of 
malnutrition,  as  shown  in  lack  of  tone  of  muscles,  or  diminution  of 
weight,  is  often  sufficient  to  point  the  way  to  successful  treatment  by 
hygienic  methods. 


THE  DATA  OBTAINED  BY  OBSERVATION.  75 

Size.  Change  in  size  may  be  general  or  local.  General  increase  or 
diminution  in  size,  not  necessarily  abnormal,  is  due  to  enlargement  or 
diminution  of  the  muscles  and  fat,  singly  or  combined.  When  large 
accumulations  of  fat  take  place  the  word  obesity  is  applied  to  the  con- 
dition. The  estimation  of  the  patient's  size  as  compared  with  his  weight 
is  usually  based  upon  the  amount  of  subcutaneous  fat.  The  general 
accumulation  can  readily  be  recognized  by  rotundity  of  the  exterior. 

Size  affords  some  information  as  to  the  degree  of  development  of  our 
patients  and  as  to  the  kind  of  diseases  to  which  they  are  most  liable. 
While  there  is  no  absolute  standard  by  which  to  compare  the  relative 
proportion  of  height  to  girth  in  individual  cases,  yet  there  is  a  type 
generally  recognized  as  being  usual,  and  variations  from  it  give  rise  to 
such  expressions  as  stout,  spare,  slender,  thin,  tall,  and  short.  Stout 
usually  expresses  an  increase  in  girth  and  a  moderate  excess  of  flesh 
over  the  normal.  When  used  in  this  sense  it  becomes  synonymous 
with  lusty,  and  indicates  an  increase  of  flesh  which  is  well  distributed 
and  due  to  healthy,  active  nutrition  without  impairment  of  physical 
activity.  In  some  cases,  especially  in  women,  stoutness  is  used  as  a 
euphemism  for  corpulency,  but  not  often  for  that  excess  of  fat  properly 
called  obesity.  Stoutness,  in  the  sense  of  lustiness,  up  to  middle  life  is 
an  indication  of  physical  and  often  of  mental  vigor.  It  is  often  found 
in  gouty  and  rheumatic  subjects.  A  tendency  to  take  on  flesh  after 
the  age  of  forty-five,  especially  if  the  person's  occupation  is  sedentary 
and  his  habit  of  body  inactive,  is  not  to  be  regarded  as  favorable.  It 
may  be  compared  to  a  warrior's  persisting  in  wearing  an  increasingly 
heavy  weight  of  armor  after  the  campaign  is  over.  Increased  weight 
under  such  circumstances  is  not  increased  strength,  but  increased 
burden,  and  the  burden  becomes  greater  with  advancing  years.  Those 
who  are  under  forty  and  stout,  in  the  sense  of  having  too  much  fat  in 
proportion  to  bone  and  muscle,  bear  fevers  and  exhausting  diseases 
badly.  Women  at  the  menopause  are  very  prone  to  take  on  flesh 
rapidly.  Fat  subjects  after  middle  life,  and  to  an  increasing  degree 
after  that  period,  are  liable  to  fatty  degeneration  of  the  heart,  blood- 
vessels, and  important  viscera. 

Persons  who  are  tall  and  thin,  especially  if  they  have  become  tall 
rapidly  after  puberty,  are  commonly  looked  upon  as  delicate,  and  as 
especially  liable  to  consumption.  There  is  reason  for  this  view.  But 
if  they  live  to  be  twenty-five  or  more,  without  disease  of  the  lungs  or 
pleura,  they  may  then  live  to  a  great  age. 

Some  patients  have  an  appearance  which  is  well  described  and  under- 
stood by  the  word  "spare."  The  form  is  compactly  put  together,  but 
with  small  bones  and  a  scanty  allowance  of  fat.  There  is  a  tendency 
to  leanness  rather  than  to  roundness  of  form. 

In  still  others  muscle  and  bone  predominate,  and  the  form  is  apt  to 
be  angular,  as  in  those  described  as  wiry.  They  are  often  possessed  of 
great  muscular  power  and  resistance  to  strain.  Those  of  spare  and 
wiry  habit  bear  disease  very  well.  Inspection  alone  may  leave  one  in 
doubt  whether  to  regard  an  individual  as  thin  and  delicate  or  spare. 
Light  will  be  obtained  from  the  patient's  occupation  and  the  amount 
of  physical  exertion  of  which  he  is  capable,  and  also  from  the  tonicity 


76  GENERAL  DIAGNOSIS. 

and  hardness  of  his  muscles.  If  one  stops  to  think  a  moment,  he  will 
see  that,  for  the  same  amount  of  heart  and  lung  capacity,  a  man  will 
be  better  off  if  spare  than  if  corpulent ;  because  in  the  latter  case  he 
has  an  additional  load  to  carry,  and  he  has  to  nourish  and  keep  up  a 
thick  blanket  of  fat  from  which  he  derives  no  adequate  advantage. 
Hence  a  person  of  spare  build,  who  survives  childhood  and  adolescence 
without  disease,  probably  has,  on  the  whole,  a  better  prospect  for  long 
life  than  a  stout  person. 

Normal  Habit.  In  estimating  the  patient's  size  or  weight  it  is 
important  to  ascertain  if  he  has  a  regular  habit  of  taking  on  flesh  at 
certain  periods  of  the  year,  for  instance,  or  if  it  has  developed  suddenly 
or  followed  acute  disease. 

Weight.  Nothing  has  yet  been  said  of  the  weight,  but,  as  it  affords 
a  precise  estimation  of  the  size,  particularly  if  considered  in  relation 
to  the  height  and  age,  the  following  discussion  will  include  the  two 
points,  size  and  weight. 

AVhile  the  eye  can  estimate  approximately  the  weight  of  the  body 
and  the  degree  of  emaciation,  the  physician  should  make  it  a  rule  to 
ascertain  the  weight  accurately  by  means  of  scales.  Machines  are 
now  made  which  can  be  used  for  weighing  the  patient  and  at  the  same 
time  noting  the  exact  height.  It  is  particularly  important  to  note  the 
weight  from  time  to  time.  In  the  course  of  wasting  disease  we  learn 
the  effects  of  treatment,  or,  on  the  other  hand,  the  march  of  disease  in 
spite  of  treatment.  In  obscure  cases,  as  in  tuberculosis,  persistent  loss 
of  flesh  is  a  serious  diagnostic  and  prognostic  symptom.  After  acute 
disease,  if  the  patient  is  weighed  every  week,  the  onset  of  insidious 
sequela?,  as  tuberculosis,  may  be  detected. 

The  relation  of  body-weight  to  height  is  of  importance.  It  is  also 
important  to  know  the  average  weight  of  the  individual  in  different 
periods  of  life.  The  progressive  increase  in  weight  which  should  take 
place  after  birth  should  be  remembered,  as  the  opposite  is  positive 
evidence  of  malnutrition. 

Mr.  Hutchinson's  table  enables  us  to  judge  the  average  weight  of  a 
healthy  man  of  a  given  height  : 

0  in.  ought  to  weigh  about    92.26  lbs. 

"  "  115.52  " 

127.86  " 

139.17  " 

144.29  " 

"  "  157.78  " 

"  "  170.86  " 

177.25  " 

In  some  life  insurance  tables  in  this  country  the  average  weight  for 
the  height  is  lower,  especially  in  persons  over  five  feet  ten  inches. 

Weight  ix  Disease.  The  question  of  w eight  is  an  important  one 
in  disease.  As  has  been  stated,  persons  with  an  excess  of  fat  do  not 
bear  fevers  and  exhausting  processes  so  well  as  those  who  have  a 
relatively  larger  proportion  of  firm  muscles.  Remember,  if  emaciation 
is  present,  to  ascertain  its  amount  and  degree,  its  possible  relation  to 
unusual  mental  care  or  to  acute  disease.     Slow  progressive  emaciation 


A  man 

Ol 

f  4  ft. 
5   " 

6 

0 

in. 

to 

5  ft.  0 
5  "    1 

it 

it 

5   " 

2 

it 

5   "    3 

u 

it 
a 

5   " 
5   " 

4 
6 

it 
ti 

5   "    5 

5   "    7 

.  " 

a 

5  " 

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5   "    9 

-  n 

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5   "  11 

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it 

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6   "    0 

THE  DATA  OBTAINED  BY  OBSERVATION.  77 

is  of  serious  moment,  as  evidence  of  tuberculosis  or  disorder  of  assimi- 
lation. Remember  the  wasting  that  is  associated  with  great  hunger, 
excessive  thirst,  and  polyuria  in  diabetes  mellitus.  On  the  other  hand, 
such  symptoms  as  occasional  cough,  slight  evening  fever,  and  impair- 
ment of  resonance  at  one  apex  of  the  lung  become  much  more  signifi- 
cant of  incipient  phthisis  if  accompanied  by  loss  of  weight.  At  any 
stage  of  phthisis  a  maintenance  of  the  body-weight  is  one  of  the  most 
favorable  elements  in  prognosis. 

Again,  while  loss  of  weight  attends  all  the  diseases  of  the  digestive 
tract  which  interfere  seriously  with  nutrition,  it  progresses  more  rapidly 
and  steadily,  and  attains  a  greater  degree,  in  malignant  disease  than  in 
the  mechanical  or  functional  diseases.  Hence  the  question  of  loss  of 
weight  is  important  iu  deciding  between  chronic  catarrhal  gastritis  and 
gastric  carcinoma.  But  still  more  important  is  the  question  of  the  time 
during  which  loss  of  flesh  has  been  taking  place,  and  whether  it  has 
been  progressive  or  interrupted  by  periods  of  gain  in  weight.  If  during 
two  or  three  years  the  patient  has  been  vomiting  occasionally,  and 
losing  flesh,  but  gaining  again  from  time  to  time,  it  is  much  more 
significant  of  gastric  catarrh  than  of  gastric  cancer. 

False  Increase  of  Weight.  In  certain  cases  of  great  anasarca, 
and  in  malignant  disease  of  the  abdomen,  especially  huge  cysts  of  the 
ovary  in  women,  and  sarcoma  of  the  kidney  in  children,  there  may  be 
actual  increase  of  weight  due  to  the  accumulation  of  water  or  to  the 
new  growth,  though  the  rest  of  the  body  is  manifestly  emaciated. 

Weight  in  Children.  In  babies  and  children  fat  is  more  likely 
to  be  a  sign  of  good  health  than  in  adults.  Nevertheless  the  quality 
of  the  flesh  is  to  be  taken  into  consideration.  There  are  fat  and  flabby 
babies  and  children,  and  there  are  others  who  are  fat  but  whose  flesh 
has  a  firm,  solid  feel.  The  former  often  gain  and  lose  flesh  rapidly, 
and,  when  ill,  do  not  appear  to  have  much  resisting  power.  The  size 
of  a  child  gives  a  good  idea  of  its  nutrition.  A  child  may  have  its 
growth  stunted  by  bad  food  and  unfavorable  hygienic  conditions,  or 
the  stunting  may  be  the  result  of  exhausting  disease,  such  as  whooping- 
cough. 

Increase  in  size  and  weight  then  may  be  due  to  changes  in  (1)  the 
skeleton  (see  Chapter  XIII.)  ;  (2)  the  muscles  ;  (3)  the  adipose  tissue  ; 
(4)  the  subcutaneous  connective  tissue,  giving  rise  to  accumulations  of 
serum,  mucin,  or  connective  tissue  dystrophies  (see  Chapter  X.). 
Diminution  in  size  is  due  to  changes  in  (1)  the  skeleton;  (2)  the 
muscles,  and  (3)  the  adipose  tissue.  The  word  emaciation  is  applied 
to  excessive  atrophy  of  fat  and  muscles.  If  it  is  accompanied  by 
great  exhaustion  and  apparent  loss  of  fluid,  the  word  marasmus  is 
employed. 

Degree  of  Loss.  The  whole  body  may  exhibit  considerable  loss 
of  flesh,  the  cheek  bones  and  temporal  fossa?  being  distinctly  visible, 
the  muscles  soft,  the  limbs  wasted,  and  the  subcutaneous  fat  dimin- 
ished. It  is  important  to  notice  whether  flesh  has  been  lost  or  not, 
and  how  much,  and  how  long  a  time  the  loss  has  been  going  on.  Such 
facts  furnish  the  clue  not  only  to  diagnosis  but  to  treatment  also. 
Flesh  is  lost  in  almost  all  diseases,  acute  or  chronic,  but  it  becomes  of 


78  GENERAL  DIAGNOSIS. 

special  moment  in  diagnosis  in  the  latter.  It  is  most  noticeable  in 
tuberculosis,  cancer,  marasmus,  cirrhosis  of  liver  and  kidneys,  diabetes, 
in  anaemias,  and  in  cachectic  conditions  due  to  prolonged  suppuration 
or  chronic  diarrhoea,  in  gastric  neurasthenia  and  anorexia  nervosa. 

Local  Change  in  Size.  There  may  be  local  increase  or  diminu- 
tion in  size,  alone  or  combined.  It  is  not  to  be  forgotten  that  accumu- 
lations of  fat  may  take  place  in  special  portions  of  the  body  ;  the  abdo- 
men is  the  favorite  seat  for  excessive  accumulation,  particularly  in 
women  and  in  men  of  sedentary  life,  with  habits  of  excessive  indul- 
gence in  food  and  drink.  When  one  part  is  increased  in  size  and 
another  growing  progressively  small  the  disparity  indicates  disease  (see 
below).  The  face  is  swollen,  especially  under  the  eyes  and  above  the 
jaws,  in  the  dropsy  of  large  white  kidney  and  in  parotitis.  The  neck 
may  be  enlarged  in  the  sterno-clavicular  notch  or  laterally  above  the 
clavicles  in  aneurism.  The  thyroid,  as  a  whole,  or  either  lobe,  is 
enlarged  in  goitrous  affections  and  in  Graves's  disease. 

The  face  may  be  thin  and  even  much  emaciated,  while  the  abdomen 
is  greatly  distended  from  dropsy  or  from  tumors  of  the  various  abdom- 
inal viscera  or  glands.  The  chest  is  enlarged  or  contracted.  Local 
decrease  in  size  in  thorax  or  abdomen  is  significant  of  tumors. 

The  head  is  much  increased  in  size  in  chronic  hydrocephalus,  while 
the  face  remains  small.  The  bones  of  the  cranium  are  enlarged  in 
leontiasis  ossea.  The  head,  face,  and  neck  enlarge  in  the  affection 
described  by  Allen  Starr  as  megalocephalie.     (See  Chapter  VII.) 

The  loss  in  flesh  in  the  extremities  or  special  muscles  may  be  local 
and  atrophic  in  character,  as  in  some  diseases  of  the  nervous  system, 
such  as  neuritis,  infantile  palsy,  hemiplegia,  and  monoplegia.  Loss  of 
flesh  of  the  arms  is  said  to  be  a  symptom  in  cystic  ovarian  tumor. 

The  increase  in  size  may  also  be  local,  as  in  hydrocephalus,  elephan- 
tiasis, dystrophies,  inyxoedema,  oedema,  and  various  tumors. 

The  General  Musculature.  The  state  of  the  muscles  must 
always  be  learned.  It  has  been  referred  to  in  the  discussion  on  emacia- 
tion. A  few  words  more  seem  necessary.  It  must  be  remembered  that 
a  person  can  be  obese  and  yet  have  poor  muscular  development,  or  have 
little  fat  and  fair  muscle.  General  lack  of  muscular  development  or 
muscular  weakness  is  an  important  sign  of  malnutrition,  and  may  ex- 
plain the  nature  of  many  symptoms.  The  muscular  weakness  can  be 
approximated  by  the  degree  of  firmness  of  the  muscle.  Weakness  of 
the  muscles  of  the  spine,  with  resulting  curvature,  or  inability  to  keep 
the  erect  posture,  is  sufficient  cause  for  the  occurrence  of  neuralgic 
pains  in  the  course  of  related  nerve-trunks,  and  for  the  displacement  of 
organs  within  the  thorax  or  abdomen,  often  causing  functional  dis- 
turbance. Various  uterine  displacements  and  functional  disorders  may 
be  mitigated  by  toning  up  the  nutrition  of  the  muscles  of  the  trunk. 
Forms  of  indigestion,  sluggishness  of  secretions,  particularly  of  the 
bowels,  follow  in  the  wake  of  debilitated  muscles  and  pass  away  as  such 
muscles  gain  tone.  It  may  be  that  the  indigestion  has  not  taken  place 
because  the  muscles  are  weak,  although  in  a  measure  there  is  relation 
between  them  ;  but  the  weak,  flabby  muscles  are  pronounced  indica- 
tions of  a  state  of  the  system  which  may  develop  indigestion.     More- 


THE  DATA  OBTAINED  BY  OBSERVATION.  79 

over,  weakened  abdominal  walls,  separated  recti  muscles,  and  diastasis 
favor  dropping  of  the  liver,  stomach,  and  other  organs,  causing  gastro- 
enteroptosis  with  its  train  of  symptoms.  The  detection  of  muscular 
deficiency  leads  to  correct  lines  of  treatment.  Atrophy  of  muscles 
occurs  because  of  disuse,  because  of  sedentary  occupation  or  of  a  life 
of  ease  and  luxury,  with  improper  nutrition.  It  is  sure  to  follow  im- 
proper assimilation,  as  seen  in  extreme  degree  in  anorexia  nervosa. 


CHAPTER    VII. 

THE  DATA  OBTAINED  BY  OBSERVATION— (Continued). 

The  face— the  facial  expression.  The  head.  Mumps — facial  hemiatrophy.  Hydro- 
cephalus. The  hair.  The  lips.  The  neck — the  thyroid  gland — exophthalmic 
goitre — the  bloodvessels  of  the  neck. 

The  Face  and  its  Expression. 

The  face  is  a  mirror  in  which  are  reflected  all  degrees  of  ill  health, 
rfrom  that  which  amounts  only  to  temporary  indisposition  and  depres- 
sion up  to  the  gravest  cachexia.  The  face  reflects  also  the  degree 
of  intelligence  of  the  patient  and  his  mental  condition  at  the  time,  as 
well  as  his  emotions,  and,  in  a  large  measure,  his  character.  The  face 
is  usually  a  fairly  good  index  of  the  temper  of  the  individual ;  benev- 
olence, amiability,  and  purity  are  written  as  plainly  on  some  faces  as 
anger,  lust,  dishonesty  on  others.  (See  Nose  and  Mouth  in  respective 
chapters  on  special  diagnosis.) 

The  face  frequently  affords  us  valuable  information  concerning  the 
health,  habits,  and  temperament  of  the  individual.  Everyone  is 
familiar  with  the  bright  eye  and  animated  countenance  of  a  friend 
which  lead  us  to  say,  "  You  are  looking  very  well  to-day,"  and  with 
that  slight  pallor,  diminished  clearness  of  the  conjunctiva,  with  per- 
haps a  dark  circle  under  each  eye,  which  lead  us  to  infer  that  he  is 
depressed  or  has  passed  a  sleepless  night.  The  face  also  gives  unmis- 
takable evidence  of  alcoholism  by  its  bloated  appearance,  injected  or 
glassy  eye,  dull  expression,  and  nervousness  when  the  patient  is 
: addressed  suddenly. 

Full-blooded  persons,  disposed  to  endarterial  changes,  frequently  as 
the  result  of  gout,  often  have,  at  a  little  distance,  the  ruddy  appearance 
of  blooming  health.  Closer  inspection,  however,  shows  that  the  ruddy 
color  is  due  to  a  dilated  or  congested  condition  of  the  minute  blood- 
vessels. Tins  condition,  when  associated  with  high  tension  in  the  arte- 
ries and  accentuation  of  the  aortic  second  sound,  is  highly  suggestive 
of  chronic  nephritis.    (For  color  and  complexion,  see  the  Skin,  Chapter 

Moreover.,  the  face  tells  of  the  presence  or  absence  of  pain,  and,  to  a 
certain  extent,  of  its  character.  Everyone  has  witnessed  the  sudden 
contraction  of  the  brow  and  eyelids  and  the  involuntary  sucking  in  of 
the  breath  when  some  one  has  bitten  upon  a  tender  tooth.  Other  face- 
bear  the  imprint  of  long-continued  more  or  less  constant  suffering. 
According  to  Eustace  Smith,  pain  in  the  head  in  children  is  indicated 
by  contraction  of  the  brows  ;  pain  in  the  chest,  by  sharpness  of  the 
nostrils  ;  and  in  the  belly,  by  a  drawing  of  the  upper  lip.  (See  the 
Face  in  Children  and  Pain,  Chapter  IV.) 


THE  DA  TA  OB  TA INED  B  Y  OBSER  VA  TION.  81 

It  will  be  seen  that  the  expression,  the  color,  and  the  outline  of  the 
face  are  valuable  indications  of  disease. 

The  master  mind  in  clinical  medicine,  the  late  Austin  Flint,  Sr., 
tersely  described  the  various  appearances  of  the  face  in  disease,  with 
their  clinical  significance,  as  follows  : 

The  Facies  of  Renal  Disease.  In  some  cases  of  acute  albuminuria 
and  of  chronic  parenchymatous  nephritis — the  large  white  kidney  of 
Bright — puffiness  of  the  face  from  oedema,  with  notable  pallor,  renders 
the  aspect  highly  diagnostic. 

The  Malarial  Facies.  Pallor  of  the  face,  sallowness,  and  slight 
puffiness,  if  renal  disease  be  excluded,  point  to  malarial  disease. 

The  Facies  of  Carcinoma.  Notable  anaemia.,  a  waxy  or  straw- 
colored  complexion,  and  more  or  less  emaciation,  in  combination,  render 
the  aspect  marked  in  some  cases  of  malignant  disease.  In  a  patient 
over  forty  years  of  age  this  aspect  has  considerable  diagnostic  import, 
although  it  is  by  no  means  always  present  when  malignant  disease  exists. 

The  Typhoid  Facies.  In  the  middle  and  later  periods  of  typhoid 
fever  the  countenance  is  often  dull,  besotted,  expressionless.  This 
facies  may  be  present  in  the  typhoid  state,  which  is  incident  to  diseases 
other  than  typhoid  fever  — e.  g.,  pneumonia.  Coexisting  with  a  dusky 
hue  of  the  skin  and  congestive  redness  of  the  conjunctiva,  it  distin- 
guishes typhus  as  contrasted  with  typhoid  fever. 

The  Facies  of  Acute  Peritonitis.  The  upper  lip  raised  so  as  to 
expose  the  front  teeth  gives  an  aspect  which  characterizes,  in  a  certain 
proportion  of  cases,  acute  peritonitis.  It  is  often  wanting,  but  when 
present  it  is  strongly  diagnostic. 

The  Facies  of  Acute  Pneumonia  and  Hectic  Fever.  Circum- 
scribed redness  of  one  or  both  of  the  cheeks,  with  abruptly  defined 
borders,  is  diagnostic  of  acute  pneumonia.  If  it  be  observed  in  a  case 
of  chronic  pulmonary  disease  it  denotes  the  so-called  hectic  fever,  and 
is  a  sign  of  phthisis.  The  wan,  emaciated  appearance  with  the  bright 
eye  and  hurriedly  expanding  nostrils  excites  our  fears  that  the  progress 
of  the  latter  affection  is  most  rapid. 

The  Facies  of  Exophthalmic  Goitre.  Projection  of  the  eyeballs, 
giving  to  the  face  a  remarkably  staring  and  sometimes  ferocious  ex- 
pression, conjoined  with  enlargement  of  the  thyroid  body  and  frequency 
of  the  pulse,  is  distinctive  of  the  affection  known  as  exophthalmic 
goitre — Graves's  or  Basedow's  disease. 

The  Choleraic  Facies.  In  the  collapse  stage  of  cholera  the  face  is 
contracted,  sometimes  wrinkled  ;  the  cheeks  are  hollow,  the  eyes  sunken, 
the  skin  is  livid,  and  the  expression  denotes  indifference.  This  com- 
bination of  traits  is  quite  distinctive.  They  are,  however,  to  a  certain 
extent  combined  in  the  state  of  collapse  which  occurs  in  some  cases  of 
pernicious  intermittent  fever  and  in  other  pathological  connections. 

The  Hippocratic  Facies.  This  facies  denotes  the  moribund  state. 
The  skin  is  pale,  with  a  leaden  or  livid  hue  ;  the  eyes  are  sunken,  the 
eyelids  separated,  and  the  cornea  loses  its  transparency  ;  the  nose  is 
pinched  and  the  eyes  are  contracted  ;  the  temples  are  hollow  and  the 
lower  jaw  drops.  Hippocrates  described  this  facies  in  graphic  terms, 
and  the  name  Hippocratic  has  ever  since  been  used  to  designate  it. 

6 


82  GENERAL  DIAGNOSIS. 

The  Face  in  Children.  Inspection  is  even  more  important  in  the 
case  of  children  than  in  adults.  The  pale,  pinched,  weazened  face  of 
some  babies  who  have  snuffles,  ulcers,  or  striated  lines  at  the  corners 
of  the  mouth,  and  look  prematurely  aged,  with  prominent  forehead  and 
a  depressed  nasal  bridge  and  retrousse  tip,  characterizes  inherited  syph- 
ilis. In  older  subjects  the  undeveloped  face  and  skull  are  striking. 
In  rickets  the  head  is  unusually  large  with  flattened  vertex,  projecting 
forehead,  and  open  fontanelle.  In  hydrocephalus  the  head  becomes 
very  much  enlarged,  the  eyes  prominent,  the  bones  of  the  face  remain- 
ing small,  the  expression  vacant.  In  adenoid  disease  of  the  pharynx, 
with  tonsillar  hypertrophy,  the  dull  apathetic  expression,  with  the 
thickened  lips,  the  small  nasal  orifices,  and  the  gaping  mouth  are  char- 
acteristic. In  cretins  the  thickened  lips,  the  protruded  tongue  with 
saliva  dribbling  from  the  open  mouth,  the  flattened  nose,  with  the 
idiotic  expression  and  pallid,  waxy  skin,  are  easily  recognized.  To  a 
lessened  degree  such  appearances  are  seen  in  "backward"  children, 
who,  it  may  be  said,  are  undeveloped  cretins.  In  measles  the  red, 
swollen  face,  the  reddened,  weeping  eyes,  and  running  nose  make  a 
very  striking  picture.  An  irritating,  excoriating  discharge  from  the 
nose  in  a  child  may  indicate  the  existence  of  a  nasal  diphtheria. 

The  Face  in  Nervous  Disease.  All  varieties  of  mental  aberration 
are  reflected  in  the  face  ;  the  suspicious,  at  times  revengeful,  look  of 
the  delusional  monomaniac  ;  the  wild  look  and  excited  maimer  of  the 
maniac ;  the  plaintive,  depressed,  injured  look  of  melancholia  ;  the 
vacant,  listless,  peaceable,  animal-like  look  of  dementia — a  look  which 
changes  to  animation  only  at  the  sight  of  food  or  some  coveted  luxury. 
All  these  expressions  come  to  be  recognized  very  readily  by  those  who 
see  much  of  the  insane.  In  addition,  in  hysteria  expressions  of  varied 
emotions  are  seen  ;  in  neurasthenia  a  worn  and  wearied  aspect  of  coun- 
tenance is  noticeable. 

The  face  often  tells  of  the  existence  of  some  organic  nervous  dis- 
order. The  peculiar  heavy  expression,  drooping  eyelids,  though  they 
close  improperly,  and  sluggishly  moving  lips,  betoken  the  early  stage 
of  the  facio-humero-scapular  type  of  muscular  atrophy,  and  is  some- 
times seen  in  Friedreich's  ataxia. 

Change  in  the  expression  and  appearance  of  the  face  more  frequently 
occurs  because  of  change  in  the  function  and  nutrition  of  the  muscles, 
on  account  of  central  or  peripheral  disease  of  the  nervous  system.  On 
this  account  Ave  have  facial  spasm  or  tremor,  and  unilateral,  bilateral, 
or  local  facial  paralysis.  Further  consideration  of  these  conditions  will 
be  found  in  the  local  examination  of  the  muscles  (Chapter  XII.)  and 
in  Diseases  of  the  Nervous  System. 

In  peripheral  facial  palsy  the  paralyzed  side  of  the  face  has  a  staring, 
vacant  expression,  owing  to  the  fact  that  the  eyelid  is  motionless. 
The  angle  of  the  mouth  on  the  affected  side  is  depressed.  The  whole 
paralyzed  side  is  devoid  of  wrinkles,  has  a  smoothed-out,  glazed  appear- 
ance ;  tears  flow  over  the  cheeks  and  saliva  dribbles  from  the  corner 
of  the  mouth.  The  contrast  with  the  normal  side  is  most  marked  when 
the  patient  smiles  or  frowns.     (See  Fig.  7.) 

In  glosso-labial  palsy  there  is  progressive  palsy,  with  tremulousness 


THE  DATA   OBTAINED  BY  OBSERVATION.  83 

of  tongue  and  lips  ;  progressive  failure  of  articulation  and  dribbling 
of  saliva.  Sometimes  the  patient  is  able  to  open  the  lips  but  unable  to 
close  them  without  the  aid  of  the  hand.  In  paralysis  agitans  the  mask- 
like expression  of  immobility  has  been  described  as  Parkinson's  mask. 

A  slow,  hesitating,  thick  manner  of  speaking,  with  a  tendency  to 
slur  the  labial  and  lingual  consonants,  when  associated  with  irregu- 
larity of  the  pupils,  slight  tremulousness  of  the  lips,  and  the  loss  of  the 
fine  adjustment  of  other  muscular  movements,  such  as  writing,  is  very 
suggestive  of  general  'paralysis  of  the  insane,  especially  when  the  condi- 
tion develops  in  a  middle-aged  man. 

Facial  hemiatrophy  is  a  peculiar  affection,  characterized  by  pro- 
gressive wasting  of  the  bones  and  soft  tissues  of  one  side  of  the  face. 
The  disease  is  rare  ;  it  begins,  as  a  rule,  in  childhood,  but  may  develop 
in  later  life.  The  local  change  is  diffuse  ;  in  some  instances,  however,  it 
slowly  spreads  from  a  spot  in  the  skin,  involving,  in  succession,  the 
tissues  underneath.  The  skin  changes  in  color  and  the  hair  falls  out. 
The  eye  is  sunken  on  the  affected  side,  on  account  of  wasting  of  the 
tissues  of  the  orbit.     The  bone  of  the  upper  jaw  atrophies  to  a  more 

Fig.  7.  Fig.  8. 


Complete  facial  pals}-.  Patient  unable  to  close  eye 

of  the  affected  side.    (Dercum.)  Facial  hemiatrophy.    (Lyman.) 

advanced  degree  than  the  other  bones  which  undergo  wasting.  Because 
of  the  wasting  of  the  alveolar  processes  the  teeth  become  loose  and  fall 
out.  The  wasting  is  sharply  limited  by  the  middle  line.  (See  Fig.  8.) 
The  disorder  is  easily  recognized.  The  patient  looks  as  if  the  face  were 
made  up  of  two  halves  from  different  persons.  It  must  not  be  mistaken 
for  facial  asymmetry  that  is  associated  with  congenital  wry-neck.  The 
contraction  of  the  sterno-mastoid  muscle  from  birth  distinguishes  the 
affection. 

The  outline  of  the  face  and  any  change  in  the  shape  of  the  head 
should  next  be  observed.  Both  changes,  as  seen  in  my.veedema  and 
scleroderma  (see  Skin,  Chapter  X.),  arc  described.  The  striking  changes 
in  acromegalia,  rickets,  and  osteitis  deformans  are  described  in  Chapter 


84  GENERAL  DIAGNOSIS. 

XIII.,  on  Bones  and  Joints.  In  leprosy  the  face  is  characteristic  ; 
the  leonine  countenance — ■facies-Ieontina — is  the  result  of  the  tuberous 
outgrowths  about  the  eyes  and  forehead. 

Enlargement  of  the  Face.  Swelling.  Other  changes  in  the  out- 
line of  the  face  and  skull  are  significant.  The  face  is  swollen  and 
deformed  in  erysipelas  and  smallpox,  and,  to  a  moderate  degree,  in 
measles.  The  specific  eruption  serves  to  distinguish  each  one.  The 
puffiness  of  the  eyelids  and  general  swelling  of  the  face  in  the  course  of 
Bright' s  disease  will  be  referred  to.     (See  CEdema.) 

(Edema  of  the  face  occurs  in  trichinosis.  It  occurs  at  two  periods  in 
the  course  of  the  disease.  It  is  seen  in  the  eyelids  in  the  beginning  of 
the  disease  and  disappears  after  a  few  days.  Later  it  returns  with 
pain,  tension,  and  restriction  of  the  movement  of  the  eye-muscles. 

Mumps.  In  mumps  the  swelling  is  characteristic.  It  usually  begins 
on  one  side.  The  swelling  of  the  parotid  gland  is  observed  in  front  of 
the  ear,  then  it  extends  below  and  around  it  and  behind  the  ramus  of 
the  jaw.  Unless  there  is  much  collateral  oedema  the  outline  of  the 
gland  is  preserved.  The  gland  is  tender  and  boggy,  not  indurated. 
Viewing  the  face  from  the  front,  the  midlateral  aspects  are  seen  to 
bulge.  The  ears  stand  out  from  the  head.  The  jaws  are  fixed.  The 
submaxillary  glands  are  usually  enlarged. 

The  data  to  be  considered  in  the  study  of  an  infectious  disease  are 
pointed  out  in  the  chapter  devoted  to  those  affections.  In  addition 
to  such  data  the  diagnostic  features  of  mumps  are  the  symptoms  of 
the  invasion  of  the  general  symptoms  and  the  local  signs. 

The  symptoms  of  the  invasion  are  sudden,  with  chilliness,  a  rise  in 
temperature,  which  is  generally  moderate  (101°  to  103°),  and  pain  at 
the  angle  of  the  jaw.  The  corresponding  parotid  rapidly  begins  to 
swell,  as  well  as  the  adjacent  cellular  tissue.  Along  with  pain  on 
movement  of  the  jaws,  any  acid  liquid,  as  vinegar,  which  stimulates 
salivary  secretion,  increases  the  pain.  At  times  the  submaxillary 
glands  are  involved  instead  of  the  parotids,  or  they  may  be  enlarged 
and  painful  several  days  before  the  parotid  is  affected.  The  disease 
may  be  limited  to  one  side  or  involve  the  opposite  side,  as  the  process 
in  the  one  first  attacked  subsides.  Barely  it  is  bilateral  from  the  start. 
When  the  swelling  has  lasted  from  three  to  five  days  the  fever  sub- 
sides and  the  swelling  begins  to  disappear  rapidly.  At  this  time,  how- 
ever, the  opposite  side  may  be  attacked  or  the  testicles  become  inflamed. 
Usually  it  is  the  right  testicle.  In  girls  and  women  the  ovary  or 
mamma  is  rarely  inflamed.  Resolution  is  extremely  rapid,  and  usually 
the  disease  is  not  followed  by  sequelae.  Sometimes,  however,  deafness 
is  left.  In  fact,  sudden  deafness  sometimes  announces  the  commence- 
ment of  an  attack. 

If  to  these  facts  we  add  the  data  obtained  in  the  social  history,  the  age 
of  the  patient  under  fifteen,  and  the  history  of  exposure  or  the  presence 
of  an  epidemic,  the  diagnosis  is  easily  made. 

It  must  be  borne  in  mind  that  parotid  swelling,  inflammation,  with 
or  without  suppuration,  may  occur  in  the  course  of  various  infections, 
notably  typhoid  fever  and  septicaemia.  It  may  also  be  traumatic. 
Chronic  enlargement  of  the  parotid  occurs  in  syphilis.     In  some  cases 


THE  DATA  OBTAINED  BY  OBSERVATION.  85 

(Osier  and  Kiimmel)  the  submaxillary  and  lachrymal  glands  are  con- 
jointly enlarged  with  the  parotid. 

The  Lips.  Color.  The  lips  are  pale  in  anaemia,  and  livid  in 
cyanosis  from  chronic  lung  or  heart  disease  with  feeble  circulation. 
Vesicles  (herpes)  are  apt  to  appear  upon  them  in  common  colds,  in  cer- 
tain febrile  diseases,  particularly  pneumonia,  and  with  many  women 
during  or  immediately  following  menstruation.  A  child  with  heredi- 
tary syphilis  may  show  ugly  fissures,  or  the  scars  which  result  from 
them,  at  the  angles  of  the  mouth.  In  facial  palsy  the  angle  of  the 
mouth  on  the  paralyzed  side  is  depressed  and  free  from  wrinkles.  In 
glosso-labial-laryngeal  palsy  the  lips  tremble,  twitch,  and  may  have  to 
be  closed  with  the  fingers  after  they  have  been  opened.  In  general 
paralysis  of  the  insane  the  lips  tremble,  and  speech  is  "  thick,"  hesi- 
tating, and  uncertain,  with  a  tendency  to  elide  syllables  and  slur  the 
labial  consonants. 

Hair.  The  hair  often  indicates  the  state  of  the  nutrition  of  the  indi- 
vidual. Changes  in  it  may  be  significant  of  syphilis  or  other  internal 
morbid  processes.  The  abnormal  growths  and  changes  in  the  texture 
due  to  local  parasitic  disease  will  not  be  referred  to.  Undue  and  rapid 
falling  out  of  the  hair  in  patches,  known  as  alopecia,  is  indicative  of 
syphilis  and  of  profound  intoxication  by  the  virus  of  this  disease.  The 
hair  can  be  pulled  out  in  large  masses  without  difficulty  or  pain.  This 
falling  of  the  hair  must  not  be  confounded  with  the  excessive  falling 
out  which  takes  place  in  the  convalescence  of  acute  disease,  particularly 
of  typhoid  fever,  nor  with  that  following  an  attack  of  gout  or  erysipelas. 

Color  of  the  Hair.  Obscure  paralysis  or  anaemia  may  be  ex- 
plained by  noting  if  the  hair  is  artificially  colored.  Lead  and  other 
poisonings  have  repeatedly  arisen  from  the  use  of  hair-dyes.  Other 
changes  in  the  color  are  often  significant.  Early  gray  hair  may  go 
hand-in-hand  with  premature  endarteritis.  The  term  "  canities  "  is 
applied  to  the  diminished  development  of  pigment.  Premature  gray 
color  in  defined  patches  occurs  in  nerve-lesions,  as  paralysis  of  one  of 
the  branches  of  the  fifth  pair,  and  is  a  trophic  change.  Sudden  change 
in  the  color  of  the  hair,  usually  to  gray,  takes  place  at  times  under  the 
influence  of  fright,  mental  anxiety,  or  deep  emotion. 

' '  Green  "  hair  is  seen  in  brass-founders  and  workers  in  copper-mines  ; 
' '  blue  "  hair  in  laborers  in  cobalt-mines  and  persons  employed  in  the 
manufacture  of  indigo.  Chemicals  applied  to  the  hair  change  its  color 
— peroxide  of  hydrogen  bleaches  the  hair,  pyrogallic  acid  turns  it 
black.  Drugs  administered  internally,  as  jaborandi  and  its  alkaloid, 
change  the  color  to  dark  hues. 

The  Head. 

The  posture  of  the  head  and  abnormal  movements  are  due  to  affec- 
tions of  the  muscles  of  the  neck,  and  will  be  considered  in  a  study  of 
local  affections  of  muscles.     (See  Chapter  XII.) 

Enlargement.  Change  in  the  size  and  shape  of  the  head  is  seen 
in  rickets,  acromegalia,  and  otitis  deformans,  along  with  other  skeletal 
changes,  and  are  discussed  in  the  chapter  on  the  Bones  and  Joints. 


86 


GENERAL  DIAGNOSIS. 


Enlargement  is  clue,  however,  to  local  hypertrophy  of  the  bones,  to 
hypertrophy  of  the  soft  tissues  (nryxcecleina  and  leprosy),  and  to 
enlargement  of  the  contents  of  the  cranium.  Enlargement  of  the  bones 
is  seen  in  leontiasis  ossea.  In  osseous  hypertrophy  the  bones  are  thick- 
ened. Gowers  states  such  thickenings  may  simulate  hydrocephalus  at 
any  age.  He  thinks  it  doubtful  whether  the  nature  of  osseous  hyper- 
trophy can  be  ascertained  during  life. 

Enlargement  due  to  increase  of  cranial  contents  is  seen  in  hydro- 
cephalus. 

Hydrocephalus.  The  enlargement  of  the  skull  is  very  conspicuous, 
and  the  disproportion  of  the  cranium  to  the  face  is  striking.  The 
cranium  is  rounded  or  globular  in  shape,  and  the  fontanelles  are  seen 


Fig.  9. 


Congenital  hydrocephalus.    Female,  aged  seventeen.    (The  thinness 
of  the  hair  could  not  be  represented. 

to  be  very  large,  tense,  and  bulging,  and  the  sutures  widely  separated. 
The  disproportion  in  size  between  the  face  and  head  is  increased  by  the 
projection  of  the  anterior  portion  of  the  skull.  The  axis  of  the  eyes  is 
directed  downward,  and  they  are  partly  covered  by  the  eyelids,  because 
of  the  oblique  direction  of  the  orbital  plates.  The  head  is  supported 
with  difficulty.  The  eyeballs  roll  from  side  to  side.  There  is  frequently 
strabismus.  The  skin  is  stretched  tightly  over  the  cranium,  and  the 
hair  is  scanty.     (See  Fig.  9.) 


THE  DATA   OBTAINED  BY  OBSERVATION.  87 

Diminution  in  the  size  of  the  head  is  seen  in  microcephalus  (circum- 
ference less  than  seventeen  inches).     It  is  usually  abnormal  in  shape. 

Fontanelles.  After  a  consideration  of  the  size  and  shape  of  the  head 
we  turn  our  attention  to  an  examination  of  the  fontanelles  and  the 
bones  of  the  head.  The  fontanelles  in  a  healthy  child,  with  the  excep- 
tion of  the  anterior,  close  in  the  early  weeks  of  life.  The  anterior 
close  from  the  sixteenth  to  the  twentieth  month.  We  note  whether 
they  are  open  or  closed,  prominent  or  depressed.  Xew  openings  or  fon- 
tanelles and  loose  bone  plates,  the  normal  fonanelles  remaining;  open,  are 
seen  in  so-called  craniotabes — a  condition  found  in  congenital  syphilis 
and  rarely  in  rhachitis. 

Prominence  or  fulness  may  be  temporary  or  permanent.  W 'hen  the 
former,  a  passing  fever  with  cerebral  congestion  may  be  the  cause ; 
when  the  latter,  hydrocephalus  and  other  brain  affections  in  which 
there  is  increase  of  internal  pressure.  Depression  of  the  fontanelles 
occurs  in  general  atrophy,  marasmus,  and  in  wasting  diseases  generally. 
It  is  present  in  collapse,  and  is  of  grave  prognostic  omen.  In  pneu- 
monia and  other  respiratory  affections  with  dyspnoea,  retraction  is 
observed.  The  former  affection,  with  cerebral  symptoms,  is  thus  dis- 
tinguished from  cerebral  meningitis  in  which  the  fontanelles  bulge. 
The  fontanelles  are  neither  prominent  nor  depressed  in  rickets,  a  point 
of  distinction  between  this  affection  and  hydrocephalus  or  enlargement 
from  other  internal  causes.  They  may  remain  open,  moreover,  long  after 
the  usual  period  of  closure  in  rhachitis,  even  to  the  third  or  fourth  year. 

The  Bones.  The  bones  of  the  cranium  may  be  thickened  ;  they 
may  be  the  seat  of  periostitis,  of  necrosis,  and  caries.  Necrosis  and 
caries  of  the  frontal  bone  are  almost  pathognomonic  of  syphilis.  Xecro- 
sis  of  the  jaw  bone  belongs  to  phosphorus-poisoning.  The  mastoid  and 
petrous  portions  of  the  temporal  bone  should  be  examined  in  many 
affections.  The  symptoms  that  should  call  our  attention  to  these  bones 
are  pain  and  tenderness  over  the  mastoid,  rigors,  and  fever,  with  the 
symptoms  of  thrombosis  of  the  cerebral  sinuses,  pain  in  the  head,  con- 
vulsions, and  strabismus.  Examination  in  this  region  should  extend 
to  the  occipito-atlantal  articulation.  Disease  of  this  articulation,  and 
particularly  tubercular  disease,  causes  stiffness  of  the  neck  or  falling 
forward  of  the  head.  On  account  of  the  stiffness,  associated  with  diffi- 
culty of  deglutition  and  pain,  the  writer  has  seen  it  mistaken  for  retro- 
pharyngeal abscess. 

Auscultation  and  percussion.  We  have  thus  far  limited  our  examina- 
tion of  the  head  to  inspection  and  palpation.  Auscultation  has  been 
practised,  and  at  one  time  it  was  thought  the  continuous  murmur  heard 
over  the  vertex  in  children  was  due  to  intracranial  disease.  Osier, 
however,  pointed  out  its  occurrence  in  healthy  children,  hence,  unless 
heard  in  adults,  its  presence  is  not  of  diagnostic  significance.  McEwen, 
of  Glasgow,  has  found  that  in  cerebral  abscess  and  tumor  and  also  in 
meningitis,  secondary  to  ear  disease,  a  difference  in  the  percussion-note 
was  found  over  the  affected  area,  and  at  the  same  time  the  percussion 
resistance  was  increased.  The  site  of  disease  was  indicated  by  a  note 
higher  in  pitch  than  the  usual  osteal  note.  Comparison  of  the  two 
sides  must  be  made. 


88  GENERAL  DIAGNOSIS. 


The  Neck. 


The  position  and  movements  of  the  larynx  and  trachea,  the  thyroid 
gland,  the  lymphatic  glands,  and  the  vessels  of  the  neck  should  be 
observed. 

The  larynx  and  trachea  occupy  the  median  line  in  health,  but  may  be 
deflected  to  the  right  or  left.  The  deflection  is  more  readily  noticed  at 
the  lower  part  of  the  neck,  and  can  be  ascertained  by  comparing  its 
position  with  the  normal  relation  to  the  adjacent  muscles.  The  change 
in  position  is  due  to  disease  within  the  thorax.  An  aneurism  or  a 
mediastinal  tumor  may  cause  this  alteration.  In  cases  of  chronic 
fibroid  phthisis  the  trachea  is  pulled  to  the  side  of  the  affected  lung. 
When  the  respiratory  movement  of  the  larynx  and  trachea  is  excessive 
and  associated  with  dyspnoea  the  source  of  the  dyspnoea  is  of  laryngeal 
origin.  When,  on  the  other  hand,  the  movements  are  lessened,  or  the 
organs  remain  fixed,  notwithstanding  violent  efforts  at  respiration,  the 
dyspnoea  is  due  to  disease  in  the  mediastinum,  as  enlargement  of  the 
mediastinal  glands,  or  aneurism  pressing  upon  a  bronchus.  Tracheal 
tugging  may  be  seen,  but  is  usually  determined  by  palpation.  It  is 
particularly  characteristic  of  aneurism  of  the  descending  portion  of  the 
aorta.  The  aneurismal  sac  presses  upon  the  bronchus,  and,  with  each 
pulsation  of  the  vessel,  tugs  or  pulls  downward  upon  the  trachea,  which 
tugging  is  transmitted  to  the  hand.     (See  Diseases  of  the  Vessels.) 

Thyroid  Gland.  It  may  be  enlarged  or  atrophied.  Atrophy  is 
shown  by  absence  of  fulness,  which  would  otherwise  be  present.  (See 
Myxoedema  and  Acromegalia.) 

Enlargement  of  the  thyroid  can  be  detected  without  much 
difficulty.  It  may  be  limited  to  one  lobe,  or  both  lobes  may  be  affected. 
It  may  vary  in  size  from  a  small  localized  swelling  to  large  masses 
which  fill  the  median  and  lateral  sides  of  the  neck,  pressing  upon  the 
trachea  and  extending  into  the  thorax.  On  palpation  the  swelling  may 
be  soft  or  hard.  In  the  fibrous  forms  the  swelling  is  not  very  large 
and  is  very  much  indurated.  In  the  cystic  forms  of  the  thyroid  en- 
largement fluctuation  may  often  be  detected  ;  it  may  be  localized  to  a 
small  area  of  the  lobe,  or  may  be  detected  over  the  entire  affected  lobe. 
In  some  cases,  on  palpation,  a  purring  or  thrill  is  transmitted  to  the 
fingers.  The  thrill  is  synchronous  with  the  heart's  action  and  due  to 
increased  vascularity  of  the  gland.  Auscultation  under  these  circum- 
stances reveals  a  systolic  murmur. 

Causes.  Enlargement  of  the  thyroid  gland  may  be  due  to  simple 
hypertrophy,  to  fibro-cystic  enlargement,  or  to  enlargement  in  which 
the  vascularity  is  more  prominent,  as  in  exophthalmic  goitre.  1.  In 
simple  hypertrophy  the  enlargement  is  often  intermittent,  increasing 
in  size  at  each  menstrual  period,  or  coming  on  in  pregnancy,  to  disap- 
pear after  labor.  It  may  then  disappear  entirely  or  return  at  the 
menopause.  2.  The  fibro-cystic  enlargement  which  occurs  in  countries 
in  endemic  form  is  persistent.  3.  The  enlargement  of  exophthalmia 
generally  continues  throughout  the  course  of  the  disease.     (See  below.) 

Exophthalmic  Goitre.  Exophthalmic  goitre,  Graves's  or  Basedow's 
disease,  is  far  more  frequent  in  women  than  in  men.     It  may  develop 


THE  DATA  OBTAINED  BY  OBSERVATION.  89 

at  any  age,  but  is  most  common  in  early  adult  life.  A  neurotic  hered- 
ity, exhausting  disease,  general  debility,  and  anaemia  are  predisposing 
causes,  while  sudden  fright  or  shock  is  the  most  common  exciting 
cause.     Graves's  disease  begins  slowly. 

The  data  just  recorded  are  those  of  the  social  and  family  history,  and 
with  the  objective  symptoms  to  be  described  complete  the  picture  of 
this  affection. 

Of  the  three  classic  symptoms,  rapidity  of  the  heart's  action,  with 
palpitation,  enlargement  of  the  thyroid,  and  prominence  of  the  eyes  (exoph- 
thalmos), the  first  is  the  essential  symptom.  It  is  also  usually  the 
earliest.  Either  enlargement  of  the  thyroid  or  exophthalmos  may  be 
absent  for  months  or  years,  and  in  some  instances  throughout  the  disease. 

1 .  Tachycardia.  Attacks  of  palpitation  may  recur  at  intervals  for 
a  long  time  before  their  true  nature  is  suspected.  In  these  attacks  the 
behavior  of  the  heart  is  much  like  that  which  occurs  under  the  influence 
of  fright  or  great  excitement.  The  frequency  may  not  be  over  100  or 
120  in  the  early  attacks,  the  rate  being  normal  in  the  intervals.  In  the 
later  and  severe  attacks,  however,  the  pulse  beats  160  or  180  or  even 
200.  It  is  small  and  regular.  The  heart  beats  with  increased  force  ; 
the  sounds  are  loud,  sharp,  and  clear,  occasionally  being  heard  several 
feet  from  the  patient.  In  time  the  heart  becomes  hypertrophied  and 
dilated,  and  there  is  often  a  loud,  basic,  systolic  murmur. 

The  larger  arteries  and  even  sometimes  the  smaller  ones  show  the 
vascular  disturbance  by  increased  pulsation,  sometimes  with  thrill. 

2.  The  Thyroid  Gland.  The  thyroid  is  usually  the  next  to  be- 
come affected.  It  enlarges  slowly  from  vascular  dilatation,  the  swell- 
ing at  first  subsiding  in  the  intervals  between  attacks,  but  subsequently 
persisting.  The  right  lobe  may  be  larger  than  the  left.  The  enlarge- 
ment is  painless,  soft,  and  compressible.  It  may  pulsate  with  or  with- 
out thrill,  and  over  it  can  be  heard  hsemic  murmurs. 

3.  The  Eyes.  Prominence  of  the  eyes  is  the  most  conspicuous 
feature  of  well-marked  cases.  Like  enlargement  of  the  thyroid,  it 
varies  in  degree,  and  rarely  is  wholly  absent.  The  protrusion  allows 
the  white  sclerotic  to  show  above  and  below  the  cornea,  giving  the  eyes 
an  unnatural,  startled,  staring  appearance.  The  protrusion  may  be  so 
great  that  the  eyelids  cannot  close  ;  more  commonly  they  close,  but 
when  the  eyeball  is  simply  directed  downward  the  upper  eyelids  do 
not  follow  but  remain  spasmodically  elevated  or  lag  behind  the  move- 
ment of  the  eyeball  (Von  Graefe's  sign).  The  eyeball  may  become 
inflamed  and  even  slough  from  undue  exposure.  In  rare  instances  one 
eyeball  alone  is  affected,  and  in  these  cases  the  lobe  of  the  thyroid  of 
the  opposite  side  is  enlarged.  Stel wag's  sign  (widening  of  the  palpe- 
bral fissures)  is  the  third  ocular  sign  of  significance  in  exophthalmic 
goitre.  Finally,  Mobius  calls  attention  to  the  frequency  of  insufficiency 
of  the  internal  recti  muscles. 

In  addition  to  these  characteristic  symptoms  loss  of  flesh  and  strength, 
moderate  pyrexia  of  irregular  type,  impaired  appetite,  diarrhoea,  and 
despondency  are  observed.  The  diarrhoea  is  of  the  nervous  type — 
increased  peristalsis  without  local  catarrh.  Menstruation  is  apt  to  be 
irregular  or  to  cease.     Tinnitus  aurium,  headache,  and  vertigo  are  not 


90  GENERAL  DIAGNOSIS. 

uncommon,  and  sometimes  there  is  profuse  sweating.  A  restless,  nervous 
excitement  (Charcot)  is  very  common.  Muscular  tremor  (Marie),  occur- 
ring on  voluntary  movement,  is  frequently  observed,  and,  with  diar- 
rhoea, is  almost  as  common  as  the  three  primary  symptoms.  (Edema 
of  the  feet  is  often  seen  if  there  is  coexisting  mitral  disease.  Transitory 
vasomotor  oedema  of  the  eyelids,  the  face,  hands,  and  the  supraclav- 
icular and  infraclavicular  regions  occurs.     It  is  usually  circumscribed, 

and  may  not  pit  on  pressure. 

Fig.  10. 


Exophthalmic  goitre. 

Graves's  disease,  as  a  rule,  runs  a  chronic  course,  lasting  for  years. 
A  few  cases  that  have  run  an  acute  course  of  a  few  weeks,  some  ending 
in  recovery  and  some  in  death,  have,  however,  been  reported.  More- 
over, there  may  be  recurring  attacks  with  apparent  recovery  in  the 
intervals. 

Death  results  from  gradual  weakening  of  the  heart  and  its  direct  and 
indirect  effects.  It  may  be  hastened  also  by  uncontrollable  diarrhoea, 
acute  mania,  and  epilepsy.  The  disease  may  also  be  complicated  with 
hemorrhages,  and  these  may  be  the  immediate  cause  of  death. 

Enlargement  of  the  thyroid  gland  from  the  above-mentioned  causes 
must  be  distinguished  from  enlargement  due  to  abscess,  cancer,  sarcoma, 
or  adenoma.  Abscess  usually  follows  infectious  diseases  ;  in  the  writer's 
case  it  followed  typhoid  fever.  With  carcinoma  and  sarcoma  there  is 
anaemia  and  gradual  loss  of  flesh.  It  must  also  be  distinguished  from 
other  tumors  in  this  region.  It  particularly  must  not  be  confounded 
with  enlargement  on  the  right  side  due  to  an  innominate  aneurism. 
(See  Aneurism.) 

The  Vessels  of  the  Neck.  Changes  take  place  in  the  arteries  and 
veins,  observed  by  inspection,  palpation,  and  auscultation.  (For  a  de- 
scription of  these  changes,  see  Arteries  and  Veins.) 

The  Lymphatic  Glands.     (See  Chapter  XI.) 


CHAPTER    VIII. 

THE  DATA  OBTAINED  BY  OBSERVATION— {Continued). 

THE  EYE  AND  EAR. 

The  Eye.  Indirectly  the  eye  and  the  skin  are  the  external  struc- 
tures that  present  the  most  evidence  of  disease  in  other  organs.  This 
is  true  of  the  eye,  because  of  the  comparative  ease  of  its  examina- 
tion, and  because  it  is  a  highly  specialized  organ,  bearing  close  relation- 
ship to  the  vascular  and  nervous  system.  Its  special  functions  are 
subservient  to  the  highest  physiological  cerebral  action  ;  hence  any  per- 
turbation of  or  organic  change  in  the  cerebrum  is  expressed  in  altered 
eye  function,  either  of  movement  or  of  vision.  Its  nerve  and  vascular 
connection  with  the  brain  render  it  sensitive  to  internal  change.  In 
diseases  of  the  nervous  system  the  eye  is  the  one  organ  the  examina- 
tion of  which  is  essential  to  make  a  diagnosis.  Constant  reference  in 
the  chapter  on  Nervous  Disease  will  be  made  to  this  section,  and  the 
converse  holds  that  in  the  study  of  this  section  reference  must  be  made 
to  the  nervous  system.  But  diseases  of  the  heart,  the  kidneys  and  sys- 
temic conditions,  such  as  gout,  rheumatism,  diabetes,  etc.,  find  expres- 
sion often  in  some  eye  change. 

Much  may  be  gained  from  an  inspection  of  the  eye  and  its  aclnexa 
regarding  the  state  of  the  general  system.  This  is  at  once  evident 
when  we  reflect  that  of  the  twelve  pairs  of  cranial  nerves  four  pairs  are 
devoted  solely  to  this  important  organ,  while  in  the  eye  itself  we  have 
unfolded  to  our  gaze  a  living  nerve-head,  the  optic  papilla,  and  the 
retinal  vessels,  which  offer  to  our  view  the  perfect  cycle  of  the  supply 
of  an  organ  with  arterial  and  the  escape  of  its  venous  blood.  More- 
over, the  eye  presents  in  compact  form  representation  of  nearly  all  the 
tissues  of  the  body. 

In  order  to  insure  that  nothing  shall  escape  scrutiny  in  the  inspec- 
tion of  the  eye,  it  is  necessary  to  follow  some  settled  plan  of  investi- 
gation, and  for  this  purpose  it  is  well  to  pursue  an  anatomical  order, 
proceeding  from  the  superficial  to  the  deeper  structures. 

The  Lids.  (Edema  is  not  an  infrequent  symptom  of  renal  disease 
(see  (Edema  of  the  Face),  and  may  occur  in  cases  of  profound  anaemia 
and  chlorosis  ;  it  may  indicate  the  prolonged  use  of  arsenic,  or  it  may 
be  originated  by  disease  of  the  orbit  or  some  of  the  periorbital  sinuses 
of  the  same  side.  The  dropsy  may  accumulate  during  the  night  and 
be  seen  in  the  morning  on  rising.  Morning  puffiness  is  natural  to 
some  individuals.  Both  it  and  the  swollen  face  following  a  debauch 
are  not  to  be  confounded  with  oedema. 

Ptosis,  or  drooping  of  the  eyelid,  may  be  congenital,  more  usually  it 
is  a  symptom  of  disease  within  the  brain.  (See  Paralysis  of  the  Third 
Nerve.) 


92  GENERAL  DIAGNOSIS. 

Lagophthalmus  is  that  condition  in  which  the  lids  can  be  closed 
but  imperfectly,  and  follows  paralysis  of  the  orbicularis  muscle,  due  to 
lesions  of  the  portio  dura.  According  to  Bull  and  Hansen,  paralysis 
of  the  orbicularis  muscle  is  of  common  occurrence  in  leprosy. 

Blepharospasm,  or  active  closure  of  the  lids  from  spasm,  is  of  a 
reflex  nature,  originated  by  excitation  of  a  filament  of  the  fifth  nerve. 
It  is  always  present  to  a  greater  or  less  degree  in  photophobia  or  intol- 
erance of  light ;  this  latter  symptom  is  a  frequent  associate  of  ocular 
disorders,  and  is  also  found  in  certain  stages  of  meningitis,  cerebral 
tumors,  typhus,  measles,  etc.  It  accompanies  many  forms  of  head- 
ache, especially  migraine,  and  it  may  be  the  expression  of  a  hyper- 
esthesia of  the  retina  in  nervous  subjects,  apart  from  any  actual  in- 
flammation of  the  retina.  Cramp  of  the  orbicularis  muscle  has  been 
noted  quite  often  as  a  symptom  of  hysteria.  Nictitation,  or  undue 
winking  of  the  eyelids,  occurs  not  infrequently  in  children  as  part  of  a 
habit  of  chorea. 

Styes  or  small  boils  which  form  on  the  tarsal  margin,  and  blepharitis 
or  inflammation  of  the  margin  of  the  lids,  while  often  due  to  an  error 
of  refraction,  may  denote  some  defect  in  the  general  health,  such  as 
anaemia  or  scrofula. 

Vaccinal  eruption  may  appear  on  the  eyelids,  occurring  as  a 
small  ulcer  with  an  indurated  border  and  yellow  floor  at  the  commis- 
sures, and  is  usually  attended  by  some  swelling  of  the  lids  and  face 
and  by  enlargement  of  the  preauricular  glands. 

Chaxcbe  may  appear  either  as  a  primary  or  secondary  sore,  and  is 
generally  situated  in  the  conjunctiva  lining  the  lids. 

Malignant  pustule,  or  specific  anthrax,  is  seen  at  times,  though 
rarely,  on  the  lids  of  those  who  are  exposed  to  infection  from  diseased 
animals  or  decayed  animal  matter. 

Xanthelasma  consists  in  the  formation  of  small,  irregular,  opaque, 
yellowish  patches,  slightly  elevated  above  the  surrounding  skin.  These 
areas  may  either  remain  localized  or  the  disease  may  involve  the  palms 
of  the  hands,  the  flexures  of  the  fingers,  and  the  inside  of  the  mouth. 
(See  Tongue.) 

The  Orbit.  Exophthalmus,  or  proptosis,  abnormal  prominence  or 
protrusion  of  the  eyeball,  is  usually  occasioned  by  some  disease  of  the 
orbit  or  of  the  neighboring  sinuses  which  encroaches  upon  the  cavity 
of  the  orbit.  It  is  one  of  the  diagnostic  features  of  exophthalmic  goitre 
(see  Exophthalmic  Goitre),  and  may  also  be  caused  by  paralysis  of  the 
ocular  muscles.  It  has  been  seen,  though  rarely,  after  spontaneous 
hemorrhages  into  the  orbit  in  cases  of  haemophilia  and  scurvy. 

Enophthalmus,  or  retraction  of  the  eyeball,  may  be  the  result  of  ex- 
hausting diseases,  such  as  peritonitis,  or  secondary  to  some  orbital 
lesion.  It  is  very  pronounced  in  the  sudden  atrophy  that  occur.-  in 
cholera  from  loss  of  water. 

Extraocular  Muscles.  Before  detailing  briefly  the  measures  em- 
ployed for  the  detection  of  paralysis  of  the  extraocular  muscles,  and 
that  the  subject  may  be  grasped  more  readily,  a  few  words  of  expla- 
nation will  be  given  regarding  the  anatomy  and  physiology  of  the 
muscles  engaged  in  the  ocular  movements. 


THE  DATA  OBTAINED  BY  OBSERVATION.  93 

The  eyeball  is  suspended  in  the  orbital  cavity  by  means  of  six  mus- 
cles— the  four  recti,  superior,  inferior,  internal,  and  external,  and  the 
superior  and  inferior  oblique.  Of  these  the  four  recti  and  the  superior 
oblique  have  their  origin  at  the  apex  of  the  orbit,  while  the  inferior 
oblique  rises  from  its  lower  inner  wall.  These  muscles  exercise  their 
action  upon  the  movements  of  the  globes  in  three  pairs,  each  pair  being 
composed  of  two  antagonistic  muscles  ;  the  rectus  internus  and  exter- 
nus  ;  the  rectus  superior  and  inferior,  and  the  superior  and  inferior 
obliques.  The  sixth  nerve  supplies  the  external  rectus,  the  fourth  the 
superior  oblique,  the  remaining  four  muscles  receiving  their  impulses 
from  the  third  nerve. 

When  all  of  the  muscles  are  in  a  state  of  equal  tension  and  the  visual 
axes  are  directed  straightforward  in  the  horizontal  plane,  the  eyes  are 
then  said  to  be  in  the  primary  position.  Any  deviation  from  this  is 
known  as  a  secondary  position,  the  simplest  of  these  being  direct  lateral 
or  vertical  movements.  Thus,  the  rotation  of  the  eye  directly  inward 
is  accomplished  by  the  rectus  internus,  outward  by  the  rectus  externus, 
upward  by  the  superior  rectus  and  the  inferior  oblique,  and  downward 
by  the  inferior  rectus  and  the  superior  oblique.  Oblique  movements 
of  the  eyeball,  however,  are  more  complicated  and  necessitate  the  action 
of  a  third  muscle  to  regulate  the  torsion  which  the  eye  undergoes  when 
it  is  moved  from  the  perpendicular.  This  is  occasioned  by  the  fact 
that  while  the  plane  of  the  points  of  origin  and  insertion  of  the  rectus 
externus  and  internus  corresponds  with  the  horizontal  plane  of  the 
eyeball,  that  of  the  rectus  superior  and  inferior  and  of  the  oblique  mus- 
cles do  not  correspond  with  the  vertical  and  horizontal  planes  respect- 
ively. Therefore,  so  soon  as  the  globe  is  moved  into  the  oblique  posi- 
tion, it  rotates  or  undergoes  a  certaion  amount  of  torsion.  Thus,  the 
superior  rectus,  in  addition  to  elevating  the  eye,  rotates  the  upper  part  of 
the  cornea  toward  the  nose,  while  the  inferior  rectus,  in  direct  antagonism 
to  it,  depresses  the  eye  and  rotates  the  upper  half  of  the  cornea  exter- 
nally ;  these  muscles  exercising  their  greatest  degree  of  torsion  when 
the  eyeball  is  turned  inward  and  either  upward  or  downward.  The 
superior  oblique  depresses  the  eye  and  rotates  the  upper  part  of  the  cornea 
internally,  while  the  inferior  oblique  elevates  the  eye  and  rotates  the 
upper  half  of  the  cornea  externally.  The  obliques,  in  antagonism  to 
the  superior  and  inferior  recti  muscles,  exercise  their  maximum  amount 
of  torsion,  therefore,  when  the  eye  is  rotated  externally  and  either 
upward  or  downward. 

It  appears  from  the  foregoing  that  in  inward  and  downward 
motion  the  rectus  internus  and  inferior  and  the  superior  oblique  will 
be  brought  into  play  ;  in  outward  and  upward,  the  rectus  externus 
and  superior  and  the  inferior  oblique  ;  and  in  outward  and  down- 
ward movements  the  rectus  externus  and  inferior  and  the  superior 
oblique. 

Manner  of  Detecting  Palsies  of  the  Extraocular  Muscles. 
Normally,  the  movements  of  both  eyeballs  are  in  perfect  association 
and  harmony,  so  that  the  images  of  objects  fall  upon  corresponding 
points  of  both  retinse,  and  single  vision  obtains.  If  this  harmonious 
action  be  interrupted  by  paralysis  of  one  or  more  of  the  extraocular 


94  GENERAL  DIAGNOSIS. 

muscles,  however,  then  this  no  longer  happens,  and  limitation  in  the 
movement  and  deviation  of  the  affected  eye  is  the  result,  coupled  with 
double  vision  or  diplopia. 

Limitation  in  the  Movements  and  Deviation  of  the  Af- 
fected Eye.  In  studying  limitations  of  motion  hi  the  eyes,  the  ex- 
aminer seats  himself  before  the  patient  and  requests  the  latter  to  follow 
with  his  eyes  the  movements  of  a  candle  which  is  carried  through  all 
the  different  meridians  of  the  visual  fields,  any  muscular  deviation 
being  made  evident  by  a  failure  in  correspondence  of  the  images  from 
the  candle  reflected  from  the  cornea,  as  well  as  by  the  lagging  in  the 
movements  of  the  eye  in  the  deviation  of  the  action  of  the  affected 
muscle.  There  are  three  general  laws  which  have  been  formulated 
which  should  be  borne  in  mind  in  this  connection.  1.  The  limitation 
in  motion  as  well  as  the  diplopia  increases  toward  the  side  of  the 
affected  muscle.  2.  The  secondary  deviation  (the  deviation  which  the 
sound  eye  makes  while  the  affected  eye  is  fixing  the  candle)  is  greater 
than  the  primary  deviation  (the  deviation  of  the  affected  eye  while 
the  sound  eye  fixes).  3.  The  image  formed  on  the  retina  of  the  affected 
eye  is  projected  in  the  direction  of  the  paralyzed  muscle. 

Diplopia.  The  character  of  the  diplopia  varies  according  to  the 
muscle  or  muscles  whose  function  has  been  disturbed.  Generally 
speaking,  diplopia  is  either  simple  or  homonymous,  or  crossed  or  heter- 
onymous. In  the  former  the  image  of  the  affected  eye  lies  on  the  cor- 
responding side  and  betokens  convergence  of  the  visual  axes,  while  in 
the  latter  the  image  of  the  affected  eye  is  projected  to  the  opposite  side 
and  indicates  divergence  of  the  visual  axes.  In  order  to  ascertain  the 
relation  of  the  two  images  to  the  respective  eyes,  it  is  essential  that  the 
diplopia  should  be  carefully  tested. 

Ted  for  Diplopia.  For  this  purpose  the  patient  is  seated  in  a  dark- 
ened room  with  a  red  glass  placed  before  one  of  the  eyes,  in  order  to 
facilitate  the  identification  of  each  image  by  its  color,  and  a  lighted 
candle  is  held  on  a  level  with  the  head  about  five  metres  off.  Having 
noticed  any  deviation  which  the  eyes  make  in  the  primary  position, 
upon  a  chart  especially  constructed  for  this  purpose,  the  candle  is  moved 
through  the  different  meridians  of  the  visual  field,  the  patient  being 
requested  to  regard  the  flame  with  both  eyes  while  the  head  remains 
quiet,  each  deviation  being  carefully  noted  on  the  chart. 

After  the  deviations  have  been  recorded  the  diagnosis  of  the  affected 
muscle  or  group  of  muscles  will  be  much  facilitated  by  the  following 
rules  :  If  the  diplopia  be  lateral,  then  the  paralysis  is  either  of  the 
rectus  interims  or  externus.  If,  in  addition,  the  images  are  crossed, 
then  the  interims  is  at  fault,  but  if  they  are  homonymous  the  ex- 
ternus is  paralyzed.  If  the  diplopia  be  vertical,  and  in  the  upper 
field,  then  the  paralysis  is  either  of  the  rectus  superior  or  the  oblique 
inferior.  If  the  images  be  crossed,  paralysis  of  the  superior  rectus  is 
indicated,  but  if  they  be  homonymous,  implication  of  the  inferior 
oblique  is  designated.  If  the  diplopia  be  vertical  and  in  the  lower 
field,  then  the  paralysis  is  either  of  the  rectus  inferior  or  obliquus  supe- 
rior— -crossed  images  indicating  paralysis  of  the  rectus  and  homony- 
mous that  of  the  oblique  muscle. 


THE  DATA   OBTAINED  BY  OBSERVATION.  95 

Additional  Symptoms.  In  addition  to  the  study  of  the  anomalies 
in  motion  and  of  the  diplopia,  considerable  information  may  also  often 
be  gained  by  noting  the  position  of  the  head  in  ocular  paralyses. 
Thus,  in  paralysis  of  the  sixth  nerve,  the  face  is  turned  toward  the 
paralyzed  side  ;  in  paralysis  of  the  fourth  nerve,  it  is  turned  downward 
and  toward  the  shoulder  of  the  paralyzed  side  ;  and  in  paralysis  of  the 
third  nerve,  the  face  looks  toward  the  shoulder  of  the  same  side.  Not 
rarely  dizziness  is  complained  of  and  false  projection  of  the  field  of 
vision,  causing  patients  to  make  faulty  estimation  of  distance. 

The  Clinical  Significance  of  Disturbances  in  the  Motility 
of  the  Extraocular  Muscles.  In  addition  to  the  significance 
which  paralysis  of  the  eye  muscles  bears  to  lesions  of  the  brain  and  of 
the  cranial  nerves,  and  which  will  be  dwelt  upon  at  length  later,  dip- 
lopia may  proceed  from  some  much  less  serious  disturbance,  as,  for 
example,  derangements  of  the  digestive  organs  or  alcoholic  intoxicants. 
Transient  attacks  of  diplopia  may  be  among  the  earliest  symptoms  of 
tabes  dorsalis,  and  may  occur  at  the  very  beginning  of  cerebral  men- 
ingitis. 

Monocular  diplopia  is  a  rare  symptom,  and  when  it  can  be  dis- 
associated from  some  local  disturbance  in  the  media  of  the  eye,  may 
be  attributed  to  hysteria. 

Ocular  deviations  or  paralytic  squint,  as  has  just  been  described,  must 
be  differentiated  from  concomitant  squint  or  strabismus.  In  this  latter 
variety  there  is  no  great  restriction  in  movements  of  the  eyes  in  any 
direction,  the  faulty  position  of  the  visual  axis  remaining  constant 
while  the  eyes  are  moved  from  side  to  side,  and  the  secondary  devia- 
tion being  equal  to  the  primary.  This  is  the  condition  which  is  com- 
monly known  as  cast  or  cross-eye,  and  usually  makes  its  appearance 
in  children  with  high  degrees  of  far-sightedness. 

Nystagmus  is  a  spasmodic  condition  of  the  muscles  of  the  eye,  pro- 
ducing rapid  oscillations  of  the  ball,  usually  horizontal,  sometimes 
rotary  and  rarely  vertical.  It  is  of  great  value  as  a  symptom,  being 
found  in  many  brain  lesions,  usually  those  of  the  restiform  bodies,  the 
vermiform  process,  and  of  the  cerebellum.  It  is  also  seen  in  Fried- 
reich's ataxia,  in  miners,  and  often  as  the  result  of  visual  defects. 

Muscular  Insufficiencies.  Of  late  years  much  attention  has 
been  given  by  ophthalmologists  and  neurologists  to  the  study  of  errors 
in  the  extraocular  muscle  balance  in  different  reflex  psychoses.  While 
the  assertion  which  has  been  made  by  some,  that  chorea  and  even  epi- 
lepsy may  be  originated  by  such  deviations,  is  extreme,  it  is  neverthe- 
less quite  true  that  many  forms  of  headache,  of  vertigo,  of  nausea,  and 
of  vague  neuralgic  pain  of  a  cephalgic  type  can  be  traced  to  this  source. 
It  is  important,  therefore,  that  the  clinician  should  be  acquainted  with 
such  errors,  and  should  be  familiar  with  the  methods  employed  for  their 
detection. 

The  device  of  Maddox  is  usually  employed  for  this  purpose.  This 
consists  of  a  glass  cylinder  which  is  fitted  into  a  linear  opening,  which 
is  made  in  a  metallic  disk.  The  patient  is  seated  before  a  candle  flame 
five  metres  off  and  requested  to  regard  the  flame  with  both  eyes.  The 
rod  is  then  placed  before  one  of  the  eyes  perpendicularly  and  an  image 


96  GENERAL  DIAGNOSIS. 

of  a  perpendicular  streak  of  light  obtained  from  that  eve.  If  the  streak 
of  light  be  deviated  toward  the  same  side  as  the  eye  before  which  it  is 
held,  a  condition  of  excessive  convergence  or  esophoria  is  present ;  but 
if  the  streak  deviates  toward  the  opposite  side,  then  a  divergence  of  the 
visual  axes  or  exophoria  exists.  If  the  streak  be  on  a  higher  or  lower 
level  than  the  flame,  vertical  imbalance  or  hyperphoria  is  present. 
Balance  of  the  muscles  is  known  as  orthophoria. 

The  Conjunctiva.  The  conjunctiva  being  a  transparent  though 
vascular  membrane,  any  changes  in  the  amount  or  the  constitution  of 
the  blood  will  at  once  evidence  itself  in  its  folds.  Thus,  in  anaemia 
there  is  always  a  pallor  of  the  conjunctival  vessels,  while  in  plethora 
there  is  usually  a  passive  dilatation  of  the  vessels  which  gives  the  eye 
an  injected  appearance,  and  occasions  the  "  bloated  eye  "  of  the  drunk- 
ard. In  jaundice  the  conjunctiva  is  yellow.  Spontaneous  hemorrhages 
into  the  membrane  are  seen  in  whooping-cough,  asthma,  epilepsy,  and 
in  calcareous  degeneration  of  the  bloodvessels,  and  it  may  be  the  seat 
of  hemorrhagic  infarcts  in  ulcerative  endocarditis. 

Inflammation  of  the  conjunctiva  is  an  early  symptom  in  measles,  and 
in  typhus  fever  it  is  a  constant  sign,  and  serves  to  distinguish  this  affec- 
tion from  typhoid.  It  is  also  present  in  yellow  fever,  and  may  likewise 
constitute  one  of  the  earliest  signs  of  meningeal  and  cerebral  diseases. 
A  passive  hyperemia  follows  disease  of  the  cervical  sympathetic. 

The  Cornea.  The  cornea  being  an  avascular  membrane,  deriving 
its  nourishment  from  the  surrounding  structures,  it  is  very  prone  to 
undergo  inflammation  whenever  the  vitality  of  the  system  becomes 
much  lowered,  and  as  a  result  of  this  inflammation  opacities  remain 
which  have  a  very  deleterious  action  upon  vision.  These  opacities  may 
be  either  superficial  or  interstitial.  When  superficial  they  are  not  infre- 
quently the  result  of  burns,  traumatisms,  and  extension  of  the  inflam- 
mation from  the  surrounding  conjunctiva  ;  in  many  cases  they  denote, 
however,  that  the  eye  has  been  the  seat  of  a  phlyctenular  inflammation, 
a  form  of  ocular  disease  which  is  quite  common  in  scrofulous  children 
and  in  individuals  below  par. 

Superficial  ulceration  of  the  cornea  is  observed  also  in  all  fevers  of  a 
typhoid  type,  when  the  patient  lies  in  a  semi-conscious  state  with  the 
lids  but  partly  closed.  Dust  and  bacteria  gather  between  the  lids, 
and  as  the  patient  winks  but  seldom  a  crust  forms  on  the  cornea,  which 
is  folloAved  by  extensive  ulceration.  Abscesses  of  the  cornea  form  in 
the  stage  of  desquamation  of  variola,  and  must  be  differentiated  from 
those  which  arise  in  the  pustular  variety  of  the  disease  at  an  earlier 
period.  Ulcers  also  form  in  the  seventh  week  of  typhoid,  being  usually 
coincident  with  abscesses  in  the  scalp  and  skin  of  the  back. 

The  type  of  interstitial  opacities  of  the  cornea  is  seen  in  inherited 
syphilis.  Indeed,  to  the  trained  eye,  the  appearance  of  the  haze  in 
this  class  of  cases  is  so  characteristic  that  the  diagnosis  of  the  systemic 
affection  might  be  made  for  the  eye  alone.  Malaria  and  scrofula  may 
also  produce  similar  types  of  corneal  inflammation.  The  small  areas 
of  opacity  which  form  in  the  upper  and  lower  parts  of  the  cornea  near 
the  limbus,  and  which  at  times  encircle  the  cornea,  are  known  as  arcns 
senilis.     This  is  commonly  supposed  to  be  indicative  of  arterial  sclero- 


THE  DATA  OBTAINED  BY  OBSERVATION.  97 

sis,  although  the  author  has  never  found  ground  to  warrant  this  asser- 
tion. It  may  always  be  diagnosed  from  a  somewhat  similar  opacity  of 
inflammatory  origin  by  the  fact  that  in  the  latter  variety,  the  opacity 
being  due  to  an  inflammation  usually  beginning  at  the  corneo-scleral 
margin,  the  haze  is  continuous  with  the  conjunction  of  the  two  mem- 
branes ;  whilst  in  arcus  senilis  there  is  a  zone  of  clear  corneal  tissue 
between  the  margin  of  the  cornea  and  the  rim  of  the  opacity. 

After  lesions  of  the  fifth  nerve  the  cornea  may  ulcerate  from  trau- 
matic and  trophic  causes,  and  after  paralysis  of  the  seventh  nerve  it 
may  suffer  from  exposure  due  to  inability  to  close  the  lids. 

Iris.  Inflammation  of  the  iris  is  a  common  symptom  of  secondary 
syphilis ;  it  occurs  under  the  form  of  a  gummatous  infiltration  of  the 
membrane  in  the  tertiary  variety,  and  is  seen,  though  rarely,  in  inher- 
ited syphilis.  It  is  not  an  infrequent  symptom  of  chronic  rheumatism 
and  gout,  and  may  be  caused  by  tuberculosis  and  rheumatoid  arthritis. 

The  Pupil.  The  pupil  may  react  either  directly  or  indirectly  to 
light  stimulus.  In  order  to  observe  this,  the  patient  is  seated  before  a 
window  and  requested  to  gaze  at  the  sky.  The  examiner,  stationed  hi 
front  of  the  patient  with  his  back  to  the  window,  excludes  one  eye  by 
placing  his  hand  over  it,  and  notes  the  size  of  the  pupil  under  diffuse 
daylight.  The  eye  is  then  covered  with  the  other  hand,  and  the  dila- 
tation which  should  follow  is  also  approximated.  The  hand  is  then 
withdrawn,  and,  if  nothing  prevents,  the  iris  will  contract  to  the  same 
size  as  that  which  existed  at  the  commencement  of  the  test.  The 
fellow  eye  is  then  to  be  tried  in  a  similar  manner.  This  is  known  as 
the  direct  reflex  action  of  the  pupil ;  indirect  or  consensual  reflex  action 
being  the  contraction  or  dilatation  which  occurs  in  the  shaded  eye  when 
the  exposed  eye  is  being  examined,  and  should  correspond  precisely 
with  the  movements  of  the  pupil  of  that  eye. 

Having  noted  the  reaction  of  the  irides  to  light  stimulus,  the  patient 
is  now  directed  to  transfer  his  gaze  to  the  examiner's  finger,  which 
should  be  made  to  slowly  approach  the  eye,  whilst  its  fellow  is  screened 
off  as  in  the  former  test.  The  amount  of  the  contraction  induced  by 
this  accommodative  effort  is  carefully  noted,  and  the  same  procedure 
repeated  in  the  fellow  eye.  The  obstructing  hand  is  finally  removed, 
and  the  patient  being  requested  to  look  fixedly  at  the  tip  of  the  sur- 
geon's finger  with  both  eyes,  observation  is  made  of  the  contraction  of 
the  pupil,  which  should  be  induced  by  the  effort  at  convergence  which 
is  occasioned  by  approximating  the  finger  to  the  eyes  in  the  median 
line. 

Hipjpus  is  a  spasmodic  alternating  contraction  and  dilatation  of  the 
pupil,  which  is  seen  at  times  in  mania,  hysteria,  and  other  allied  disor- 
ders. Rhythmical  alterations  in  the  size  of  the  pupils  occur  frequently 
in  the  so-called  Cheyne-Stokes  respiration ;  the  pupil  contracting 
during  the  period  of  apncea  and  dilating  with  the  first  few  breaths. 

Modification  in  the  Size  and  Behavior  of  the  Pupils  as 
the  Result  of  Disease.  Pupillary  reaction  to  light  is  a  reflex  phe- 
nomenon, the  optic  nerve  being  the  afferent  nerve,  and  the  third  nerve 
the  efferent  nerve,  supplying  the  sphincter  of  the  iris  ;  communicating- 
fibres  between  the  corpora  quadrigemina  and  the  centre  from  the  third 

7 


98  GENERAL  DIAGNOSIS. 

nerve  making  such  a  reflex  possible.  The  mechanism  of  pupillary 
reaction  being  of  an  extremely  complicated  nature,  and  necessitating 
the  activity  of  a  number  of  nerves  and  nuclei,  it  is  not  strange  that 
anomalies  in  its  behavior  should  be  frequently  met  with  in  disorders 
of  the  central  nervous  system. 

Dilatation  of  the  pupil  (mydriasis),  apart  from  local  diseases,  of 
which  glaucoma  is  the  type,  may  be  produced  by  certain  psychical 
emotions,  such  as  fright  and  emotion,  or  it  may  be  caused  by  diseased 
processes  giving  rise  to  irritation  of  the  pupil — dilating  centre  or  fibres 
(irritative  or  spasmodic  mydriasis),  or  by  paralysis  of  the  pupil — con- 
tracting centre  or  fibres  (paralytic  mydriasis  or  iridoplegia). 

Irritation  mydriasis  occurs  (a)  in  hyperemia  of  the  cervical  portion 
of  the  spinal  cord  and  in  spinal  meningitis  ;  (b)  in  the  early  stages  of 
new  growths  in  the  cervical  portion  of  the  cord  ;  (c)  in  cases  of  intra- 
cranial tumor  and  other  diseases  causing  high  intracranial  pressure, 
according  to  Raehlmann,  although  Leeser  points  out  that  these  may 
also  give  rise  to  paralytic  mydriasis  ;  (d)  in  the  spinal  irritation  of 
chlorotic  or  aneemic  people,  after  severe  illness,  etc.  ;  (e)  as  a  premoni- 
tory sign  of  tabes  dorsalis  ;  (/)  in  cases  of  intestinal  worms,  owing  to 
the  stimulation  of  the  sensitive  nerves  of  the  bowel,  and  sometimes  in 
other  forms  of  intestinal  irritation  ;  (g)  in  psychical  excitement — e.  g., 
acute  mania,  melancholia,  progressive  paralysis  of  the  insane  (often, 
then,  unilateral,  with  myosis  in  the  other  eye).     (After  Swanzy.) 

Paralytic  mydriasis  (iridoplegia)  may  be  due  either  to  a  paralysis  of 
the  pupil  contracting  centre  or  as  a  result  of  the  stimulus  not  being 
conducted  from  the  retina  to  that  centre.  It  may  be  found  under  the 
former  circumstances  :  (a)  Sometimes  in  progressive  paralysis  where 
at  first  there  was  myosis  ;  (b)  in  various  diseased  processes  at  the  base 
of  the  brain  affecting  the  centre  of  the  third  nerve  ;  (c)  in  a  late  stage 
of  thrombosis  of  the  cavernous  sinus  ;  (d)  in  orbital  processes  which 
cause  pressure  on  the  ciliary  nerves.     (After  Swanzy.) 

It  is  said  to  be  present  in  acute  dementia,  when  there  is  oedema  of 
the  cortex,  and  is  found  in  cerebral  softening.  It  occurs  in  irritation 
of  the  cervical  sympathetic  and  occasionally  in  aortic  insufficiency. 

Contraction  of  the  Pupil  (Myosis).  Having  excluded  myosis 
from  local  causes,  especially  from  the  sequelae  of  iritis,  it  will  be  found 
that  contraction  of  the  pupil  may  be  caused  by  a  disease  process  irri- 
tating the  pupil-contracting  centre  or  nerve-fibres  (the  irritative  myosis 
of  Leeser),  or  by  one  causing  paralysis  of  the  pupil-dilating  centre 
or  nerve-fibres  (the  paralytic  myosis  of  Leeser),  or  by  a  combination 
of  both. 

Irritation  myosis  is  found  in  (a)  the  early  stages  at  least  of  all  in- 
flammatory affection  of  the  brain  and  its  meninges,  in  simple,  tuber- 
cular, and  cerebro-spinal  meningitis.  When,  in  these  diseases,  the 
medium  myosis  gives  place  to  mydriasis,  the  change  is  a  serious  prog- 
nostic sign,  indicating  the  stage  of  depression  with  paralysis  of  the 
third  nerve  ;  (b)  in  cerebral  apoplexy  the  pupil  is  at  first  contracted, 
according  to  Berthold,  who  points  out  that  this  contraction  is  a  diag- 
nostic sign  between  apoplexy  and  embolism,  in  which  latter  the  pupil 
is  unaltered  ;  (c)  in  the  early  stages  of  intracranial  tumors  situated  at 


THE  DATA  OBTAINED  BY  OBSERVATION.  99 

the  origin  of  the  third  nerve  or  in  its  course  ;  (d)  at  the  beginning  of 
a  hysterical  or  of  an  epileptic  attack  ;  (e)  in  tobacco  amblyopia,  prob- 
ably from  stimulation  of  the  pupil-contracting  centre  by  the  nicotine  ; 
(/)  in  persons  following  certain  trades,  as  the  result  of  long  main- 
tained effort  of  accommodation  (watchmakers,  jewelers,  etc.),  the  pupil- 
contracting  centre  being  subject  to  an  almost  constant  stimulus  ;  ((/)  as 
a  reflex  action  in  ciliary  neurosis  ;  consequently,  in  many  diseased  con- 
ditions of  those  parts  of  the  eye  supplied  by  the  fifth  nerve.  (After 
Swanzy.) 

Paralytic  myosis  occurs  in  spinal  lesions  above  the  dorsal  vertebra — 
e.  g.,  injuries  and  inflammations,  especially  of  the  chronic  form.  The 
contracted  pupil  occurring  in  gray  degeneration  of  the  posterior  columns 
of  the  spinal  cord  has  been  long  known  as  spinal  myosis.  In  the 
simple  form  of  this  myosis  the  pupil  has  but  a  medium  contraction, 
and  reacts  both  to  light  and  on  convergence.  This  condition  is  found 
in  the  early  stages  alone,  when  the  disease  has  attacked  merely  the 
cilio-spinal  centre,  or  higher  up,  as  far  as  the  medulla  oblongata  ;  later 
on,  when  Meynert's  fibres  become  engaged,  we  have  the  Argyll-Rob- 
ertson pupil.  The  very  minute  pupil  often  seen  in  tabes  dorsalis  is 
probably  due  to  secondary  contraction  of  the  sphincter  pupillse. 

Paralytic  myosis  is  also  found  in  general  paralysis  of  the  insane.  In 
acute  mania  the  pupil  is  usually  much  dilated,  and  when  this  mydriasis 
is  changed  for  myosis  approaching  general  paralysis  may  be  prognosti- 
cated. Myosis,  following  on  irritation  mydriasis,  is  also  found  in  mye- 
litis of  the  cervical  portion  of  the  cord.  In  bulbar  paralysis,  if  paralytic 
myosis  occurs,  the  disease  is  probably  complicated  with  progressive 
muscular  atrophy,  or  with  sclerosis  of  the  brain  and  spinal  cord. 
Myosis  may  also  be  due  to  paralysis  of  the  cervical  sympathetic,  result- 
ing from  injury,  from  pressure  of  an  aneurism  of  the  carotid,  innomi- 
nate, or  aorta,  or  from  pressure  of  enlarged  lymphatic  glands.  In 
apoplexy  of  the  pons  varolii  myosis  is  present,  but  it  is  not  yet  certain 
whether  it  is  an  irritation  myosis  or  a  paralytic  myosis. 

Inequality  of  the  pupils  may  denote  lesion  of  the  third  nerve,  affection 
of  the  cervical  sympathetic  in  the  cervical  region  of  the  spinal  cord, 
general  paralysis  of  the  insane,  or  some  unilateral  lesion  of  the  brain. 

The  Lens.  Cataract.  An  opacity  in  the  crystalline  lens  should 
always  awaken  the  suspicion  of  its  being  due  to  diabetes,  as  cataract  is 
of  not  infrequent  occurrence  in  this  disease.  Although  renal  disease 
also  has  been  held  accountable  by  some  for  the  occurrence  of  cataract, 
no  satisfactory  evidence  has  been  given  to  prove  this  assertion. 

The  Eye  Ground.  In  order  to  study  the  remaining  structures  of 
the  eye,  it  is  necessary  to  have  recourse  to  the  ophthalmoscope.  The 
essential  part  of  this  instrument  consists  in  a  concave  mirror,  whereby 
the  light  from  a  lamp  .which  is  placed  back  and  slightly  to  the  side  of 
the  patient's  head  may  be  projected  into  the  interior  of  the  eye  about 
to  be  examined.  This  mirror  is  provided  with  a  small  central  aper- 
ture, through  which  the  examiner  looks  and  studies  the  details  of  the 
back  of  the  eye  or  fundus  oculi,  as  it  is  technically  called.  When  the 
instrument  is  held  close  to  the  eye,  and  the  eye-ground  studied  without 
the  intermediation  of  other  means,  the  procedure  is  known  as  the  direct 


100  GENERAL  DIAGNOSIS. 

method  of  ophthalnioscopical  examination.  In  the  indirect  method,  on 
the  other  hand,  the  ophthalmoscope  is  held  about  sixteen  inches  from 
the  eye  and  an  inverted  image  of  the  fundus  obtained  by  means  of  a 
convex  lens,  which  is  interposed  between  the  ophthalmoscope  and  the 
eye,  and  serves  to  collect  the  rays  of  light  into  a  focus  between  the  lens 
and  the  eye  of  the  examiner.  The  former  method  possesses  the  advan- 
tage of  magnifying  the  interior  of  the  eye  about  fourteen  times,  while 
the  indirect,  although  of  less  magnifying  power,  permits  of  the  exami- 
nation of  a  greater  part  of  the  fundus  at  a  glance. 

The  ophthalmoscope,  in  addition  to  giving  us  information  in  regard 
to  the  condition  of  the  media  of  the  eye,  as,  for  example,  of  the  exist- 
ence of  commencing  cataracts,  or  of  opacities  within  the  vitreous  humor, 
unfolds  to  our  gaze  the  head  of  the  optic  nerve  as  well  as  the  retina 
and  the  choroid,  and  renders  patent  to  our  view  the  different  diseases  to 
which  they  are  liable.1 

Retlnttis.  The  systemic  affection  which  is  accompanied  by  a  lesion 
of  the  retina  more  often  than  any  other  is  disease  of  the  kidneys,  espe- 
cially chronic  interstitial  nephritis.  Indeed,  about  30  per  cent,  of  all 
cases  of  this  variety  of  renal  lesion  have  an  ocular  manifestation.  Ret- 
initis may  also  be  seen  as  an  early  symptom  in  the  nephritis  of  scarlet 
fever  and  pregnancy.  Its  occurrence  in  the  cirrhotic  kidney  is  of 
gloomv  import,  for  patients  with  a  retinal  complication  in  this  disease 
usually  die  within  two  years  of  its  first  appearance.  Retinitis  may  also 
be  occasioned  by  pernicious  anaemia,  leukaemia,  diabetes,  syphilis,  and 
heart  disease. 

Choroiditis  is  usually  the  result  of  syphilis,  but  may  in  rare  in- 
stances be  the  seat  of  tubercles.  Gout  may  also  originate  a  subacute 
inflammation  of  the  membrane. 

Optic  Xeueitis.  The  optic  nerve  being  really  a  prolongation  of 
the  brain,  and  being,  of  a  consequence,  so  often  liable  to  be  affected  in 
cerebral  disorders,  it  is  of  the  utmost  importance  that  the  clinician 
should  be  able  to  recognize  changes  in  its  appearance.  Indeed,  it  is 
safe  to  say  that  the  study  of  a  "  nervous  case,"  so  called,  is  never  com- 
plete without  the  report  of  the  ophthalmoscopic  findings. 

Papillitis,  or  choked  disk,  an  inflammation  of  the  head  of  the  optic 
nerve,  is  rarely  idiopathic,  but  is  occasioned  by  cerebral  growths  and 
by  meningitis,  especially  of  the  base  of  the  brain,  and  by  the  same  con- 
stitutional diseases  which  originate  retinitis.  It  also  occurs  in  acute . 
fevers,  and  it  may  be  the  result  of  suppression  of  the  menstruation. 
Usually,  however,  choked  disk  is  the  result  of  an  intracranial  tumor, 
occurring  in  90  per  cent,  of  all  such  cases,  and  as  it  is  an  early  sign,  its 
detection  has  frequently  been  the  means  of  the  discovery  of  many  in- 
tracranial neoplasms.  As  a  rule,  tumors  of  the  cerebellum  and  those 
of  the  cerebrum  which  interfere  with  the  circulation  in  the  lymph  pas- 
sages of  the  brain  originate  it,  the  size  and  the  character  of  the  tumor 
not  seemingly  influencing  its  production. 

The  variety  of  optic  neuritis  which  has  just  been  discussed   is  an 

1  It  has  not  been  thought  proper  in  a  work  of  this  kind  to  give  further  details  re- 
garding ophthalmoscopy,  the  student  being  referred  to  special  text-books  upon  ophthal- 
mology for  a  perusal  of  that  important  subject. 


THE  DATA  OBTAINED  BY  OBSERVATION.  101 

ascending  neuritis,  the  inflammation  beginning  at  the  intraocular  termi- 
nation of  the  nerve  and  spreading  upward  from  this  to  the  brain. 
There  is  also  an  interstitial  or  descending  neuritis  which  is  commonly 
caused  by  meningitis.  Retrobulbar  or  toxic  neuritis  is  a  variety  of 
inflammation  of  the  optic  nerve  where  the  disease  confines  itself  to  the 
bundle  of  nerve-fibres  which  go  to  supply  the  macular  regions.  This 
disease  is  commonly  caused  by  alcohol  and  tobacco,  although  it  may  be 
originated  by  quinine,  the  salicylates,  lead,  and  iodoform.  It  may  also 
be  caused  by  rheumatism  and  catching  cold,  and  there  is  a  rare  form 
where  the  disease  is  transmitted  through  certain  families  from  genera- 
tion to  generation. 

Optic  Atrophy.  This  may  be  secondary  to  some  inflammation  of  the 
optic  nerve  or  retina,  or  it  may  be  a  primary  disease. 

Secondary  or  consecutive  atrophy  is  usually  the  result  of  optic  neu- 
ritis ;  it  may,  however,  be  originated  by  local  causes  either  within  the 
eye  or  the  orbit.  Primary  atrophy,  on  the  other  hand,  though  occa- 
sionally idiopathic,  is  generally  found  associated  with  some  disease  of 
the  spinal  cord,  especially  with  locomotor  ataxia.  In  this  affection  it 
is  frequently  an  early  sign,  and  it  has  been  noted  by  Benedikt,  of 
Vienna,  that  when  this  occurs  it  is  rare  for  a  tabetic  patient  to  become 
ataxic.  It  has  also  been  remarked  that  cases  in  which  blindness  is 
well  advanced  suffer  but  little  from  the  pains  which  are  characteristic 
of  this  disease.  Simple  atrophy  occurs  also  in  lateral  and  insular 
sclerosis,  and  is  frequently  seen  in  general  paralysis  of  the  insane. 

Before  proceeding  further  with  the  consideration  of  the  cerebral 
expansion  of  the  optic  nerve,  it  becomes  necessary  to  study  the  methods 
which  are  used  in  the  determination  of  the  visual  acuity,  both  central 
and  peripheral,  as  these  are  valuable  and  often  necessary  adjuncts  in 
establishing  the  diagnosis  of  many  obscure  cases  of  cerebral  disease. 

Central  vision  is  tested  by  means  of  black  letters  printed  on  a 
white  test  card,  those  devised  by  Snellen  being  usually  employed  on 
account  of  the  admirable  system  upon  which  they  are  founded.  The 
patient  is  seated  five  metres  away  from  the  card,  and  one  eye  being  blind- 
folded he  is  requested  to  read  the  lowest  line  of  letters  which  he  can 
distinguish.  If  the  vision  fails  to  correspond  to  the  standard,  it  is 
necessary  to  exclude  hypermetropia,  myopia,  and  astigmatism  by  means 
of  convex,  concave,  and  cylindrical  lenses  before  it  can  be  definitely 
asserted  that  the  vision  is  lowered  as  the  result  of  disease. 

Peripheral,  vision,  or  the  extent  of  space  of  which  the  eye  is  con- 
scious when  it  is  fixed  on  any  given  point,  may  be  estimated  in  several 
ways;  it  is  accomplished,  however,  most  accurately  by  means  of  ihe 
perimeter.  This  is  an  instrument  which  consists  of  an  upright  rest 
for  the  chin  and  a  semi-circular  arc  or  bar,  graded  in  degrees,  which  re- 
volves upon  a  middle  point,  and  is  capable  of  describing  a  hemisphere 
in  space.  The  eye  under  examination  being  directed  straight  ahead  at 
the  fixation  point,  the  fellow  eye  being  blindfolded,  the  test  object,  a 
small  square  of  white  paper,  is  brought  from  the  periphery  toward 
fixation.  The  patient  is  then  asked  to  indicate  the  instant  the  object 
is  perceived,  and  the  examiner  marks  the  degree  upon  a  chart  pro- 
vided for  the  purpose.     If  the  perimeter   be  not  at  hand,  the  field 


102 


GENERAL  DIAGNOSIS. 


may  be  obtained  fairly  accurately  as  follows  :  The  patient  is  seated 
opposite  the  surgeon  with  one  eye  bandaged.  He  is  then  directed  to 
look  at  the  corresponding  eye  of  the  examiner  whilst  the  observer's 
finger  is""slowly  brought  in  from  the  periphery  toward  the  eye  through 
the  different  meridians.     In  this  way  the  surgeon  can  ascertain  whether 


Fig.  11. 


The  McHardy  perimeter. 

the  patient  permits  his  eye  to  wander  from  the  fixation  point,  and  at 
the  same  time  he  can  compare  the  extent  of  the  patient's  field  with 
that  of  his  own.  The  field  for  form  or  white  extends  over  150° 
horizontally  and  110°  vertically,  that  of  the  different  colors  falling 
within  this  in  the  following  order — yellow,  blue,  red,  and  green. 

Scotoma.  As  the  patient's  macula  corresponds  to  the  fixation  point 
in  the  visual  field,  the  physiological  blind  spot  which  is  occasioned  by 
the  entrance  of  the  optic  nerve  into  the  eye  will  be  found  in  the  tem- 
poral portion  of  the  field.  Pathological  blind  spots  are  known  as 
scotoma,  and  these  may  be  either  central,  paracentral,  or  disseminated. 
When  central,  they  indicate  either  a  disease  of  the  macula  or  of  the 
fibres  of  the  optic  nerves  supplying  the  macula,  so  that  a  central 
scotoma  is  one  of  the  diagnostic  features  of  retrobulbar  neuritis. 

Hemianopsia.  This  term  is  used  to  imply  a  defect  in  one-half 
the  field  of  vision,  the  defect  being  named  according  to  the  blind  area. 
Thus,  temporal  hemianopsia  means  that  the  eye  cannot  perceive  objects 
when  situated  in  the  outer  half  of  the  field.     The  most  common  form 


PLATE    I. 


LEFT  VISUAL  FIELD.    RIGHT  VISUAL  FIELD. 
Fixation  Pouit.  Fixation  Pomf . 


^.._ 


Z.  Genicu/afe  Body 


L  Int  Capsule 


\JR.  Exf.Genicu/ate 
Body 

R.fnf.Capsu/e 


Orr. 


Cc'/>Sfrr/  Corf  ft- 


P.  Occip>tnl 


THE  DATA  OBTAINED  BY  OBSERVATION.  103 

of  hemianopsia  is  the  loss  of  the  temporal  field  in  one  eye  and  of  the 
nasal  field  in  the  other,  this  condition  being  known  as  lateral  homony- 
mous hemianopsia.  If  the  temporal  portions  of  both  fields  are  lost, 
the  defect  is  known  as  bitemporal  hemianopsia ;  binasal  hemianopsia, 
indicating;  a  loss  in  the  nasal  fields  of  both  eyes.  Superior  and  inferior 
hemianopsia  are  very  rare. 

It  is  often  possible  by  studying  the  changes  in  the  visual  fields  to  locate 
quite  definitely  the  seat  of  the  cerebral  lesion.  By  a  reference  to  the 
diagram  (Fig.   12)  it    will    be    at   once  evident  that  a    lesion    of  the 


h  f  %   R 

Diagram  showing  the  course  of  the  optic  fibres  in  the  chiasm.    (Hirt.) 

chiasm  would  necessarily  comprise  the  crossed  fibres  of  the  optic  nerve, 
and  would  occasion  bitemporal  hemianopsia.  Such  a  lesion  may  be  due 
to  basilar  meningitis,  periostitis,  hyperostitis,  fracture  of  the  body  of 
the  sphenoid,  distentions  of  the  infundibulum,  and  of  the  third  ven- 
tricle, or  to  tumors,  especially  those  of  the  pituitary  body,  and  finally 
syphilitic  gumma.  If  due  to  the  latter  cause,  there  may  be  transient 
recurrent  attacks  of  the  hemianopsia.  Bitemporal  hemianopsia  is  also 
an  early  symptom  of  acromegalia.  The  lesion  in  superior  and  inferior 
hemianopsia  is  usually  in  the  chiasm  also,  affecting  its  superior  or  in- 
ferior portions  ;  these  defects  in  the  fields  may,  however,  be  caused  by 
symmetrical  cortical  lesions  and  by  optic  neuritis.     (See  Plate  I.) 

If  the  lesion  affects  the  outer  angle  of  the  chiasm,  then  monocular 
nasal  hemianopsia  is  the  result. 

Lesions  of  the  Tract  and  Centres.  As  shown  in  Plate  I., 
the  optic  tract  after  crossing  the  cms  to  the  hinder  part  of  the  optic 
thalamus  divides  into  two  branches,  one  going  to  the  thalamus  and  the 
external  geniculate  bodies  and  to  the  anterior  quadrigeminal  bodies 
from  which  fibres  pass  into  the  hinder  part  of  the  internal  capsule,  and 
entering  the  occipital  lobe,  form  the  fibres  of  the  optic  radiations  termi- 
nating in  the  cuneus,  the  perceptive  visual  centres  ;  while  the  fibres  of 
the  other  branch  pass  to  the  internal  geniculate  bodies  and  the  posterior 
(juadrigeminal  bodies. 

A  lesion  affecting  the  optic  fibres  anywhere  posterior  to  the  optic 
chiasm  will  produce  lateral  hemianopsia,  so  that  this  symptom  of  itself 
is  of  little  value  in  localizations.  There  are,  however,  certain  accessory 
symptoms  which,  when  taken  in  conjunction  with  it,  will  often  serve  to 
establish  the  seat  of  the  lesion  in  most  instances.  Tims,  in  hemian- 
opsia from  lesions  of  the  optic  tract  there  is  an  absence  of  the  symptoms 
which  occur  when  the  cortex  is  affected — as  mind-blindness,   word- 


104  GENERAL  DIAGNOSIS. 

blindness,  etc. — while  other  symptoms  indicating  a  basal  lesion  are  apt 
to  be  present,  as,  for  example,  implication  of  the  cranial  nerves,  espe- 
cially those  supplying  the  ocular  muscles.  Lesions  of  the  optic  tract 
are  also  frequently  associated  with  a  disease  of  the  crus  cerebri,  so  that 
hemianesthesia  or  hemiplegia  of  the  opposite  side  of  the  body  would 
be  associated  with  the  hemianopsia.  There  is,  however,  a  sign  which 
enables  us  at  once  to  say  definitely  whether  the  lesion  be  in  the  optic 
tract  or  not,  and  this  is  known  as  the  Wernicke  or  pupillary  inaction 
sign.  This  is  elicited  as  follows  :  The  patient  is  seated  in  a  darkened 
room  with  one  eye  blindfolded,  and  is  directed  to  look  straight  ahead 
into  the  darkness.  The  eye  being  slightly  illuminated  by  an  assistant 
by  means  of  the  diffuse  light  from  a  plane  mirror,  which  is  reflected 
into  the  eye  from  a  light  placed  behind  the  patient's  head,  the  examiner 
slowly  throws  a  small  beam  of  concentrated  light  from  a  concave  mirror 
upon  the  blind  half  of  the  retina.  If  the  pupil  fails  to  react,  the  lesion 
is  then  in  the  geniculate  bodies  or  in  the  tract,  inasmuch  as  the  failure 
in  the  pupillary  activity  indicates  that  the  lesion  must  have  involved 
the  sensory  motor  arc  of  the  pupil  as  well  as  the  visual  fibres. 
Although  when  present  the  Wernicke  sign  is  of  great  value,  recent 
observations  have  shown  that  its  absence  is  not  conclusive.  Lesions 
of  the  optic  tract  may  be  due  either  to  neoplasms  or  to  tubercular  or 
gummatous  meningitis,  or  more  rarely  they  may  be  the  result  of  cere- 
bral softening  and  hemorrhage.  As  yet  clinical  evidence  is  too  meagre 
to  permit  of  a  diagnosis  of  lesions  of  the  primary  optic  ganglia  (pulvi- 
nar  anterior  corpora  quadrigemina  and  external  geniculate  bodies), 
although  in  lesions  of  the  pulvinar  two  typical  symptoms  occur — viz., 
hemianopsia  and  athetosis — and  sometimes  hemianesthesia  may  be 
present.  In  like  manner,  also,  while  it  is  generally  believed  that 
lesions  of  the  optic  radiations  cause  homonymous  hemianopsia,  it  has 
not  been  definitely  proven  that  these  fibres  have  solely  to  do  with 
vision. 

The  hemianopsia  is  usually  thought  to  depend  upon  cortical  lesions 
in  the  occipital  lobe,  when  it  is  unaccompanied  by  any  of  the  accessory 
symptoms  which  have  just  been  detailed.  The  chief  diagnostic  symp- 
tom of  a  central  lesion,  however,  is  what  is  designated  as  negative 
vision,  "  vision  nulle,"  for  in  these  cases  the  patient  has  no  subjective 
sensations  of  the  defect  in  his  visual  field.  Cortical  hemianopsia  may 
also  be  incomplete,  but  a  quadrant  of  the  field  being  lost. 

Transitory  hemianopsia,  or  scintillating  scotoma,  is  the  occurrence  of 
symmetrical  defects  in  the  field  of  vision  which  usually  conform  to  the 
hemianopic  type,  and  in  which  a  play  of  lights  frequently  appears  as  a 
precursor  of  an  attack  of  migraine.     (See  Migraine.) 

Visual  hallucinations  may  also  be  hemianopic  in  character,  and  are 
due  to  irritation  of  the  visual  memory  centre. 

Hysterical  amblyopia  may  manifest  itself  either  in  complete  blindness 
or  central  scotoma,  but  more  commonly  as  defective  central  vision  with 
concentric  contraction  and  reversal  of  the  visual  fields. 

Paralysis  of  the  Motor  Nerves  of  the  Eyeball.  Although  in  the 
section  which  dealt  with  the  diseases  of  the  ocular  muscles  the  vari- 
ous forms  of  ocular  deviation  and  the  different  varieties  of  diplopia 


THE  DATA  OBTAINED  BY  OBSERVATION.  105 

which  resulted  therefrom  were  mentioned  at  length,  it  is  necessary  to 
refer  still  further  to  their  causes  and  to  point  out  their  connection  with 
cerebral  diseases. 

Paralysis  of  the  orbital  muscles  may  be  due  to  orbital  lesions  or  to 
those  at  the  base  of  the  brain  ;  they  may  indicate  pontine  lesions,  or 
they  may  be  originated  by  causes  operating  higher  up  in  the  cerebrum 
above  the  nuclei.  In  making  the  differential  diagnosis  between  central 
and  peripheral  palsies,  it  must  be  remembered  that  those  of  central 
origin  are  frequently  associated  with  other  symptoms  which  denote 
intracranial  involvement,  while  peripheral  palsies  are  generally  isolated 
and  often  complete. 

Peripheral  paralyses  of  the  orbital  muscles  are  generally  the 
result  of  either  rheumatism  or  syphilis.  When  due  to  the  latter 
disease  they  are  usually  tertiary  manifestations,  and  especially  is  this 
apt  to  be  the  case  if  the  third  nerve  is  involved,  which  seems  to  be 
singularly  prone  to  be  attacked  by  gumma  of  the  base.  Paralysis  of 
the  sixth  nerve  is  frequently  of  rheumatic  origin. 

Syphilis  causes  fully  one-half  the  cases  of  central  paralysis,  affecting 
either  the  nuclei  of  the  nerves  or  the  neighboring  brain  structure,  the 
third  and  fourth  ventricles,  or  the  aqueduct  of  Sylvius. 

Diphtheria  usually  causes  a  paralysis  of  the  ciliary  muscle  ;  it  may, 
however,  affect  one  or  more  of  the  external  muscles.  Diabetes  is  com- 
plicated at  times  by  paralysis  of  the  external  rectus.  Influenza,  herpes 
zoster,  and  whooping-cough  are  also  rare  causes  of  ocular  palsies. 
Paralysis  of  the  eye  muscles  is  seen  in  paretic  dementia,  bulbar  paraly- 
sis, and  in  multiple  and  posterior  sclerosis.  In  locomotor  ataxia  they 
may  be  transient  and  appear  at  an  early  stage  of  the  disease.  Ocular 
palsies  have  also  been  caused  by  poisoning  by  lead,  nicotine,  sulphuric 
acid,  carbonic  oxide,  and  tainted  meat. 

Complete'  paralysis  of  the  third  nerve  causes  the  following 
symptoms  :  The  upper  lid  droops,  the  pupil  is  partially  dilated  and 
immovable,  and  the  power  of  accommodation  is  lost.  The  globe  is 
slightly  protruded  and  strongly  diverged  externally  by  the  two  unaf- 
fected muscles  (the  external  rectus  and  the  superior  oblique).  In  in- 
complete paralyse  of  the  third  nerve,  as  well  as  in  paralysis  of  the  fourth 
and  sixth  nerves,  the  diagnosis  is  made  by  a  study  of  the  deviations  and 
by  the  character  of  the  diplopia,  which  has  been  already  referred  to. 

There  is  a  peculiar  form  of  intermitting  paralysis  of  the  third  nerve, 
known  as  ophthalmoplegic  migraine,  which  occurs  in  the  young  and  is 
associated  with  headache  and  at  times  with  vomiting. 

Paralysis  of  the  ciliary  muscle,  or  cycloplegia,  follows  a  lesion  of  the 
trunk  of  the  oculomotor  nerve  or  of  the  anterior  part  of  its  nucleus. 
It  is  quite  common  as  a  sequel  of  diphtheria,  and  occurs,  though  rarely, 
in  connection  with  spinal  disease. 

Ophthalmoplegia  externa  and  interna  refer  to  paralyses  of  all  or  nearly 
all  of  the  external  and  internal  muscles.  As  the  lesion  in  this  affec- 
tion is  central,  it  is  frequently  known  also  as  nuclear  paralysis.  In  its 
acute  form  it  is  due  either  to  an  acute  inflammatory  process  in  the 
nuclei  or  to  hemorrhage,  while  the  chronic  depends  upon  a  degenerate 
atrophy  of  the  nerve  nuclei,  similar  to  that  which  is  seen  in  progressive 


106  GENERAL  DIAGNOSIS. 

muscular  atrophy  and  in  chronic  bulbar  paralysis,  with  which  they 
may  become  associated. 

In  conjugate  lateral  deviations  of  the  eyes,  although  the  axes  of  vision 
of  both  eyes  are  deviated  from  the  middle  Hue,  yet  they  remain  parallel 
with  one  another.  This  condition  is  generally  the  result  of  a  cortical 
lesion  which  involves  the  movements  of  the  eyes  to  the  right  or  to  the 
left,  and  is  usually  the  result  of  apoplexy.  A  spasm  deviation  of  the 
eyes  in  the  same  direction  occurs  as  the  result  of  irritative  lesions  of  the 
brain,  involving  the  association  centres  or  tracts,  and  also  in  hysteria. 

The  Localizing  Value  of  Paralysis  of  the  Orbital  Muscles.' 

Paralysis  of  the  Third  Nerve.  Ptosis,  the  most  frequent  symptom 
of  diseases  of  this  nerve,  may  be  present  as  a  focal  symptom  in  cortical 
lesions  without  paralysis  of  any  other  branch  of  the  third  nerve.  This 
would  seem  to  indicate  a  special  centre  for  the  elevator  of  the  lids,  and 
though  not  definitely  ascertained,  such  a  centre  is  believed  to  exist  in 
front  of  the  upper  extremity  of  the  ascending  frontal  convolution  close 
to  the  centre.  Ptosis  on  the  side  of  the  lesion,  without  paralysis  of  the 
other  branches  of  the  third  nerve,  has  been  seen  in  disease  of  the  pons, 
and  again  by  forming  a  factor  of  a  crossed  paralysis  may  seem  to 
localize  a  lesion  in  the  crus  cerebri,  although  when  the  third  nerve  is 
paralyzed  by  a  lesion  in  this  situation  it  is  usually  involved  as  a  whole. 

Grossed  hemiplegia  is  a  term  used  to  express  a  disease  of  the  crus 
cerebri  when  there  is  paralysis  of  the  third  nerve  on  the  side  of  the 
lesion,  with  hemiplegia,  hemiansesthesia,  and  often  facial  and  sometimes 
hypoglossal  paralysis  of  the  opposite  side  of  the  body. 

Complete  paralysis  of  every  branch  of  the  third  nerve  without  any 
other  paralysis  is  almost  always  basal ;  so,  also,  are  those  cases  in 
which  when  there  is  hemiplegia  it  is  slight  as  compared  with  the  degree 
of  the  third-nerve  paralysis.  Lesion  of  the  interpeduncular  space  and 
thrombosis  of  the  cavernous  sinus  also  indicate  third-nerve  palsies  ;  but 
in  the  latter  the  other  orbital  nerves,  as  well  as  the  fifth  and  the  optic 
nerve,  may  be  involved  as  well  Third-nerve  symptoms  may  also  be 
distant  symptoms  of  tumors  of  the  cerebral  hemispheres,  more  particu- 
larly if  accompanied  by  violent  general  head  symptoms. 

As  a  symptom  of  cerebral  lesion  solitary  paralysis  of  the  fourth  nerve 
is  rare.  AVhen  present  it  is  apt  to  be  produced  by  a  basal  lesion.  In 
combination  with  paralysis  of  the  third  nerve  it  speaks  for  a  lesion  in 
the  cerebral  peduncle  extending  back  to  the  valve  of  Vieussens. 

When  paralysis  of  the  sixth  nerve  occurs  as  the  only  focal  sign  it  is 
probably  due  to  disease  of  the  base  as  a  distinct  symptom.  On  account 
of  the  lengthened  course  these  nerves  take  over  the  most  prominent 
part  of  the  pons,  which  renders  them  readily  affected  by  distant  press- 
ure ;  they  are  more  liable  to  provide  a  distant  symptom  than  any  other 
cranial  nerve.  Thus  paralysis  of  this  nerve  is  not  infrequently  a  dis- 
tant symptom  of  tumor  of  the  cerebellum,  whereas  paralysis   of  the 

1  This  section  has  been  epitomized  from  the  excellent  article  on  the  subject  in 
Swanzy's  Hand  Book  of  Diseases  of  the  Eye. 


THE  DATA  OBTAINED  BY  OBSERVATION.  107 

third  nerve  is  more  apt  to  be  a  distant  symptom  in  a  lesion  of  the  cere- 
bral hemisphere. 

Paralysis  of  the  sixth  nerve,  simultaneous  in  its  onset  with  hemi- 
plegia of  the  opposite  side  of  the  body,  indicates  a  lesion  in  the  pons, 
usually  a  hemorrhage,  on  the  side  corresponding  to  the  paralyzed  nerve. 
Basal  paralysis  of  the  nerve  is  frequently  double,  especially  in  syphilis. 
In  combination  with  paralysis  of  the  facial,  paralysis  of  the  sixth 
nerve  is  referable  to  a  pontine  lesion. 

The  Ear. 

Subjective  Symptoms.  Buzzing,  roaring,  hissing,  singing,  and 
other  sounds  in  the  ear — tinnitus  aurium — are  symptoms  which  may 
or  may  not  be  due  to  disease  of  the  ear.  If  associated  with  vertigo,  it 
may  be  due  to  Meniere 's  disease.  They  may  be  the  aura  preceding  an 
epileptic  attack  or  the  subjective  phenomena  attending  syncope.  Many 
drugs  when  pushed  to  physiological  effects  cause  tinnitus. 

The  External  Ear.  The  external  ear  should  always  be  examined. 
The  thin  ear  may  show  the  anaemic  or  chlorotic  hue  more  strikingly 
than  other  portions  of  the  body,  or  the  opposite  condition  may  be 
more  vividly  shown.  Hcematoma  auris  is  seen  in  general  paralysis  of 
the  insane  and  in  other  forms  of  insanity.  It  is  a  trophoneurosis. 
The  ear  is  thickened  and  deformed,  on  account  of  effusion  of  blood 
between  the-  cartilages  and  the  perichondrium.  It  is  discolored,  and 
simulates  the  subcutaneous  effusion  due  to  injury.  Tophi  are  observed 
in  the  external  ears  of  patients  with  a  gouty  diathesis.  They  are 
small,  hard,  gritty  accretions,  seen  in  the  external  ear  along  the  margin 
or  in  the  depressions.     They  consist  of  urate  of  soda. 

The  Discharge.  When  cerebral  symptoms  or  symptoms  of  infec- 
tion (pyaemia)  are  present  the  presence  or  absence  of  ear  discharge  must 
be  ascertained.  Middle-ear  disease  very  frequently  results  in  inflam- 
mation of  the  mastoid,  and  from  thence  the  sinuses  and  adjacent  mem- 
branes of  the  brain  become  inflamed  ;  or  the  ear  suppuration  may  be 
the  primary  focus  from  which  general  infection  has  taken  place.  It 
may  not  be  possible  in  all  cases  to  observe  a  discharge.  It  may  have 
diminished  or  disappeared  on  account  of  the  fever.  Tenderness  and 
oedema  over  the  mastoid,  perforation  or  bulging  of  the  ear-drum,  as 
well  as  other  inflammatory  signs,  point  to  the  occurrence  of  suppura- 
tion of  the  middle  ear  and  mastoid  cells.  It  must  not  be  forgotten 
that  a  bloody  discharge  from  the  ear  may  take  place  in  fractures  of  the 
skull.  The  ears  must  also  be  examined  in  cases  of  coma  from  injury, 
or  if  the  origin  of  coma  is  obscure. 

The  Auditory  Nerve.  The  Hearing.  The  power  and  acuteness  of 
hearing  must  be  tested.  This  may  be  done  with  the  voice,  a  watch,  or 
a  tuning-fork.  Normally,  the  instrument  should  be  heard  at  an  equal 
distance  from  either  ear.  If  both  sides  are  equally  affected  the  hear- 
ing of  a  patient  must  be  compared  with  that  of  a  healthy  person.  The 
ticking  of  a  watch  should  be  heard  at  a  distance  of  about  three  feet. 
The  tuning-fork  is  used  by  placing  it  on  the  skull.  In  some  cases  the 
voice  may  be  easily  heard,  while  the  ticking  of  a  watch  can  be  distin- 


108  GENERAL  DIAGNOSIS. 

guishecl  only  with  great  difficulty.  The  tuning-fork  is  used  to  deter- 
mine by  bone  conduction  whether  deafness  is  due  to  obstruction  or 
disease  of  the  auditory  nerve.  If  it  is  due  to  obstruction  the  vibrating 
tuning  fork  placed  on  the  vortex  is  heard  better  on  the  deaf  side  on 
contact  with  the  skull  than  when  held  close  to  the  ear  (Rhine's  test). 
Obstructive  deafness,  is  always  due  to  disease  of  (1)  the  external  meatus, 
(2)  the  tympanic  membrane  and  middle  ear,  or  (3)  the  Eustachian  tube. 

Deafness  from  internal  ear  disease  may  be  due  to  affections  of  the 
labyrinth — as  inflammation,  caries,  and  necrosis — or  of  the  auditory 
nerve.  The  tuning-fork  is  not  heard  on  contact  with  the  skull.  The 
auditory  nerve  may  be  diseased  in  its  course,  or  the  auditory  centre 
may  be  affected.     (See  Nervous  Diseases,  Part  II.,  Chapter  VIII.) 

It  must  not  be  forgotten  that  certain  drugs,  as  quinine  and  the  sali- 
cylates, may  cause  deafness.  It  may  be  an  early  and  premonitory 
symptom  of  typhoid  fever,  or  cerebro-spinal  meningitis,  and  may  occur 
early  or  late  in  the  course  of  mumps.  Deafness  due  to  occupation  is 
worthy  of  mention.  It  is  not  uncommon  in  blacksmiths,  boiler-makers, 
locomotive  engineers,  and  firemen.  In  some  instances  the  patients  can 
hear  better  in  the  noise  incident  to  their  work  than  when  the  surround- 
ings are  absolutely  quiet. 

Hyperesthesia  or  the  Auditory  Nerve.  Very  rarely  in  cer- 
tain cases  of  facial  paralysis,  and  not  seldom  in  hysteria,  there  is  abnor- 
mal acuteness  of  hearing  (oxyacoia).  In  some  individuals  suffering 
from  hemicrania  or  tic  douloureux,  and  in  meningitis,  the  hearing  of 
certain  sounds — for  example,  high  musical  notes  and  whistling — is 
accompanied  by  pain.  Nervous  patients  often  complain  of  subjective 
noises,  buzzing,  roaring,  hissing,  and  singing — the  so-called  tinnitus 
aurium. 

Paralysis  of  the  Auditory  Nerve.  No  case  of  absolute  uni- 
lateral deafness,  due  to  a  focal  lesion  in  a  hemisphere,  has  as  yet  been 
observed.  Deafness  from  disease  of  the  auditory  nucleus  is  very  rare. 
That  due  to  disease  of  the  peripheral  nerve  is  much  more  common. 
We  may  have  a  rheumatic  auditory  paralysis  similar  to  that  of  the 
facial  nerve,  or  the  deafness  may  be  due  to  pressure  from  a  tumor  or 
inflammatory  exudate  at  the  base  of  the  brain,  or  disease  of  the  mas- 
toid process  of  the  temporal  bone.  The  localization  of  the  lesion  is 
often  extremely  difficult.  The  only  positive  point  is,  that  labyrinthine 
disease  is  apt  to  be  accompanied  by  vertigo  while  in  disease  of  the 
nerve-trunk  vertigo  is  absent. 

Meniere's  Disease.  Aural  Vertigo.  We  may  define  vertigo  as  a 
subjective  feeling  of  motion  referred  by  the  patient  either  to  his  own 
body  or  to  surrounding  objects,  with  loss  of  equilibrium  and  without 
unconsciousness. 

In  this  disease,  first  described  by  P.  Meniere  in  1861,  there  is 
paroxysmal  vertigo  (sometimes  so  sudden  and  intense  as  to  throw  the 
patient  to  the  ground),  tinnitus  aurium,  nausea,  pallor,  clammy  sweat, 
and  vomiting.  The  severity  of  the  attacks  varies  greatly.  There  may 
be  momentary  unconsciousness.  There  is  sometimes  jerking  of  the 
eyeballs,  nystagmus,  or  diplopia.  The  disease  is  paroxysmal  in  char- 
acter, but  slight  vertigo  and  tinnitus  are  apt  to  persist  between  the 


THE  DA  TA  OB TA  [NED  B  Y  OBSER  VA TION.  109 

attacks.  Some  deafness  is  present.  The  attacks  may  vary  in  frequency 
from  several  in  a  day  to  only  one  in  several  months. 

Paralyzing  Vertigo.  Gerlier  describes  a  remarkable  form  of  parox- 
ysmal vertigo  accompanied  by  weakness,  paresis  in  the  extremities, 
drooping  of  the  eyelids,  marked  lassitude,  and  depression  without  un- 
consciousness. It  occurs  only  in  men,  and  is  epidemic  in  the  Canton 
of  Geneva. 

Hysterical  or  functional  deafness  is  recognized  by  (1)  its  association 
with  undoubted  symptoms  of  hysteria ;  (2)  its  sudden  occurrence 
after  shock,  emotional  disturbance,  or  trauma  ;  (3)  the  absence  of  a 
cause  in  the  auditory  apparatus  for  the  deafness  ;  (4)  impairment  of 
bone-conduction  and  aerial  conduction  to  the  same  degree  ;  (5)  the 
frequent  coexistence  of  anaesthesia  of  the  pinna  and  external  meatus  ; 
(6)  frequently  recovery  takes  place  suddenly. 

Hysterical  deaf-mutism  is  a  rare  condition,  characterized  by  (1)  sudden 
origin  ;  (2)  absolute  aphasia  and  aphonia  ;  (3)  absence  of  signs  of  paralysis 
of  the  lips  and  tongue  and  of  any  paralytic  phenomena  except  hysterical 
hemiplegia ;  (4)  preservation  of  intellectual  faculties  and  power  of 
writing ;  (5)  frequent  coexistence  of  hysterical  stigmata ;  (6)  usually 
rapid  recovery. 


CHAPTER    IX. 

THE  DATA  OBTAINED  BY  OBSERVATION— (Continued), 

The  extremities  —  hands  The  shape  —  temperament  —  occupation  —  "claw-hands" — 
"seal-fin  hands" — rheumatoid  arthritis — nervous  affections — "spade"  hands 
— large  bones  of  acromegalia — osteo  arthropathy — wrist-drop.  The  movements 
— spasm — tremor.  The  skin —  color — moisture.  Fingers.  Heberden's  nodosities 
—  contraction  of  fascia — Dupuytren's  contraction — deviations  in  shape.  The 
nails.  Trophoneuroses— cold  hands  and  feet.  Raynaud's  disease — erythro 
melalgia. 

THE  EXTREMITIES. 

The  Hands. 

The  Shape.  We  bear  in  mind  the  variation  in  the  form  of  the 
hand  in  different  types  of  individuals — the  broad  and  heavy  hand  of 
the  sanguine,  the  slender,  dexterous  hand  of  an  individual  of  the  nervous 
temperament  (see  Chapter  VI.),  the  large  joints  of  the  hand  of  so- 
called  strumous  persons,  and  the  effeminate  hand  of  the  one  who  is 
inclined  to  tuberculosis,  present  sharp  contrasts.  Then,  too,  the  ' '  occu- 
pation "  hand  indicates  in  a  general  sense  the  disease  the  patient  is 
liable  to — none  more  striking  than  the  hand  of  the  miner,  the  blue- 
black  dottings  of  which  sharply  indicate  the  possibility  of  anthracosis. 
Finally,  we  note  the  broad  hand  and  clubbed  fingers  that  are  seen  in 
congenital  heart  disease.  The  withered  hand  of  age  and  wasting  of  the 
hands,  as  in  phthisis  or  malignant  disease,  need  not  be  referred  to,  as* 
they  are  part  of  the  general  process. 

Fig.  13. 


Pseudo-muscular  atrophy.    Claw-hand.    (Geay.) 

Presenting  more  striking  changes  in  shape  are  the  peculiarly  de- 
formed hands  seen  in  affections  of  the  muscles  and  joints.  These 
deformities  will  be  described  in  the  respective  sections  (Chapters  XII.. 


THE  DATA  OBTAINED  BY  OBSERVATION. 


Ill 


and  XIII.),  although  in  passing  they  may  be  grouped  together.     First 
we  have  the  "  claw-hand  "  of  progressive  muscular  atrophy,  of  inflam- 


Fig.  14. 


Rheumatoid  arthritis.  The  tapering  fingers  are  seen.  The  phalangeal  joints  are  swollen  ;  many 
are  anchylosed.  The  wrist  is  stiff.  The  muscles  are  atrophied ;  the  forearm-muscles  much 
wasted. 

Fig.  15. 


Photograph  of  a  case  of  lead-paralysis  affecting  the  extensor  muscles.    (Gray.  ) 

mation  of  the  ulnar  and  median  nerve,  and  of  chronic  poliomyelitis; 
the  "  seal-fin"  hand  of  chronic  gout  and  rheumatoid  arthritis,  spasm 
of  the  extensor  muscles  causing  deflection    to    the  ulnar    side.      The 


112 


GENERAL  DIAGNOSIS. 


gnarled  hand  of  rheumatoid  arthritis  and  the  knotted  hand  of  gout  are 
characteristic.  In  the  former  the  tapering,  shining  fingers,  the  bulbous 
phalangeal  joints,  the  pallid,  clammy  surface,  dotted  with  freckles,  the 
locked  joints,  the  atrophied  muscles,  combined  with  exquisite  tender- 
ness of  the  involved  parts,  make  a  picture  never  to  be  forgotten.     The 


Fig.  16. 


Examples  of  the  positions  of  the  fingers  in  the  movements  of  athetosis.    (StrOjipell.) 

peculiar  deformity  occurring  in  scleroderma  is  described  in  the  chapter 
devoted  to  the  skin.  Then  we  have  the  deformity  resulting  from 
flexion  of  the  hand  on  the  forearm,  the  forearm  on  the  arm  as  seen  in 
cerebral  palsies  of  children  and  in  the  hemiplegias. 


THE  DA  TA   OB  TAIN  ED  B  Y  OBSER  VA  TION.  1 1 3 

The  ' '  spade-like  "  hands  of  myxoedema  and  the  enlarged  bones  of 
the  hands  of  acromegalia  and  pulmonary  osteo-arthropathy  are  described 
in  other  sections. 

Deformities  of  the  hand  from  other  causes  than  the  ones  just  men- 
tioned are  often  observed.  Temporary  contractures  occur  in  tetany, 
in  temporary  hemiplegia  or  monoplegia,  and  in  paralysis  of  the  exten- 
sors. Dropping  of  the  hand  from  the  radius  toward  the  ulna  occurs  in 
acute  poliomyelitis  from  paralysis  of  the  extensors.  Then  we  have 
paralysis  of  the  median,  ulnar,  and  other  nerves,  with  their  character- 
istic deformity.  (See  Nervous  Diseases.)  So-called  wrist-drop  is  seen 
in  peripheral  neuritis  (musculo-spiral  nerve),  and  may  be  unilateral  or 
bilateral.  The  hand  hangs  from  the  wrist  on  account  of  paralysis  of  the 
extensor  muscles.  Both  hands  may  drop,  although  it  sometimes  happens 
that  one  is  affected  from  a  few  days  to  a  few  weeks  before  the  other. 

Movements.  One  can  infer  the  limitation  of  movements  of  the  hands 
in  the  affections  described  above.  The  stiffened  and  immobile  hand 
of  chronic  rheumatism,  in  which  enlarged  joints  are  prominent,  contrast 
with  the  painfully  locked  hand  of  rheumatoid  arthritis.  Involuntary 
movements,  as  tremors  and  spasms,  are  also  observed.  The  tremor  of 
age,  of  hysteria,  of  paralysis  agitans,  of  exophthalmic  goitre,  of  mer- 
curial and  other  intoxications,  and  of  disseminated  sclerosis,  is  most 
marked  in  the  hands.  It  is  in  the  hands  and  arms  we  see  that  most 
significant  tremor  or  twitching  with  aimless  picking  at  the  bedclothes, 
described  in  an  account  of  the  typhoid  state  (Chapter  XIV.),  known 
as  subsultus  tendinum.  Twitching  and  spasm  of  the  hand  or  arm  are 
seen  in  convulsive  disorders,  and  may  be  unilateral  or  bilateral,  as  in 
hysteria,  chorea,  epilepsy,  true  and  Jacksonian,  tetanus,  and  tetany. 
When  permanent,  it  is  seen  as  an  expression  of  a  chronic  cerebral 
j)rocess,  as  hydrocephalus.  Alternating  spasm  and  relaxation  of  the 
lingers,  hand,  and  arm  are  seen  in  athetosis. 

Having  noted  the  shape  and  movement  of  the  hand,  we  direct  atten- 
tion to  the  skin,  the  nails,  and  the  fingers. 

The  Skin. 

The  skin  of  the  hand  need  not  be  considered  apart  from  the  skin  of 
the  rest  of  the  body.  It  is  smooth  or  rough,  dry  and  harsh,  moist  and 
warm,  under  the  same  circumstances  that  affect  the  skin  generally.  In 
rheumatoid  arthritis  it  has  been  described  as  peculiar.  Both  the  dorsal 
surface  and  the  palm  are  moist  and  very  soft,  and  the  former  is  dotted 
with  freckles.  In  progressive  muscular  atrophy  and  exophthalmic  goitre 
the  skin  is  moist.  The  cold,  clammy  skin  of  one  laboring  under  excite- 
ment, as  may  be  caused  by  the  first  visit  to  the  physician,  is  well  known. 

Color.  The  color  of  the  hands  is  significant  of  the  state  of  the  cir- 
culation and  the  condition  of  the  blood.  The  blue  finger-tips  and  the 
pallid  hand  accompany  similar  color  changes  in  the  lips,  and  are  early 
signs  of  cyanosis  and  of  anseinia. 

The  swelling*  of  the  hand,  inflammatory  or  (Edematous,  do  not  differ 
from  swellings  of  the  joints  or  the  subcutaneous  connective  tissues  in 
other  portions  of  the  body.     Several  exceptions  are  to  be  noted.     First, 


114 


GENERAL  DIAGNOSIS. 


Fig.  17. 


the  swelling  that  attends  articular  rheumatism  with  involvement  of 
the  wrist-joint  extends  over  the  dorsum  of  the  hand  frequently,  while 
the  fingers  are  free  from  the  process.  Second,  a  localized  swelling  on 
the  dorsum  of  the  hand  is  often  due  to  a  ganglion  from  a  local  affection 
of  the  tendons.  Third,  Gubler's  tumor  is  a  swelling  that  is  seen  in 
wrist-drop  from  displacement  backward  of  the  carpal  bones.  Fourth, 
long-continued  inflammatory  swelling,  with  subsequent  rupture  of  the 
skin,  is  seen  in  mycetoma.  Finally,  traumatic  injuries  produce  tendo- 
synovitis,  bone  affections,  and  palmar  abscess.  Syphilis  and  gonorrhoea 
may  be  causal  factors  in  the  production  of  such  processes,  it  is  impor- 
tant to  remember.     (See  Chapters  X.  and  XIII.) 

The  Fingers. 

In  gout  and  rheumatism  the  joints  of  the  fingers  are  enlarged  and 
painful.  The  swellings  of  the  joints  of  each  condition  cannot  well  be 
distinguished.  In  gout,  tophi,  hard,  white,  sometimes  glistening 
masses  are  likely  to  be  present  hi  the  joints  or  along  the  tendons,  on 

account  of  great  accumulation  of 
urate  of  soda.  They  are  more  promi- 
nent on  the  dorsal  surface  of  the 
joints,  and  sometimes  break  through 
the  skin,  so  that  the  "  chalk-like  " 
concretion  exudes.  It  was  said  by 
Sir  Thomas  Watson  that  a  gouty  sub- 
ject under  his  care  used  his  joints  to 
keep  tally  while  playing  cards. 

Heberden's  Nodes.  Haygarttis 
nodosities.  The  term  "  end -joint 
arthritis  "  is  also  applied  to  this  con- 
dition. This  node  belongs  to  the 
first  of  the  three  divisions  Charcot 
makes  of  rheumatoid  arthritis.  The 
nodules  develop  gradually  at  the 
sides  of  the  distal  phalanges.  The 
subject  may  be  in  good  health,  or 
may  have  had  attacks  of  gout,  or 
have  suffered  from  acid  dyspepsia. 
At  first  the  joints  may  be  a  little 
swollen  and  tender.  The  swelling 
and  tenderness  may  be  periodical, 
and  the  size  may  be  increased  with 
each  fresh  paroxysm.  The  tubercles 
are  seen  at  the  side  of  the  dorsal 
surface  of  the  second  phalanx,  the 
corresponding  cartilage  becomes  soft, 
the  ends  of  the  bone  may  be  ebur- 
nated.  A  moderate  anchylosis  takes  place.  The  nodules  are  often 
considered  of  good  prognostic  omen  ;  it  is  even  said  that  they  are  a  sign 
of  longevity.  It  is  certain  that  the  large  joints  are  rarely  involved 
when  these  nodules  are  present. 


Heberden's  nodes. 


THE  DATA   OBTAINED  BY  OBSERVATION.  115 

The  tips  of  the  fingers  may  be  bulbous,  or  club-shaped,  in  some  cases 
of  phthisis  and  of  other  forms  of  chronic  lung  disease,  and  also  of 
chronic  heart  disease.  It  is  most  common,  however,  in  bronchitis  and 
phthisis.  The  clubbing  is  associated  with  changes  in  the  nails  (see 
below  and  illustration  of  pulmonary  osteo-arthropathy). 

Deviations  in  Position  and  Shape.  Eversion  is  characteristic  of 
rheumatoid  arthritis,  but  deviations  due  to  abnormal  flexion  or  exten- 
sion are  the  most  characteristic.  Flexion  of  the  first  phalanx  of  the 
little  finger  is  due  to  contraction  of  the  palmar  fascia  or  to  paralysis  of 
the  common  extensor  from  disease  of  the  musculo-spiral  nerve.  Con- 
traction of  the  fascia  of  the  hand,  causing  more  or  less  flexion  of  the 
little  and  ring  fingers,  is  frequently  seen,  and  may  be  an  indication  of 
gouty  diathesis.  It  is  certain  that  these  contractions  are  seen  in  several 
members  or  generations  of  a  family  in  which  gout  is  prevalent.  It  is 
called  Dupuytren's  contraction. 

Abnormal  extension  is  usually  very  marked.  Hyper-extension  of 
the  middle  phalanx  is  due  to  paralysis  of  the  flexor  sublimis  from 
disease  of  the  median  nerve ;  hyper-extension  of  the  distal  phalanges 
to  paralysis  of  the  flexor  profundus  muscle  from  disease  of  the  median 
and  ulnar  nerves.  Extension  of  the  proximal  phalanx,  with  extreme 
flexion  of  the  two  distal  phalanges,  contributes  to  form  the  "  claw- 
hand."  (See  Muscles.)  Contractions  due  to  chorea  or  to  central 
lesions,  as  post-hemiplegic  contractions,  will  be  considered  under 
special  diagnosis.  It  is  thus  seen  that  the  peculiar  combined  exten- 
sion and  flexion,  causing  abnormal  shape  of  hands  and  fingers,  is  due 
to  (1)  local  joint  inflammation  (subluxations)  ;  (2)  local  neuritis  and 
paralysis  ;  (3)  progressive  (spinal)  muscular  atrophy  ;  (4)  idiopathic 
muscular  atrophy,  rarely. 

The  Circulation.  Raynaud's  Disease.  Local  Asphyxia.  The 
hands  or  fingers  become  pale  and  intensely  cold  ;  they  are  the  seat  of 
numbness,  and  are  without  sensation.  The  term  "dead  fingers" 
graphically  describes  the  appearance.  The  pallor  usually  comes  on 
suddenly,  and  continues  for  a  variable  period.  As  the  pallor  disap- 
pears there  is  a  gradual  return  of  warmth,  and  the  color  changes  to 
a  livid  red,  dark  blue,  or  even  blackish  hue.  The  paroxysms  of 
alternating  pallid  and  livid  hue  may  occur  several  times  in  twenty-four 
hours.  In  some  cases  the  lividity  becomes  so  intense  that  gangrene 
ensues  in  small  superficial  spots,  or  even  involves  the  whole  finger. 
Pain  may  or  may  not  be  present,  and  does  not  increase  when  the  hand 
hangs  down.  In  my  experience  it  is  more  frequently  present  and  ex- 
cruciating at  the  time  the  fingers  are  "  dead."  The  tip  of  the  nose 
and  the  lobe  of  the  ear  may  be  affected,  and  occasionally  other  parts  of 
the  surface.  The  sensitiveness  to  touch  is  markedly  lessened.  Ray- 
naud's disease  occurs  usually  in  ill-nourished  subjects,  or  after  an  acute 
disease,  as  typhoid  fever.  It  may  be  associated  with  vascular  spasm 
in  internal  organs,  giving  rise  to  epilepsy,  hemoglobinuria,  temporary 
aphasia,  or  hemiplegia.     It  is  usually  worse  in  cold  weather. 

Erythromelalgia.  Local  changes  in  color  are  often  due  to  neuritis 
either  of  the  trunk  or  of  the  terminal  endings  of  the  nerves.  When 
such  changes  are  associated  with  pain  we  use  the  term  erythromelalgia. 


116 


GENERAL  DIAGNOSIS. 


It  is  characterized  by  redness  of  the  surface  with  increased  tempera- 
ture ;  it  is  usually  seen  in  the  extremities  and  is  limited  to  the  distri- 
bution of  the  affected  nerve.  It  is  worse  in  summer,  increased  by 
artificial  heat,  and  aggravated  when  the  extremity  is  dependent  or 
pressed  upon.  The  redness  is  attended  by  burning  and  extreme  local 
discomfort,  in  which  all  sorts  of  sensations  are  described — tearing  of 
the  finger-nails,  pulling  or  pricking  of  the  skin,  twistings  of  thousands 
of  needles,  and  other  forms  of  torture.  I  know  of  no  peripheral  pain 
which  is  the  source  of  greater  agony. 

Glossy  skin  is  seen  after  nerve-injuries  and  neuritis,  and  in  central 
affections  in  which  the  trophic  nerves  are  involved.  The  skin  is  shiny, 
smooth,  drawn  very  tightly  over  the  surface,  and  sometimes  atrophied. 
Red  and  pale  mottling  may  be  seen.  The  surface  is  free  from  hair. 
Burning  pain  precedes  and  accompanies  the  change.     (See  Nails.) 

The  Nails. 

The  Shape.  The  appearance  of  the  nails  enables  us  to  estimate  the 
duration  of  certain  diseases,  or  the  time  when  convalescence  began  ;  it 
also  indicates  local  interference  with  the  nutrition  of  the  parts.  Thus, 
curving  of  the  nails,  with  the  club-shape  of  the  finger-ends,  occurs  only 


Fig.  18. 


Clubbed  fingers  with  curved  nails  (middle  finger  slightly  flexed). 

in  chronic  diseases,  as  phthisis  or  emphysema,  or  in  chronic  cardiac 
disease  and  aneurism.  In  the  latter  it  is  sometimes  found  on  one  hand 
only.  It  is  sometimes  seen  in  other  chronic  wasting  diseases.  The 
nails  may  curve  transversely  or  longitudinally.  When  transversely 
the  appearance  is  like  that  of  a  filbert,  and  when  longitudinally  they 
are  said  to  be  incurvated.  This  change  in  shape  may  occur  without 
clubbing  of  the  fingers.  The  shape  is  altered  in  acromegalia  and 
pulmonary  osteo-arthropathy.     (See  Chapter  XIII.) 


THE  DATA  OBTAINED  BY  OBSERVATION.  117 

Color.  White  marks  on  the  surface  are  usually  seen  after  an  illness, 
and  may  indicate  the  date  of  recovery.  The  marks  develop  at  the 
root  of  the  nail,  and  as  the  nail  grows  the  marks  approach  the  tips  of 
the  fingers,  and  thus  their  position  denotes  the  time  that  has  elapsed 
since  convalescence  set  in.  If  they  are  seen  half-way  up  the  nails,  con- 
valescence is  probably  of  three  months'  standing.  We  get  a  good  idea 
of  the  condition  of  the  blood  in  the  capillaries  from  the  appearance  of 
the  tissue  under  the  nails.  If  there  is  anaemia,  pressure  on  the  finger- 
tips will  drive  the  blood  from  the  capillaries.  Stephen  Mackenzie's 
rule,  that  if  such  pressure  completely  empties  the  vessels  so  that  they 
become  pale,  it  indicates  that  the  globular  richness  of  the  blood  is  re- 
duced one-half,  is  a  fair  and  rapid  test  of  the  degree  of  the  anaemia. 
The  purplish  and  bluish-black  discoloration  of  cyanosis  previously 
referred  to  is  first  seen  under  the  nails.  Sometimes  the  capillaries 
pulsate,  and  this  pulsation  is  more  visible  under  the  nails  than  in  any 
other  part  of  the  body  except  the  retina.  It  may  occur  in  aortic 
regurgitation. 

Nutritive  Changes.  The  nails  undergo  chronic  inflammation  with 
destruction  in  various  skin  affections,  and  the  matrix  is  the  seat  of  acute 
inflammation  in  onychia.  Onychia  may  be  simple  or  syphilitic.  Its 
presence  may  indicate  the  organic  origin  of  otherwise  obscure  nervous 
symptoms.  It  may  be  only  a  simple  inflammation,  or  it  may  result  in 
the  loss  of  the  nail  and  necrosis  of  the  bone. 

Deformity  of  the  nails  (toe)  occurs  in  acute  and  chronic  myelitis.  In 
locomotor  ataxia  the  nails  fall  out. 

In  neuritis  the  trophic  change  is  marked  ;  the  growth  is  arrested, 
and  the  nail  becomes  dark  and  brittle  and  curved  in  its  long  axis,  while 
lateral  arching  takes  place.  The  cutis  underneath  thickens  and  the 
skin  at  the  base  retracts.  The  fingers  may  be  clubbed.  When  growth 
is  resumed  a  distinct  roughened  line  of  demarcation  is  seen.  In  leprous 
neuritis  there  is  destruction  of  nails  and  phalanges.  Atrophy  and  ulcer- 
ation at  the  base  of  the  nails,  followed  by  necrosis  of  the  phalanges,  is 
seen  in  so-called  Morvan's  disease,  which  is  not  really  a  disease  but  a 
symptom  of  neuritis  or  syringomyelia.  Enlargement  with  thickening 
and  sometimes  twisting  occurs  after  fevers,  as  typhoid,  or  in  the  course 
of '  syphilis  and  in  sclerodactyle.  The  nutrition  is  changed  in  Ray- 
naud's disease.  In  some  cases  the  nails  become  dry,  scaly,  and  cracked, 
or  hypertrophied  entirely.  In  the  hemiplegia  from  cerebral  apoplexy 
the  growth  is  arrested  on  the  paralyzed  side.  This  is  tested  by  stain- 
ing the  nails  of  the  two  hands  at  the  same  level  with  nitric  acid  ;  the 
relative  position  of  the  stain  upon  corresponding  nails  of  the  two  hands 
will  show  whether  there  has  been  growth  or  not.  The  return  of  func- 
tional power  is  indicated  by  renewed  growth. 

The  Feet. 

Enlargement  or  deformities  of  the  feet  and  legs  may  be  due  to 
changes  in  the  joints,  the  bones,  and  the  subcutaneous  connective 
tissue.  Hence  we  would  have  swelling  due  to  oedema  and  myxoedema, 
and  enlargements  due  to  acromegalia  and  pulmonary  osteo-arthropathy. 


118  GENERAL  DIAGNOSIS. 

The  chapters  so  frequently  referred  to  will  contain  a  discussion  of  these 
subjects,  and  to  the  Chapter  on  Joints  must  be  referred  all  articular 
changes.  It  must  be  recalled  that  pain  may  be  due  to  flat-foot  and  to 
neuralgia  of  the  third  interosseous  nerve.  (See  Pain.)  Flat-foot  must 
always  be  looked  for  when  inability  to  walk  is  complained  of.  Changes 
in  the  shape  of  the  foot  from  muscular  affections  will  be  described, 
bearing  in  mind  that  "  claw-foot "  is  a  prototype  of  "  claw-hand," 
found  in  progressive  muscular  atrophy  and  in  Friedreich's  ataxia. 

Three  nutritional  changes  take  place  in  the  feet  that  are  of  diagnos- 
tic significance  :  perforating  ulcer  of  the  foot,  a  trophic  change  occur- 
ring in  locomotor  ataxia  ;  gangrene,  the  result  of  endarteritis  (usually 
senile),  or  occurring  in  the  course  of  diabetes  mellitus  ;  mycetoma,  or 
"  Madura  foot."  Perforating  ulcer  usually  begins  as  a  blister,  then  an 
abscess,  and  finally  an  ulcer. 

The  nails  of  the  feet  are  subject  to  the  same  changes  that  take  place 
in  the  nails  of  the  fingers. 

Cold  Hands  and  Feet.  Patients  frequently  complain  of  coldness 
of  the  extremities.  It  is  a  common  and  often  serious  complaint.  It 
is  natural  to  expect  a  peripheral  coldness  when  the  central  organ  of 
circulation  is  weakened.  Coldness  takes  place  in  the  final  hours  pre- 
ceding death.  It  occurs  in  collapse,  in  hemorrhage,  and  in  shock. 
But  we  also  see  it  in  organic  disease  of  the  heart,  with  impairment  of 
the  circulation.  It  is  a  common  vasomotor  condition  in  nervousness, 
independent  of  hysteria.  It  is  a  marked  feature  in  NothnagePs  angina 
pectoris  vaso  motoria,  as  well  as  in  true  and  false  angina  pectoris. 
A  visit  to  a  physician,  or  excitement  from  any  cause,  is  likely  to  be 
attended  by  coldness  of  the  hands  and  feet.  Under  these  circum- 
stances the  extremities  are  often  bathed  in  a  cold  and  clammy  perspi- 
ration.    In  senile  endarteritis  cold  hands  and  feet  frequently  occur. 

They  are  an  index  to  the  state  of  the  peripheral  circulation  in  other 
parts  of  the  body,  as  the  brain. 

The  poisons  of  gout,  of  rheumatism,  and  of  other  diseases,  which  irri- 
tate peripheral  and  vasomotor  nerves,  may  cause  cold  hands  and  feet. 

In  gastric  and  intestinal  dyspepsia,  with  the  absorption  of  toxic  prin- 
ciples, as  leucomaines,  this  symptom  may  be  present. 

Changes  of  sensation  in  the  skin  of  the  extremities  will  not  be  con- 
sidered in  this  section.  They  will  be  taken  up  in  the  chapters  devoted 
to  the  diseases  of  the  nerves.  It  is  sufficient  to  state  that  ancesthesia 
in  local  areas,  and  due  to  causes  limited  to  the  skin,  is  seen  in  morphoea, 
in  the  anaesthetic  form  of  leprosy,  and  in  certain  ischseniic  states  (urti- 
caria). It  is  accompanied  by  loss  of  tactile  sensibility.  Hyperesthesia 
and  paresthesia  occur  with  various  local  affections,  but  they  are  with- 
out diagnostic  significance  except  in  nervous  diseases. 


CHAPTER    X, 

THE  DATA  OBTAINED  BY  OBSERVATION— {Continued). 

The  skin.  The  color — redness — pallor — jaundice — cyanosis — the  bronzed  skin — Addi- 
son's disease — hemochromatosis — chloasma — tinea  versicolor — vagabond's  dis- 
ease— argyria — freckles.  The  nutrition.  Moisture  and  dryness — hyperidrosis 
— anhidrosis.  Scars  Hemorrhages — mode  of  recognition — cause — significance. 
Eruptions — their  clinical  significance — nature  of  the  lesion — distribution — asso- 
ciate morbid  phenomena — general  symptoms.  Table  of  skin  diseases — erythema 
— herpes— erythema  nodosum — urticaria — medicinal  rashes — erythema  of  infec- 
tious diseases — roseola — miliaria  or  sudamina.     General  diagnosis. 

THE  SKIN. 

Color.  The  portions  exposed  to  the  air  exhibit  more  varied  and 
pronounced  changes  of  color  than  parts  that  are  covered.  The  changes 
in  color  herein  described  refer  more  particularly  to  the  face  and  hands. 
The  color  of  other  parts  partakes  of  the  same  tint  as  that  of  the  face, 
other  things  being  equal,  except  that  the  intensity  is  less.  Comparison 
of  the  two  should  always  be  made,  and  the  mucous  membranes  examined, 
as  control  observations.  For  the  latter  the  conjunctivae,  lips,  and  mouth 
are  sufficient,  always  remembering  the  possibility  of  hyperemia  of  the 
conjunctiva  from  other  causes. 

Local  color  changes  of  the  face  will  be  particularized  in  this  section. 
It  is  not  to  be  forgotten  that  the  color  varies  with  the  type — whether 
blonde  or  brunette  —  and  that  variations  in  the  latter  at  times  easily 
escape  recognition. 

The  skin  in  a  healthy  child  is  of  a  faint  pink  color  ;  as  age  advances 
it  loses  its  fresh  appearance  and  becomes  paler,  except  in  those  whose 
occupation  exposes  them  to  atmospheric  influences.  In  the  latter,  the 
skin  becomes  weather-stained,  and  may  assume  a  mahogany  or  reddish- 
brown  hue.  In  old  age,  the  color  is  apt  to  deepen  and  become  duller, 
while  the  loss  of  subcutaneous  fat  allows  the  skin  to  lie  in  folds,  espe- 
cially about  the  jaws  and  neck,  and  wrinkles  are  marked,  especially 
between  the  eyebrows,  over  the  nose,  and  at  the  angles  of  the  eyes  and 
mouth. 

Apart  from  these  changes,  which  are  physiological  or  necessarily  the 
result  of  occupation,  the  skin  exhibits  changes  which  are  the  result  of 
the  habits  or  health  of  the  individual.  Some  persons,  especially  if 
blondes,  retain  to  old  age  the  fresh,  pink  skin  of  childhood.  In  others 
is  seen  early  a  dull,  muddy  complexion.  This  is  common  in  those 
who  use  coffee  to  excess  and  are  habitually  constipated.  In  others 
digestive  derangements,  particularly  constipation,  uterine  disorders,  or 
gouty  derangements  produce,  in  addition  to  a  muddy  complexion,  crops 
of  acne  and  comedones,  or  black-heads.    It  must  be  admitted,  however, 


120  GENERAL  DIAGNOSIS. 

that  some  persons  preserve  a  fresh  complexion  in  spite  of  marked 
digestive  disturbance.  Considerable  congestion  of  the  superficial  blood- 
vessels, giving  a  person  a  florid  appearance,  may  be  due,  especially  in 
a  young  person,  to  alcoholic  excesses  ;  and  there  is  a  popular  belief 
which  connects  such  an  appearance,  when  coupled  with  a  tuberous  nose 
and  a  crop  of  angry-looking  pustules,  with  a  prolonged  use  of  spirits. 

The  sebaceous  glands  of  the  skin  of  the  face  merit  but  a  passing 
notice.  Deficiencies  or  excesses  of  secretion,  or  alteration  of  it,  are 
usually  due  to  local  causes.  Excessive  secretion  of  sebaceous  matter, 
known  as  seborrhea,  or  steatorrhoea,  is  seen  in  two  forms.  First,  with 
oily  exudation  ;  second,  with  drying  of  the  secretion  and  the  formation 
of  crusts.  It  may  be  more  pronounced  in  strumous  subjects.  The 
opposite  condition,  or  asteatodes,  is  seen  in  wasting  diseases,  particularly 
diabetes,  and  in  xeroderma  and  ichthyosis. 

Color  Increased.  The  Abnormally  Red  Skin.  Physiological 
hyperemia  has  been  spoken  of.  The  color  is  intensified  when  the 
capillaries  are  overfilled  or  the  blood-current  is  unusually  rapid.  The 
hyperemia  may  be  general  or  local,  and  is  due  to  dilatation  of  the  capil- 
laries, possibly  from  nerve-influences.  General  hyperemia  is  seen  in 
fever,  in  poisoning  from  atropine,  and  from  organic  poisons  derived 
from  food  or  the  result  of  intestinal  putrefaction. 

Local  hyperemia  attends  the  phenomena  of  blushing,  and  comes  and 
goes  in  nervous  persons  with  every  psychical  impression.  Rarely  in 
neurasthenics  the  hyperemias  may  be  extreme,  amounting  almost  to  an 
erythromelalgia.  Abnormal  redness  may  be  diffused  over  the  whole 
face  or  may  present  the  circumscribed  flush  of  phthisis  ;  the  local  deep- 
red  area,  on  one  cheek,  of  pneumonia  ;  the  evanescent  flush  of  anaemia, 
with  cardiac  palpitation  ;  and  the  creeping  flush,  with  raised  border,  of 
erysipelas,  appearing  on  the  bridge  of  the  nose  or  at  the  nostril.  In 
phthisis,  moderate  excitement  or  exertion,  the  taking  of  food,  or  the 
onset  of  fever,  tinges  the  cheek  with  the  blush  of  hectic.  In  migraine, 
the  burning  flesh  may  be  limited  to  one  side.  Capillary  congestion  on 
the  cheeks  or  on  the  tip  of  the  nose  occurs  with  the  endarteritis  of  the 
aged,  but  is  seen  also  in  early  life  in  cases  of  hepatic  cirrhosis  or  of 
obstruction  of  the  hepatic  circulation  from  other  causes. 

Color  Lessened.  It  is  caused  by  diminution  of  the  amount  of 
blood  in  the  capillaries,  or  because  its  richness  in  haemoglobin  has  been 
reduced. 

Pallor.  Diminished  amount  of  blood  in  the  capillaries  occurs 
from  active  contraction  or  spasm  of  the  arterioles,  from  hemorrhage, 
or  from  weak  heart.  The  pallor,  therefore,  is  usually  acute  or  tem- 
porary, and  may  be  recurrent.  It  attends  fright,  syncope,  or  nausea 
and  vomiting.  It  occurs  also  in  acute  poisoning,  in  acute  disease,  such 
as  diphtheria,  and  in  hemorrhage.  The  pallor  due  to  loss  of  blood 
may  be  instantaneous  if  the  hemorrhage  is  sudden  and  large,  or  develop 
gradually  if  it  is  small  and  continued  over  a  long  period.  The  onset 
of  sudden  pallor  is  of  diagnostic  significance  in  diseases  in  which  hem- 
orrhage may  occur,  as  in  aneurism,  gastric  or  intestinal  ulcer,  and 
typhoid  fever.  Symptoms  of  collapse  are  seen  with  this  form  of 
pallor. 


THE  DATA  OBTAINED  BY  OBSERVATION.  121 

Pallor  of  long  duration,  or  chronic  pallor,  if  we  may  so  term  it,  is 
seen  in  a  number  of  diseases.  In  all  of  them  there  are  diminution  in 
the  amount  of  red  corpuscles  and  destruction  of  the  haemoglobin.  It 
is  characteristic  of  blood  affections,  as  the  various  forms  of  anaemia.  It 
does  not  necessarily  occur  in  leucaemia  ;  indeed,  the  cheeks  and  lips 
may  be  red.  It  is  seen,  in  a  striking  form,  in  chronic  Bright' s  disease, 
in  cancer,  in  chronic  poisoning,  as  from  lead  or  arsenic,  in  chronic 
catarrh  of  the  stomach  or  of  the  bowels,  and  in  chronic  infectious  pro- 
cesses, as  tuberculosis  and  syphilis. 

While  paleness  is  recognized  as  the  fundamental  or  prevailing  color 
of  the  skin  in  many  of  the  above-noted  affections,  a  further  tinge  gives  a 
characteristic  hue  to  the  skin  ;  thus,  in  chlorosis  there  is  a  greenish 
appearance  of  the  face,  which  is  in  striking  contrast  to  the  pearly  col- 
ored conjunctivae.  In  carcinoma  the  yellowish  tinge  of  the  pallor  often 
causes  it  to  be  mistaken  for  jaundice.  In  pernicious  anosmia  a  straw- 
colored  appearance  of  the  skin  has  been  frequently  described,  which 
may  cause  it  to  be  mistaken  for  carcinoma.  It  is  worthy  of  remark 
that  the  cachectic  pallor  in  carcinoma  is  not  likely  to  occur  unless 
there  are  primary  or  secondary  deposits  in  the  gastro-intestinal  tract  or 
the  liver,  and  it  is  well  known  that  pernicious  anaemia  is  usually  sec- 
ondary to  gastric  or  hepatic  disorder.  The  peculiar  hue  of  the  pallor, 
therefore,  may  be  due  to  a  common  cause  in  these  affections.  The 
pallor  that  attends  Bright's  disease  is  usually  associated  with  slight 
puffiness  under  the  eyelids,  or  local  dropsical  accumulations  elsewhere. 
In  chronic  poisoning  with  lead  pallor  is  associated  with  a  blue  line 
upon  the  gums  and  drop-wrist ;  while  in  arsenical  poisoning  there  are 
frequently  associated  a  puffiness  of  the  eyelids  and  looseness  of  the 
bowels. 

It  is  not  well  to  lay  much  stress  upon  the  variations  in  hue  of  the 
pallor.  They  are  not  of  diagnostic  importance  in  themselves,  but  only 
when  associated  with  the  characteristic  symptoms  and  signs  of  the 
respective  affections  in  which  this  hue  occurs. 

It  must  not  be  forgotten  that  there  are  a  large  number  of  individuals 
in  whom  pallor  is  the  normal  condition.  This  is  particularly  the  case 
with  those  who  lead  a  sedentary  life  and  are  confined  within  doors. 
There  are  a  number  of  occupations  which  predispose  to  pallor. 

Abnormal  Color.  I.  The  Yellow  Skin.  Jaundice.  The  yel- 
low coloration  is  seen  not  only  in  the  skin  but  in  the  sclera?  (see  the 
Eye)  and  the  mucous  membranes.  The  discoloration  of  the  skin  is  not 
difficult  of  recognition.  It  varies  in  shades  from  a  slight  yellow  hue  to 
yellow-green  or  olive-green,  and  in  many  forms  of  jaundice  to  brownish- 
yellow.  The  yellow  hue  of  the  skin  in  jaundice  may  be  preceded  and 
is  always  accompanied  by  tingeing  of  the  conjunctivae;  its  presence  in 
this  situation  confirms  the  observation.  The  mucous  membrane  under 
the  tongue  early  gives  evidence  of  jaundice ;  or,  if  the  lips  are  everted 
and  a  glass  slide  pressed  evenly  on  the  surface,  the  yellow  discoloration 
of  the  mucous  membrane  will  shine  through. 

The  yellow  tint  of  the  conjunctivae  must  not  be  confounded  with  the 
same  color  due  to  subconjunctival  fat.  The  latter  is  not  uniform  in  the 
conjunctivae,  but  may  occupy  cone-shaped  areas. 


122  GENERAL  DIAGNOSIS. 

The  physiological  yellow  color  of  the  skin  that  is  seen  in  infants 
shortly  after  birth  is  not  a  true  jaundice,  but  in  all  probability  arises 
from  excessive  destruction  of  red  corpuscles  in  the  over-congested 
skin.  On  light  pressure  with  the  finger  the  color  changes.  It 
fades  from  shades  of  yellow  into  the  genuine  flesh-color.  The  con- 
junctiva? are  natural,  and  the  urine  is  free  from  bile-pigment. 
The  faeces  are  normal.  By  these  symptoms  a  distinction  can  be 
made. 

Jaundice  is  a  symptom  due  to  a  number  of  diseases.  In  the  first 
place,  it  is  most  frequently  due  to  disease  of  the  liver ;  this  form  is 
known  as  hepatogenous  jaundice.  It  may  possibly  be  due  to  destruc- 
tion of  the  corpuscles  of  the  blood  and  liberation  of  the  haemoglobin, 
the  so-called  hcematogenous  jaundice.  The  various  causes  of  the  former 
will  be  considered  under  diseases  of  the  liver.  The  latter  is  said,  not 
without  objection,  to  be  due  to  destructive  agencies  in  the  blood,  such 
as  ptomaines,  which  are  absorbed  in  gastro-intestinal  disease,  or  to 
poisons  that  develop  in  the  course  of  pyaemia,  yellow  fever,  malarial 
and  relapsing  fevers  ;  it  may  also  be  due  to  snake-bite  or  to  poisons  that 
are  imported,  as  in  mineral  poisonings,  or  chloroform,  ether,  or  chloral. 
In  both  instances  the  yellow  coloration  of  the  skin  is  due  to  coloring- 
matter  of  the  bile  or  of  the  blood,  or  bilirubin,  which  is  deposited  in 
the  cells  of  the  rete  mucosum. 

Other  symptoms  due  to  the  same  cause  are  associated  with  hepato- 
genous jaundice.  Their  presence  may  be  of  diagnostic  value  in  deter- 
mining the  nature  of  the  yellow  color  of  the  skin  in  cases  of  doubt. 
These  symptoms  are  :  (1)  Itching.  This  symptom  is  intolerable  ;  the 
surface  of  the  body  is  often  seen  to  be  covered  with  scratch-marks  on 
account  of  the  irritation  of  the  peripheral  ends  of  the  nerves  in  the  skin 
by  bile-pigment.  (2)  Slow  pulse.  Slowness  of  the  pulse  also  fre- 
quently attends  jaundice.  (3)  Secretions  and  excretions.  The  saliva, 
or  expectoration,  if  present,  is  bile-tinged,  and  the  urine  is  dark  col- 
ored, due  to  the  presence  of  the  pigment.  (See  Urine.)  While  the 
excretions  are  all  tinged  with  bile  in  the  hepatogenous  form,  the  faeces 
are  free  from  bile,  hence  they  are  pale  or  of  an  ashy  color.  On  account 
of  the  absence  of  bile  in  the  intestines  its  physiological  effects  are  lost, 
and  therefore  flatulency  from  fermentation  becomes  an  important 
symptom. 

II.  The  Blue  Skix.  Cyanosis.  This  peculiar  hue  is  recognized 
without  difficulty.  The  bluish  or  bluish-red  appearance  of  the  skin  is 
first  seen  at  points  furthest  from  the  central  organ  of  circulation,  as  in 
the  extremities.  The  mucous  membranes,  in  which  the  capillary  cir- 
culation is  readily  seen,  also  exhibit  the  change  early.  It  is  early  seen 
also  in  the  finger-tips,  particularly  underneath  the  nails,  about  the 
phalangeal  joints,  and  in  the  lips.  Subsequently  the  entire  surface  of 
the  skin  may  become  dusky  or  cyanosed,  as  its  cause  increases  in 
degree.  Its  onset,  it  is  said,  can  be  anticipated  by  the  state  of  the 
veins  on  the  under  part  of  the  tongue  ;  overfilling  or  extreme  disten- 
tion of  these  vessels  always  occurs  in  cyanosis.  At  first  the  color, 
wherever  situated,  usually  disappears  on  pressure,  but  as  the  hue 
deepens  it  remains  in  spite  of  pressure. 


THE  DATA  OBTAINED  BY  OBSERVATION.  123 

Causes.  Cyanosis  is  (1)  respiratory,  due  to  overfilling  of  the  veins 
and  capillaries  with  blood  not  sufficiently  oxygenated,  or  (2)  vascular, 
to  an  excess  of  venous  blood,  oxygenation  not  being  interfered  with. 

1.  Respiratory.  All  conditions  which  interfere  with  the  aeration 
of  the  blood  cause  more  or  less  cyanosis.  Practically  sufficient  air 
cannot  get  to  the  blood,  or  sufficient  blood  to  the  air.  Obstruction  of 
the  air-passages,  diminution  of  respiratory  area,  and  diminished  or  in- 
efficient respiratory  movements  prevent  oxygen  getting  into  the  blood  ; 
interference  with  the  circulation  in  the  lungs  prevents  the  blood  getting 
air.     Both  causes  are  often  combined. 

a.  Obstruction  of  the  Air-passages.  This  may  occur  in  the 
upper  respiratory  tract,  or  in  the  capillary  bronchi.  (1)  Fancied  ob- 
struction, by  pharyngeal  abscess  or  tonsillitis,  or,  in  rare  cases,  by 
diphtheria,  causes  moderate  cyanosis.  (2)  Obstructive  laryngeal  dis- 
eases produce  cyanosis  varying  in  degree  with  the  amount  of  obstruc- 
tion and  its  persistence.  The  cyanosis  is  of  short  duration  in  spasmodic 
croup  and  in  laryngismus  stridulus  ;  it  is  prolonged  in  the  more  per- 
sistent inflammatory  affections.  Its  gradual  onset,  in  moderate  degree, 
as  seen  by  the  purple  lips  or  dusky  finger-tips,  is  of  serious  prognostic 
import  in  the  course  of  tuberculous  laryngitis  even  if  symptoms  of 
grave  obstruction  have  not  arisen.  (3)  Tumors,  pressing  on  the  trachea 
or  bronchi,  narrowing  the  air-channel,  cause  cyanosis.  The  tumors 
may  be  situated  in  the  neck,  as  the  thyroid  gland,  or  within  the  medi- 
astinum. (4)  Spasm  of  the  bronchi,  as  in  asthma,  occlusion  of  the 
bronchioles,  as  in  bronchitis,  both  acute  and  chronic,  and  particularly 
the  grave  forms  of  capillary  bronchitis  in  childhood,  cause  cyanosis. 
(5)  Foreign  bodies  anywhere  in  the  upper  regions  of  the  respiratory 
tract  are  fruitful  sources  of  cyanosis. 

b.  Diminution  of  the  Respiratory  Area.  Cyanosis  from  this 
cause  occurs  in  pneumonia,  in  oedema  of  the  lungs,  in  tuberculosis,  and 
in  all  forms  of  pleural  effusion  and  of  intrathoracic  tumors  compressing 
the  lung.     It  is  an  important  diagnostic  feature  of  acute  tuberculosis. 

c.  Diminished  or  Insufficient  Respiratory  Movements.  De- 
ficient chest-expansion,  because  the  action  of  the  respiratory  muscles  is 
interfered  with,  lessens  the  respiratory  area.  This  interference  may 
be  either  on  account  of  muscular  or  pleuritic  pain,  on  account  of  paraly- 
sis, or,  in  the  case  of  the  diaphragm,  on  account  of  upward  pressure  by 
accumulations  in  the  abdominal  cavity,  as  large  peritoneal  effusions,  an 
enlarged  liver  or  spleen,  or  an  abdominal  tumor.  In  bulbar  paralysis 
and  peripheral  neuritis,  in  paralysis  of  the  diaphragm,  and  in  spasm  of 
the  muscles  of  respiration  (as  in  tetanus)  there  is  diminished  respira- 
tory movement.  In  forms  of  progressive  muscular  atrophy  and  in  other 
rare  affections  of  the  muscles,  as  trichinosis,  cyanosis  is  also  observed 
for  the  same  reasons. 

d.  Obstruction  of  the  Pulmonary  Vessels.  Interference  with 
the  circulation  within  the  lungs,  from  pressure  on  the  pulmonary  artery 
or  vein  by  aneurism  or  mediastinal  tumor,  or  from  disease  of  the  heart 
itself,  is  a  most  frequent  cause  of  cyanosis.  In  affections  of  the  heart  it  is 
not  seen  until — in  the  case  of  valvular  disease,  for  instance — compensa- 
tion is  lost  and  the  right  heart  is  dilated,  causing  an  accumulation  of 


124  GENERAL  DIAGNOSIS. 

blood  in  the  lungs.  In  the  latter  condition  the  bronchitis  of  passive  con- 
gestion of  the  mucous  membrane  is  an  additional  cause  for  the  cyanosis. 

2.  Cakdio-vasculab.  Obstruction  to  the  flow  of  venous  blood 
anywhere  in  the  circulation  will  lead  to  the  development  of  cyanosis. 
This  is  the  cyanosis  of  passive  congestion.  Cyanosis  due  to  causes 
mentioned  above  is  always  general.  Cyanosis  arising  from  the  causes 
indicated  in  this  section  may  be  general  or  local,  depending  upon  the 
seat  of  obstruction.  General  cyanosis  may  occur  in  (1)  congenital 
heart  disease  ;  (2)  in  valvulitis,  when  compensation  is  lost  and  dila- 
tation has  taken  place ;  (3)  in  incompetency  of  the  valves  from 
dilatation  ;  (4)  in  weak  heart  or  enfeebled  action  from  pericardial 
effusion.  In  congenital  heart  disease  the  cyanosis  is  so  great  and  so 
persistent  that  the  affection  has  been  termed  "  blue  disease  "  or  "  morbus 
cceruleus." 

Local  cyanosis  is  seen  when  there  is  obstruction  of  the  venous  trunks 
from  external  pressure,  or  from  disease  of  the  venous  wall,  causing 
thrombosis.  It  may  be  limited  to  the  head  and  upper  extremities,  in 
obstruction  of  the  descending  cava  by  tumor  or  aneurism,  or  to  the 
lower  portion  of  the  trunk  and  the  lower  extremities  in  obstruction  of 
the  ascending  cava  by  pressure  from  tumors  within  the  abdomen  and 
thorax.  One  extremity  may  be  the  seat  of  local  venous  stasis  from 
pressure  upon  the  veins,  or  its  occlusion  by  thrombosis  ;  the  arm  in 
cases  of  cancer  of  the  breast  and  axillary  glands,  the  leg  in  cases  of 
femoral  phlebitis,  represent  typical  forms  of  venous  stasis.  A  striking 
form  is  due  to  causes  affecting  the  vasomotor  nerves,  giving  rise  to 
peripheral  capillary  spasm.     (See  under  Fingers,  Raynaud's  Disease.) 

III.  The  Bronzed  Skin.  Pigmentation.  Addison's  Disease.  The 
most  marked  form  of  bronzing  is  seen  in  Addison's  disease — an  affec- 
tion characterized  by  a  gradual  loss  of  strength  without  much  loss  of 
flesh  ;  by  gastric  uneasiness  and  occasional  vomiting  ;  feeble  circula- 
tion, and  a  bronze  hue  of  the  skin. 

Social  History.  The  disease  occurs  most  frequently  during  the  active 
period  of  life,  from  the  age  of  twenty  to  forty  years,  and  nearly  twice 
as  often  in  males  as  in  females. 

Asthenia.  The  disease  begins  insidiously  with  gradual  and  progres- 
sive loss  of  strength.  It  becomes  evident  from  the  patient's  languor, 
weariness  on  slight  exertion,  and  inaptitude  for  mental  effort  that  he 
is  suffering  with  some  exhausting  disease.  The  most  characteristic 
symptom  is  the  extreme  prostration  without  any  obvious  cause.  Any 
exertion  requires  great  effort  and  may  induce  fainting. 

Gastric  Symptoms.  The  appetite  is  impaired  or  lost,  there  is  more 
or  less  discomfort  at  the  epigastrium,  and  occasional  vomiting. 

Perhaps  at  this  time  a  close  inspection  may  show  some  discoloration 
of  the  skin,  but  usually  this  appears  later.  By  degrees  the  gastric 
symptoms  become  more  prominent,  and  vomiting  may  be  so  frequent 
as  to  shorten  life  materially.  Finally,  the  patient  is  unable  to  leave 
the  bed.  Dull  pains  in  the  head,  back,  and  abdomen  are  not  uncom- 
mon ;  neuralgic  pains  in  the  limbs  may  be  complained  of  ;  and  Osier 
states  that  there  is  tenderness  on  pressure  in  the  lumbar  region  in  a 
considerable  proportion  of  cases. 


PLATE    II. 


•%-:        WB*- 


Addison's  Disease,  Showing  Bronzing  of  Skin,  and  White 
Areas  of  Atrophy.     (Coleman.) 


THE  DATA  OBTAINED  BY  OBSERVATION.  125 

The  pulse  is  extremely  small  and  feeble  ;  in  the  later  stages  it  may 
be  absent  at  the  wrist. 

Bronzing.  The  discoloration  of  the  skin  is  the  most  striking  symp- 
tom of  the  disease  when  it  is  well  marked.  The  external  surfaces  are 
changed  in  hue,  and  delicate  portions  of  the  skin  underneath  the  cloth- 
ing are  also  bronzed.  The  discoloration  is  not  removed  by  pressure. 
The  areas  are  irregular  in  shape.  The  skin  is  soft  and  pliable.  The 
pigment  which  causes  the  discoloration  is  deposited  in  the  rete  Mal- 
pighia. 

The  pigmentation  is  never  seen  in  the  cornea  or  in  the  nails.  The 
axilla,  the  flexure  of  joints,  the  median  line,  the  areola  about  the  nipple 
and  other  normal  areas  of  pigment  deposit  are  the  common  sites. 
Bronzed  areas  in  sharply  circumscribed  patches  are  also  seen  in  the 
mucous  membrane  of  the  lips  and  cheeks. 

Sometimes  the  whole  body  becomes  of  a  walnut-juice  color,  a  bronz- 
ing which  is  deeper  in  exposed  surfaces.  At  times  only  portions  of 
the  body  are  discolored,  in  which  case  the  dark  hue  shades  oft'  grad- 
ually into  the  normal  hue  of  the  skin.  Wilks1  states  that  in  all  the 
cases  which  he  has  seen  the  scalp,  finger-nails,  soles  of  the  feet,  and 
palms  of  the  hands  escaped  pigmentation. 

Nevertheless,  discoloration  of  the  skin  is  not  an  essential  symptom 
of  the  disease  ;  in  some  cases  it  is  entirely  absent.  These  cases,  espe- 
cially if  associated  with  much  vomiting,  run  a  more  acute  course  than 
the  others,  lasting  only  a  few  weeks.  Such  cases  have  been  mistaken 
for  typhus  fever. 

On  the  other  hand,  diseases  of  the  suprarenal  capsules  not  usually 
associated  with  the  Addison  symptom-complex,  as  carcinoma,  are 
attended  by  pigmentation.  In  about  an  equal  proportion  of  cases  it 
is  absent,  however. 

The  discoloration  of  the  skin  in  Addison's  disease  must  not  be  con- 
founded with  that  of  sunburn.  The  latter  discoloration  is  limited  to 
parts  that  are  exposed  to  the  sun,  is  more  uniform,  and  the  mucous 
membranes  are  free.  Moreover,  the  anaemia  and  debility  of  Addison's 
disease  do  not  attend  it.  The  pigmented  areas  in  the  mucous  mem- 
brane of  the  mouth,  seen  in  a  certain  class  of  negroes,  must  not  be 
mistaken  for  the  pigmentation  of  Addison's  disease.     (See  Plate  II.) 

In  persons  living  in  filth  general  discoloration  of  the  skin  takes  place, 
known  as  "  vagabond's  disease  ;"  but  because  it  is  so  general  and  the 
skin  is  rough  and  thickened,  and  other  evidences  of  filth  are  seen,  it 
can  easily  be  recognized.  In  the  latter  stages  of  jaundice  the  dark- 
green,  olive,  or  black  hue  of  the  skin  might  be  taken  for  the  general 
bronzing  of  Addison's  disease.  The  appearance  of  the  conjunctiva  is 
sufficient  to  indicate  the  cause  of  the  bronzing.  In  certain  cases  of 
tuberculous  peritonitis,  even  if  the  adrenals  are  not  involved,  the  pecu- 
liar brown  discoloration  which  simulates  Addison's  disease  is  present. 
In  scleroderma  pigmentation  occurs,  although  rarely. 

The  pigmentation  that  occurs  in  uterine  disease  or  in  pregnancy  (uterine 
chloasma)  resembles  the  bronzing  of  Addison's  disease.     It  is  usually 

1  Reynolds'  System  of  Medicine,  Philadelphia,  1880,  iii.  561. 


126  GENERAL  DIAGNOSIS. 

confined  to  the  forehead  and  cheeks  and  the  normal  pigmentary  areas  of 
the  skin.  The  mucous  membranes  are  not  affected,  although  in  pregnancy 
there  may  be  the  characteristic  change  of  the  vaginal  mucous  membrane. 
The  vomiting  and  weakness  that  attend  pregnancy  may  sometimes  lead 
to  confusion — vomiting  is  early,  pigmentation  late  in  pregnancy. 

The  affections  just  described  must  not  be  confounded  with  the  dis- 
coloration— yellowish-brown  in  hue — of  tinea  versicolor,  a  parasitic  skin 
disease.  The  latter  is  recognized  by  its  color  and  irregular  dissemina- 
tion. It  especially  occupies  the  chest  and  spreads  to  the  abdomen.  It 
rarely  ascends  above  the  neck.  It  does  not  usually,  therefore,  occur 
in  parts  exposed  to  the  air,  or  in  parts  that  are  the  seat  of  normal  pig- 
mentation. Then,  again,  the  surface  desquamates  in  brownish  scales. 
Examination  of  the  scales  in  a  drop  of  dilute  liquor  potassse,  under  the 
microscope,  shows  both  spores  and  mycelium.  The  spores  are  of  the 
fungus  micro-sporon  furfur.  Another  skin  affection  is  attended  by 
bronzing — leucoderma.  In  diabetes  bronzing  is  often  seen  independently 
of  any  parasitic  invasion  of  the  skin,  and  apparently  the  result  of  the 
cachexia.  It  is  possible  that  it  is  due  to  the  cirrhosis  of  the  liver 
which  causes  the  glycosuria.  But  if  the  pancreas  is  primarily  at 
fault  the  skin  change  is  more  likely  to  occur.  In  certain  forms  of 
hepatic  cirrhosis,  as  so-called  Hanot's,  or  the  hypertrophic  form, 
bronzing,  undoubtedly  the  result  of  blood  destruction,  hoemochroma- 
tosis,  is  seen  in  rare  instances. 

At  times  the  bronzing  and  other  characteristic  symptoms  of  Addi- 
son's disease  are  associated  with  tuberculosis  in  other  organs.  Con- 
versely, in  cases  of  phthisis  in  which  there  is  bronzing,  tuberculous 
disease  of  the  suprarenal  capsules  may  be  suspected,  and  it  adds  to  the 
gravity  of  the  prognosis. 

Argyria.  If  nitrate  of  silver  is  administered  over  a  long  period  of 
time,  fine  black  particles  of  the  metal  or  of  the  albuminate  are  deposited 
in  the  kidneys,  the  intestines,  and  the  skin.  The  corium  is  the  principal 
seat  of  the  deposition.  The  discoloration  of  the  skin  is  gray  or  gray- 
ish-black. It  is  not  changed  by  pressure,  and  is  usually  limited  to  the 
face  and  hands.  Small  specks  may  also  be  noted  in  the  mucous  mem- 
brane of  the  mouth.  The  cornea  and  nails  are  not  affected.  Persons 
are  usually  in  good  health,  although  the  presence  of  the  skin-change,  if 
seen  in  a  patient  with  coma,  would  point  to  the  possible  presence  of 
epilepsy,  on  account  of  which  the  drug  had  been  taken. 

Freckles.  Freckles  are  not  usually  of  special  diagnostic  significance. 
Their  occurrence  in  an  unusual  degree  on  the  back  of  the  hand  and 
forearm  has  been  observed,  however,  in  cases  of  rheumatoid  arthritis. 

Hemorrhages. 

Hemorrhages  in  the  skin  are  called,  according  to  their  size,  petechia;, 
ecchymoses,  vibices,  and  Ivxmatomata.  The  petechia?  and  ecchymoses  are 
apt  to  appear  in  the  hair  follicles,  and  vary  in  size  from  a  pin-point  to 
a  split  pea. 

Mode  of  Recognition.  They  must  be  distinguished  from  erythe- 
matous and  other  eruptions.     They  may  be  raised  above  the  surface  of 


THE  DATA  OBTAINED  BY  OBSERVATION.  127 

the  skin  ;  they  do  not  disappear  upon  pressure,  and  vary  in  hue  from 
deep  red  to  yellow-brown,  according  to  their  depth  beneath  the  surface 
and  to  the  degree  of  absorption  that  has  taken  place  since  the  hemor- 
rhage occurred. 

Vierordt  advises  the  following  test  to  distinguish  them  from  erythe- 
mas :  Press  a  piece  of  glass  (a  microscope  slide)  upon  the  suspected 
spot.  A  hemorrhage  is  rendered  more  distinct,  while  the  surrounding 
part  becomes  more  anaemic.  An  inflammatory  hyperemia,  on  the 
other  hand,  disappears. 

Cause.  Hemorrhages  may  be  due  to  affections  of  the  blood  or  dis- 
ease of  the  bloodvessels.  They  occur  in  the  course  of  blood  diseases, 
because  such  change  in  the  quality  of  the  blood  takes  place  that  permits 
diapedesis  more  readily.  They  are  more  particularly,  but  not  exclu- 
sively, seen  in  dependent  parts,  especially  in  the  lower  extremities. 

Significance.  While  subcutaneous  hemorrhages  are  easily  recog- 
nized, their  diagnostic  significance  is  more  difficult  to  determine,  and 
must  depend  upon  the  phenomena  with  which  they  are  associated. 
Moreover,  the  situation  of  the  hemorrhage  is  in  a  measure  an  index  of 
its  causal  origin  ;  thus  hemorrhages  about  joints  are  usually  purpuric 
or  hsemophilic. 

1.  Hemorrhage  with  Fever.  Subcutaneous  hemorrhages  in  the 
infections  are  due  to  changes  in  the  quality  of  the  blood,  and  indicate 
the  severity  of  the  infection,  or  to  obstruction  of  the  bloodvessels  with 
emboli.  To  the  former  class  belong  cerebrospinal  fever  and  measles, 
variola,  and  scarlatina.  In  the  exanthemata  they  precede,  develop  with, 
or  even  replace  the  characteristic  eruption,  the  latter  being  darker  in 
color  than  normal.  Hemorrhages  will  probably  take  place  at  the  same 
time  from  the  mucous  membranes ;  perhaps  the  nares  will  be  occluded, 
and  the  mouth  and  fauces  filled  with  clotted  blood.  In  milder  infections 
sordes  collect  in  the  mouth  only.  They  indicate  the  degree  of  malignancy 
of  these  affections.  To  the  same  class  of  affections  belong  epidemic 
hemoglobinuria  and  morbus  maculosus  neonatorum,  diseases  of  newborn 
infants  but  little  understood,  although  no  doubt  of  an  infectious  nature. 
To  these  may  be  added  the  severe  forms  of  purpura  hemorrhagica, 
attended  by  fever,  marked  visceral  disturbances,  skin  eruptions,  and 
great  oedema. 

Hemorrhages  due  to  obstruction  of  the  vessels  are  known  as  hemor- 
rhagic infarcts,  and  are  seen  iajpycemia  and  ulcerative  endocarditis.  The 
hemorrhages  are  small,  sometimes  elevated,  more  abundant  on  the 
extremities,  but  distributed  over  the  trunk  ;  they  are  seen  as  small 
areas  in  the  mucous  membranes,  observed  in  the  conjunctivae,  and,  on 
ophthalmoscopic  examination,  in  the  retina.  The  association  of  chill, 
fever,  and  sweat,  the  presence  of  pus  in  some  structures  of  the  body, 
and  the  characteristic  joint  affections  point  to  pyaemia.  On  the  other 
hand,  if  due  to  ulcerative  endocarditis,  the  physical  signs  of  this  affec- 
tion render  the  recognition  of  the  cause  of  the  hemorrhage  clear. 
Finally,  in  rheumatic  fever  with  involvement  of  the  joints  we  have  the 
occurrence  of  purpura.     (See  Erythema,  same  chapter.) 

2.  Hemorrhage  with  Anaemia.  Hemorrhages  occur  in  all  forms 
of  ancemia  attended  by  debility.      In   idiopathic  or  pernicious  anaemia 


128  GENERAL  DIAGNOSIS. 

they  are  usually  small,  but  may  become  extensive.  They  occur  on  the 
extremities,  and,  usually,  on  the  dorsum  of  the  feet  or  hands.  There 
may  also  be  retinal  hemorrhages.  They  are  also  seen  in  the  secondary 
anaemias  that  arise  in  the  later  stages  of  tuberculosis  and  of  carcinoma, 
particularly  of  the  stomach  ;  in  the  later  stages  of  Bright' s  disease,  and 
of  cirrhosis  of  the  liver. 

Scurvy  is  an  affection  characterized  by  ansemia,  debility,  and  wasting, 
in  which  there  are  hemorrhages  under  the  skin  as  well  as  from  the 
mucous  surfaces.  The  gums  are  particularly  affected.  They  bleed 
easily.  Hemorrhages  also  occur  in  the  deep  lymphatic  spaces,  in  the 
muscles,  underneath  the  periosteum,  and  in  the  joints.  In  scurvy- 
rickets  similar  hemorrhages  are  seen.     (See  Chapter  XIII.) 

3.  Purpura.  Primary  purpura  occurs  without  any  known  cause. 
It  has  been  divided,  for  convenience,  into  simple  and  hemorrhagic 
purpura,  though  the  two  probably  differ  only  in  intensity. 

Secondary  purpur a  occurs  in  connection  with  a  variety  of  febrile  and 
constitutional  diseases :  1.  Scurvy.  2.  Haemophilia.  3.  Hodgkin's 
disease.  4.  Splenic  leucocythsemia.  5.  Pernicious  ansemia.  6.  Chronic 
lesions  of  the  kidney  and  liver,  with  or  without  jaundice.  7.  Ulcera- 
tive endocarditis.     8.  Malignant  sarcomata.     9.  Infectious  diseases. 

A.  In  simple  purpura  the  hemorrhages  are  limited  to  the  skin. 
They  consist  of  :  1.  Bright-red  spots,  varying  in  size  from  a  pin- 
head  to  a  silver  three-cent  piece.  These  spots  are  under  the  skin 
and  are  unaffected  by  pressure.  They  fade  gradually  from  red  to 
yellow  and  disappear.  2.  Larger  spots  or  streaks  called  vibices.  3. 
Ecchymoses. 

The  disease  is  said  to  be  most  common  about  the  age  of  puberty. 
It  may  come  on  in  the  midst  of  apparent  health,  or  it  may  follow  an 
illness,  as  typhoid  fever. 

Purpura  occurs  especially  upon  the  legs,  the  standing  position  seem- 
ing to  favor  its  occurrence.  It  comes  on  in  successive  crops.  Some- 
times large  blebs,  filled  with  thin  blood,  form  under  the  skin,  and 
gangrene  at  times  occurs. 

B.  In  the  hemorrhagic  form1  hemorrhages  occur  from  the  nose, 
stomach,  bowels,  vagina,  and  bronchi,  or  into  the  kidney  or  other 
viscus.     Cutaneous  and  submucous  hemorrhages  also  occur. 

The  onset  of  these  cases  is  sudden,  though  there  may  be  a  day  or 
two  of  depression,  lassitude,  headache,  and  nausea.  The  first  symptom 
noticed  is  generally  fever,  which  is  apt  to  be  moderate,  then  eruption 
upon  the  skin  is  detected,  and  for  a  day  or  two  the  patient  may  seem 
to  be  only  slightly  ailing.  Copious  epistaxis  may  now  occur,  or  a 
hsematemesis  or  hematuria,  or  all  of  these  and  other  hemorrhages,  may 
occur  the  same  day.  The  temperature  may  be  only  moderately  raised, 
or  it  may  reach  104°  to  105°,  or  even  a  higher  point.  The  pulse  at 
first  is  frequent  (120  to  140),  but  of  good  volume  and  tension.  Subse- 
quently, in  unfavorable  cases,  it  becomes  thready  and  very  frequent. 
Respiration  is  not  affected,  and  the  mind  is  clear  ;  the  face  is  pale  and 

1  See  Grave  Forms  of  Purpura  Hemorrhagica.  Musser :  Trans.  Association  of 
American  Physicians,  vol.  vi. 


THE  DA  TA  OB  TAINED  B  Y  OB  SEE  VA  TION.  129 

anxious.  Hemorrhage  may  also  occur  into  the  choroid  and  brain- 
substance,  with  blindness  and  paralysis  as  sequels.  It  may  also  occur 
into  the  uvula  or  tonsil. 

The  subjective  symptoms  are  pains  in  the  loins,  limbs,  epigastrium,  or 
chest.  Often  these  pains  announce  a  fresh  hemorrhage,  as  into  the 
kidney,  or  a  fresh  crop  of  purpuric  spots.  The  degree  of  anaemia 
depends  upon  the  copiousness  of  the  hemorrhage  and  the  length  of  time 
the  disease  lasts.  Sometimes  the  hemorrhages  cause  great  exhaustion, 
with  a  tendency  to  collapse. 

The  urine,  in  the  case  of  hemorrhage  into  the  kidney,  of  course 
contains  blood  ;  sometimes  casts  are  also  found. 

C.  Another  variety  of  purpura  is  known  as  peliosis  rheumatica,  the 
peculiar  features  of  which  are  tender  and  swollen  joints,  oedema  of  the 
subcutaneous  cellular  tissue,  and  purpura  associated  with  urticarial 
wheals  and  intense  itching  (purpura  urticans).  The  subcutaneous 
hemorrhages  consist  of  petechia?,  vibices,  and  ecchymoses.  There  may 
be  such  large  hemorrhages  into  the  penis,  scrotum,  and  uvula  as  to 
result  in  gangrene  and  slow  separation  of  the  dead  tissue  by  ulceration. 
Epistaxis  may  occur,  but  copious  hemorrhages  from  the  stomach,  the 
bowel,  or  into  the  kidney  or  other  organs  are  rare.  Endocarditis  and 
pericarditis  occur  as  complications  in  some  cases.  The  duration  is 
apt  to  be  long,  convalescence  being  delayed  by  repeated  outbreaks  of 
purpura  with  multiple  arthritic  symptoms  and  oedema. 

Diagnosis.  It  is  distinguished  from  scurvy  by  the  absence  of  ante- 
cedent debility  and  anaemia,  of  spongy  gums,  of  brawny  induration  in 
the  limbs,  and  by  the  fact  that  the  hemorrhages  do  not  usually  occur 
around  a  hair  follicle.  In  scurvy  there  is  a  history  of  deprivation  of 
vegetable  food,  whereas  purpura  may  occur  in  the  midst  of  robust 
health.  As  a  rule,  the  cutaneous  hemorrhages  are  larger  in  scurvy 
than  in  purpura. 

It  is  distinguished  from  acute  infectious  diseases,  particularly  typhus, 
cerebro-spinal  fever,  and  smallpox,  by  the  absence  of  severe  constitu- 
tional symptoms  which  characterize  the  graver  forms  of  these  diseases 
— in  which  alone  a  purpuric  eruption  is  likely  to  be  severe  enough  to 
cause  doubt.  Hemorrhages  from  mucous  surfaces  are  rare  in  the 
latter. 

Hcemophilia  is  distinguished  by  the  history  the  patient  gives  of  being 
a  bleeder  by  heredity,  and  the  fact  that  the  bleeding  has  been  started 
by  some  injury,  wound,  or  operation. 

It  is  distinguished  from  the  hemorrhages  of  leukaemia  by  the  absence 
of  enlarged  spleen  and  liver,  and  by  the  fact  that  there  is  no  excess  of 
leucocytes  in  the  blood. 

31alif/nant  sarcoma  causing  hemorrhages  is  recognized  by  the  pre- 
vious history  of  anaemia  and  cachexia,  and  by  the  detection  of  pri man- 
or secondary  growths. 

It  must  not  be  confounded  with  Raynaud's  disease,  a  vasomotor 
affection  characterized  by  local  syncope,  local  asphyxia,  and  gangrene. 

4.  Haemophilia.  The  diagnostic  significance  of  subcutaneous  hemor- 
rhage is  clearer  when  associated  with  profuse  hemorrhages  in  other 
portions  of  the  body,  and  when  there  is  also  a   history  of  the  occur- 

9 


130  GENERAL  DIAGNOSIS. 

reuce  of  such  hemorrhages  in  the  family.  Hamophilia  is  a  constitu- 
tional affection  characterized  by  bleeding,  which  is  spontaneous  or 
occurs  upon  slight  injury.  It  is  nearly  always  hereditary,  but  may 
arise  de  novo. 

Males  are  very  much  more  liable  to  it  than  females,  the  ratio  being 
about  11  to  1.  This  curious  disposition  to  bleeding  maybe  transmitted 
for  generations,  and  almost  always  to  the  males  through  the  female 
members  of  the  family — that  is  to  say,  the  daughter  of  a  bleeder  is  not 
usually  affected,  but  she  transmits  the  tendency  to  her  sons,  who 
become  bleeders  ;  so,  too,  the  granddaughters  are  not  bleeders,  but  they 
in  turn  transmit  the  disposition  to  their  male  offspring.  It  generally 
shows  itself  early  in  life,  usually  before  the  end  of  the  second  year,  and 
almost  invariably  by  puberty. 

The  affection  usually  first  declares  itself  by  the  occurrence  of  a  hem- 
orrhage, either  spontaneous  or  the  result  of  slight  injury,  the  bleeding 
being  far  more  profuse  than  would  be  natural,  and  in  some  cases  abso- 
lutely uncontrollable. 

Legg1  has  divided  haemophilia  into  three  degrees,  according  to  the 
severity  of  the  symptoms.  The  first  is  characterized  by  external  and 
internal  bleedings  of  every  kind,  and  by  joint-affections  ;  the  second, 
by  spontaneous  hemorrhages  from  mucous  membranes,  but  no  trau- 
matic bleeding  or  ecchymoses,  and  no  joint -affections  ;  the  third,  by  a 
tendency  simply  to  ecchymoses.  The  first  form  is  seen  most  fre- 
quently in  men  ;  the  second  most  frequently  in  women  ;  and  the  third 
in  either  sex. 

The  most  frequent  seat  of  hemorrhage  is  the  nose,  and  the  next  the 
gastro-intestinal  tract.  The  bleeding  is  from  the  capillaries  ;  it  may 
prove  fatal  in  a  few  hours,  or  last  for  days  and  weeks  with  final  recov- 
ery. Intense  anaemia  follows  the  prolonged  hemorrhage,  but  the  blood 
is  replaced  with  remarkable  rapidity.  All  operations,  even  the  most 
trivial,  are  extremely  dangerous  in  bleeders.  Circumcision,  extraction 
of  teeth,  and  leeching  are  credited  Avith  the  most  deaths  by  Grandidier. 

Joint-symptoms  are  very  common.  The  knees,  elbows,  ankles,  and 
shoulders  are  the  ones  most  frequently  involved.  The  attack  may  be 
marked  by  pain,  redness,  swelling,  inflammation,  and  fever  ;  or  fever 
may  be  absent ;  or  pain  alone  may  be  complained  of.  The  attacks  are 
liable  to  recur,  especially  in  cold,  damp  weather,  and  may  result  in 
stiffened,  deformed  joints. 

The  diagnosis  is  easy  when  the  history  of  a  hereditary  tendency  to 
bleed  can  be  obtained.  Osier2  properly  remarks  that  slight  joint-trouble 
and  petechia?  are  as  much  a  manifestation  of  the  disease  as  the  more 
severe  hemorrhages.  In  cases  in  which  no  history  can  be  secured 
the  diagnosis  is  made  by  noting  a  persistent  liability  to  hemorrhage, 
without  adequate  cause,  and  associated  with  joint-affections. 

Osier  gives  the  following  excellent  summary  of  the  affections  with 
which  haemophilia  can  be  confounded  : 

1.  The  umbilical  hemorrhages  of  infants,  due  to  jaundice  or  to  syph- 
ilis, haemorrhagica  neonatorum,  etc. 

1  Haemophilia.     London,  1892. 

2  Quoted  by  Osier,  Pepper's  System  of  Medicine,  1885,  iii.  932. 


THE  DATA   OBTAINED  BY  OBSERVATION.  131 

2.  Purpura  simplex,  often  seen  in  debilitated,  rarely  in  healthy  chil- 
dren, usually  confined  to  the  legs,  and  in  some  cases  associated  with 
rheumatic  pains  or  swellings  in  the  knees  and  ankles. 

3.  Peliosis  rheumatica. 

4.  Purpura  hemorrhagica,  morbus  maculosus  Werlhofii,  a  grave 
disease,  characterized  by  extensive  cutaneous  ecchymoses,  mucous  hem- 
orrhages, but  not  dependent  on  any  local  disease,  or,  as  far  as  known, 
on  any  specific  poison. 

5.  Infective  purpura  due  to  the  action  of  some  specific  poison — 
smallpox,  measles,  scarlet  fever,  cerebro-spinal  fever,  etc.  The  hem- 
orrhages may  be  cutaneous  and  trivial,  or  may  be  in  the  most  aggra- 
vated form  of  interstitial  and  mucous  bleedings,  as  seen,  for  example, 
in  black  smallpox. 

6.  Toxic  purpura,  as  in  snake-bites  and  many  poisons,  such  as  phos- 
phorus. 

7.  Simple  hemorrhagic  diathesis,  under  which  may  be  included  those 
cases  in  which,  without  any  hereditary  disposition  or  previous  hemor- 
rhagic history,  there  is  a  tendency  to  uncontrollable  hemorrhage  from  a 
slight  wound. 

8.  Hsematidrosis,  bloody  sweats,  which  occur  usually  in  hysterical 
or  epileptic  females,  and  are  in  rare  instances  accompanied  by  mucous 
hemorrhages. 

5.  Hemorrhage  in  Central  Nervous  Disease.  Neuritis.  Pur- 
pura in  some  instances  is  believed  by  Mitchell  to  be  due  to  primary 
disease  of  the  nervous  system  ;  certainly  we  do  see  it  in  neuritis,  in 
Raynaud's  disease,  in  myelitis,  and  in  locomotor  ataxia.  It  may  occur 
in  hysteria,  when  drops  of  blood  ooze  through  the  skin  at  the  time  of 
the  attack  (hsematidrosis). 

6.  Hemorrhage  of  Toxic  Origin.  The  virus  of  snakes  causes  hem- 
orrhages under  the  skin.  In  jaundice  the  blood  is  disintegrated  and 
hemorrhages  take  place.  In  malignant  types  the  mucous  membrane 
bleeds  and  sordes  collect  on  the  tongue,  lips,  and  gums.  To  the  same 
class  belong  the  subcutaneous  hemorrhages  that  follow  the  adminis- 
tration of  certain  drugs,  as  copaiba,  iodide  of  potassium,  quinine,  and 
belladonna.     (See  Medicinal  Rashes.) 

Eruptions. 

Diseases  of  the  skin  are  usually  characterized  by  eruptions.  Now, 
such  eruptions  may  be  primary  and  local  (from  causes  operating  directly 
on  the  skin)  in  the  sense  that  they  occur  independently  of  any  internal 
affection  ;  or  secondary,  the  resultant  of  an  internal  morbid  process. 
The  morbid  processes  are  the  same,  and  morbid  processes  in  the  skin 
do  not  differ  from  such  processes  in  other  epithelial  structures.  The 
anatomical  and  physiological  peculiarity  of  the  part  causes  the  difference 
in  the  phenomena.  Hence  anaemias  and  hyperaemias,  inflammations, 
acute  or  chronic,  with  or  without  exudation  ;  hemorrhages-,  atrophies,  and 
hypertrophies,  new  growths,  and  parasitic  affections  are  found  in  both. 
But  instead  of  a  painless  inflammation  with  transudation  of  mucus,  as  in 
mucous  membrane  inflammation,  we  have  a  more  or  less  painful  infiam- 


132  GENERAL  DIAGNOSIS. 

mation,  with  itching  (nerve-supply),  and  with  sebaceous  and  sudorifer- 
ous gland  exudation.  Otherwise  the  same  symptoms  attend  each  ;  but 
ocular  examination  of  the  inner  mucous  membranes  is  not  possible. 

While  the  reader  is  referred  to  special  works  on  skin  diseases  for  a 
description  of  the  primary  or  local  skin  affections,  the  secondary  affec- 
tions will  be  briefly  noted.  It  must  not  be  forgotten  that  the  local 
affections — eczemas,  parasitic  disease,  etc. — are  modified  by  the  general 
conditions  or  state  of  health  of  the  patient. 

Clinical,  Significance.  This  depends,  first,  upon  the  special 
character  of  the  eruption,  the  nature  of  the  lesion  ;  second,  its  distribu- 
tion (a)  in  the  layers  of  the  skin,  (6)  over  the  surface  of  the  body  ; 
third,  its  association  with  other  morbid  phenomena  or  various  circum- 
stances. 

I.  The  Nature  of  the  Lesion.  Observation  concerning  the 
nature  of  the  lesion  includes  (1)  its  anatomical  character,  (2)  the  order 
of  appearance,  (3)  its  uniformity,  and  (4)  the  mode  of  invasion. 

A  knowledge  of  anatomical  lesions  is  essential  in  order  to  be  able  to 
define  exactly  the  morbid  process  and  determine  the  primary  cause  of 
the  lesion.  For  a  long  period  of  time  the  lesions  were  divided  into 
primary  and  secondary.  The  lesions  known  as  scabs,  scale,  raw  sur- 
faces, scratch-marks,  and  ulcers  are  always  secondary.  Scars  and 
macula?  appear  latest.     The  other  lesions  herein  described  are  primary. 

The  writer  follows  Dr.  Pye-Smith  in  the  description  of  them,  as  well 
as  in  most  of  the  matter  appertaining  to  cutaneous  affections. 

1.  Hyperemia,  or  congestion. 

a.  Mere  overfulness  of  the  vessels  from  paralysis  of  the  vasomotor 
nerves,  with  redness  and  heat,  but  without  the  exudation  and  tissue 
changes  which  accompany  inflammation.  This  hypersemic  blush,  readily 
produced  in  the  physiological  laboratory,  is  rarely  seen  as  an  uncompli- 
cated morbid  condition  (e,  g.,  Trousseau's  tache-cerebrale). 

b.  Active,  arterial,  or  inflammatory  hypoxemia ,  varying  in  color  from 
brilliant  scarlet  to  rose-pink,  and  combined  with  heat,  tingling,  or  other 
sensations. 

c.  Passive,  venous,  or  congestive  hyperemia,  dependent  upon  retarded 
circulation  and  distended  venules.  The  color  is  purple,  bluish,  or  livid, 
the  surface  is  cold,  and  there  are  no  painful  sensations. 

2.  Pimple,  or  papule.     A  small,  solid  elevation  of  the  skin. 

a.  The  acute  inflammatory  papule. 

b.  The  chronic  large  inflammatory  papule,  discrete  or  confluent. 

c.  A  solid  non-inflammatory  papule. 

d.  Solid  elevations  of  the  skin,  which  may  be  called  false  papules. 

3.  Vesicle.  A  visible  cavity  in  the  skin  filled  with  transparent 
liquid. 

4.  Pustule.     A  cutaneous  abscess. 

5.  Bulla,  or  bleb.     A  very  large  vesicle. 

6.  Scab,  or  crust,  A  dried-up  concretion  of  the  contents  of  a  vesi- 
cle, pustule,  or  "bleb. 

7.  Scale  (squama).     A  dry  flake  of  epidermic  cells. 

8.  Wliecd  (pomphos).  A  flat,  solid  elevation  of  the  skin,  much  larger 
than  a  papule,  and  of  ephemeral  duration. 


THE  DATA  OBTAINED  BY  OBSERVATION.  133 

9.  Scratch-mark.  An  injury  to  the  skin,  of  linear  form  and  curved 
outline. 

10.  Raw.     A  surface  which  has  lost  its  horny  layer  of  epidermis. 

11.  Chap  (rima).  A  crack  or  fissure  which  goes  through  the  epi- 
dermis. 

12.  Sore  (ulcus).  The  result  of  destruction  by  inflammation,  which 
has  reached  below  the  Malpighian  layer  and  has  destroyed  the  papillae. 

13.  Scar  (cicatrix).  The  result  of  the  healing  process  after  an  injury 
or  disease  deep  enough  to  destroy  the  papilla?  of  the  part. 

14.  Nodule.  A  solid  elevation  of  the  skin  larger  than  a  papule  and 
seated  in  its  deep  layer. 

15.  Stain  (macula).     A  patch  of  increased  pigmentation  of  the  skin. 

16.  Hemorrhage  (ecchymosis).  When  a  bloodvessel  of  the  cutis  vera 
gives  way  a  dark-red  or  purple  mark  is  produced,  which  (like  the 
macula)  does  not  disappear  on  pressure. 

The  recognition  of  the  exact  anatomical  lesion  is  not  sufficient  for 
diagnosis  unless  the  mode  of  invasion  is  observed  at  the  same  time. 
The  rash  often  spreads  from  a  single  focus,  or  numerous  foci  appear 
and  coalesce.  The  lesion  is  best  studied  in  the  most  recent  part.  Not 
only  is  the  mode  of  local  invasion  to  be  noted,  but  also  the  uniformity  of 
the  anatomical  lesion.  Often,  instead  of  a  simple  lesion,  various  kinds  are 
present  at  the  same  time,  or  they  develop  in  successive  order  ;  thus,  in 
smallpox,  we  have  first  the  papule,  then  the  vesicle,  and  finally  the  pustule. 

II.  Distribution.  The  location  of  the  lesion  in  the  various  layers  of 
the  skin,  and  the  distribution  over  the  surface  of  the  body,  must  be 
observed.  The  layers  of  skin :  (1)  The  horny  layer  of  the  epidermis 
manifests  the  pathological  changes  of  hypertrophy,  atrophy,  dryness, 
or  desquamation  of  the  cuticle.  Dead  scales  result,  in  addition  to  the 
hypertrophies  and  atrophies  indicated  in  the  outline.  (2)  The  eruption 
in  a  large  number  of  cases  is  limited  to  the  living  Malpighian  layer  of 
the  epidermis  and  to  the  papillary  layer  of  the  cutis.  The  hyperemias 
(erythemata),  and  inflammations  of  all  kinds,  are  confined  to  these 
layers.  In  this  situation  they  never  leave  scars.  (3)  The  deep  layer 
of  the  cutis  is  so  intimately  connected  with  the  subcutaneous  tissue  that 
morbid  changes  in  it  involve  the  latter,  and  even  extend  more  deeply. 
The  affections  are  more  severe,  but  less  numerous  than  affections  of  the 
superficial  layers,  and  are  always  followed  by  cicatrices.  The  changes 
in  the  sweat  glands,  sebaceous  glands,  hair,  and  nails,  so  far  as  they 
refer  to  internal  medicine,  have  been  treated  in  another  section. 

Area  of  distribution  :  The  distribution  of  the  eruption  over  different 
areas  of  the  body  is  of  great  importance  in  the  diagnosis  of  the  various 
erythemata  due  to  exanthems  and  to  morbid  conditions  of  the  gastro- 
intestinal tract.  It  will  be  noted  more  in  detail  when  the  specific  erup- 
tions are  considered.  The  student  should  also  bear  in  mind  the  rela- 
tionship of  eruptions  or  cutaneous  changes  of  nutrition  (trophic  disor- 
ders) to  the  affected  nerve-supplies. 

III.  Associate  Morbid  Phenomena.  The  student  of  internal 
medicine  should  particularly  observe  the  associated  morbid  phenomena, 
or  concomitant  circumstances,  in  order  to  determine  the  nature  of  the 
skin  affection,  which  may  be  the  expression  of  internal  disorder.     The 


134  GENERAL  DIAGNOSIS. 

associated  morbid  phenomena  of  diagnostic  significance  are  fever,  jaun- 
dice, albuminuria,  and  the  phenomena  of  past  or  present  syphilitic  dis- 
ease, tuberculosis,  rheumatism,  or  the  rheumatic  habit.  The  presence  of 
one  of  these  processes  or  diseases  points  to  particular  affections.  Thus, 
a  large  number  of  eruptions  is  attended  with  fever  ;  another  group  is 
of  frequent  occurrence  in  the  course  of  rheumatism  ;  another  class 
belongs  to  syphilis,  while  a  fourth  class  is  associated  with  anaemia,  jaun- 
dice, or  albuminuria.  This  subdivision  is  not  based  on  the  nature  of 
the  eruption  but  on  its  association  with  other  phenomena.  It  will  be 
learned  later  that  all  the  groups  belong  to  the  hemorrhages  or  the  ery- 
themata.  The  true  relationship  of  the  two  classes  of  phenomena  can  be 
fully  ascertained  only  by  inquiry  into  the  history  and  course  of  the  erup- 
tion and,  in  addition,  into  the  concomitant  phenomena.  Thus,  if  the 
eruption  is  thought  to  be  due  to  the  exanthemata,  the  period  of  incuba- 
tion, mode  of  infection,  symptoms  of  the  invasion,  and  the  progress  of 
the  attack  must  be  inquired  into. 

General  Symptoms.  In  order  to  determine  accurately  the  cause  of 
an  eruption  and  appreciate  its  diagnostic  significance,  the  general  health 
must  be  inquired  into,  the  condition  of  the  stomach  and  bowels  and 
the  character  of  the  urine  must  be  ascertained.  It  must  be  remembered 
that  local  skin  disorders  are  influenced,  for  good  or  ill,  by  the  general 
health.  Functional  disorders  of  the  stomach  and  bowels  are  a  fre- 
quent source  of  many  of  the  erythemas,  while  in  diabetes  pruritus  and 
forms  of  dermatitis  are  of  common  occurrence.  The  latter  are  also  ob- 
served in  Bright's  disease.  The  cause  for  the  eruption  is  the  same  in 
both,  in  all  probability — that  is,  a  perverted  secretion  of  the  skin,  or, 
if  oedema  is  present,  impaired  nutrition  of  the  surface. 

The  subjective  symptoms  are  of  great  importance  in  the  attempt 
to  ascertain  the  true  nature  of  an  eruption.  Pain,  itching,  burning, 
smarting,  and  tenderness  are  significant  of  the  inflammations.  Pain 
due  to  inflammation  is  constant  and  smarting,  burning  or  throbbing  in 
character.  Sometimes,  however,  pains  of  a  neuralgic  character,  inter- 
mittent and  distributed  in  the  course  of  nerve-  trunks,  precede  the 
development  of  eruption.  This  is  seen  in  herpes  zoster.  Itching  is  an 
important  symptom  in  disease  of  the  skin.  It  is  not  present  in  the 
eruption  due  to  the  exanthemata  generally,  except  in  smallpox,  chicken- 
pox,  and  rubella.  Its  absence  is  a  striking  peculiarity  of  the  erup- 
tions of  syphilis  ;  but  in  erythema,  especially  if  associated  with  oedema, 
it  is  a  most  annoying  symptom.  In  other  skin  diseases,  as  eczema, 
psoriasis,  and  the  parasitic  affections,  it  is  much  more  common  and  of 
extreme  annoyance. 

Itching  may  be  present  without  any  anatomical  evidence  of  skin 
disease.  It  is  seen  in  the  troublesome  pruritus  that  occurs  in  the  aged, 
particularly  about  the  intestinal  and  genito-urinary  orifices,  symptom- 
atic of  affections  of  the  organs  related  thereto.  It  is  a  symptom  which 
should  lead  to  an  examination  of  the  urine,  as  diabetes  is  sometimes* 
found  to  be  the  fundamental  source  of  the  complaint.  It  has  been  pre- 
viously noted  that  itching  occurs  to  a  high  degree  in  jaundice.  It  is 
also  due  to  the  internal  administration  of  drugs,  as  opium  and  mor- 
phine, and  sometimes  quinine. 


THE  DA  TA   OB  TAIN  ED  B  Y  OBSEB  VA  TION.  \  35 

In  addition  to  the  associate  pathological  phenomena  which  should  be 
ascertained  in  the  study  of  skin  eruptions,  in  order  to  determine  their 
relationship  to  internal  affections,  other  circumstances  should  be  inquired 
into,  such  as  the  occupation,  the  character  of  the  clothing,  degree  of 
cleanliness  of  the  patient ;  the  effects  of  climate,  the  season,  tempera- 
ture, and  the  state  of  the  air. 

The  following  very  concise  outline,  taken  from  the  work  of  the  above- 
named  author,  to  whom  the  writer  is  indebted  for  much  of  the  data 
of  this  section,  is  here  given  to  enable  the  student  to  appreciate  more 
thoroughly  the  pathological  relations  of  the  various  skin  diseases.  The 
table  also  shows  at  once  the  relation  of  the  eruptions  to  the  internal 
disorders  which  concern  us  more  particularly  in  this  work  : 

Diseases  of  the  Skin  Regarded  as  Physiological  Processes. 
( Pathological  Arrangement.  ^ 

Acute  Inflammations. — Diffuse,  e.  g.,  scarlatina,  morbilli,  syphilis,  roseola  (eruptive 
fevers,  erythema). 

With  venous  congestion— Erythema  nodosum  (rheumatism). 

With  oedema — Urticaria,  erythema  nodosum  (gastro-intestinal  disorder  and  rheu- 
matism). 

With  necrosis — Furunculus,  anthrax  (diabetes). 

Localized  in  papules — Enterica  (erythemata),  syphilis,  eczema,  prurigo. 

Localized  in  vesicles — Eczema,  zona,  variola,  scabies,  herpes,  varicella  (eruptive 
fevers,  infectious  diseases). 

Localized  in  pustules — Impetigo,  variola,  scabies,  syphilis,  sycosis,  acne. 

Localized  in  blebs — Pemphigus,  scabies,  rupia. 

Desquamating  during  involution — Scarlatina,  etc. 

Chronic  Inflammations. — With  venous  congestion — Acne  rosacea,  pernio. 

With  over-production  of  epidermis  — Psoriasis,  pityriasis  rubra. 

With  oedema — Elephantiasis. 

With  fatty  degeneration — Xanthelasma. 

With  hypertrophy — Elephantiasis. 

With  cicatrization — Cheloid. 

With  ulceration — Lupus,  syphilis,  lepra. 

New  growths — Xanthelasma,  lupus,  lepra,  syphilis,  cancer. 

Atrophy — The  senile  skin,  linae  gravidarum. 

Hypertrophy — Ichthyosis,  cornu  cutaneum,  clavis,  verruca. 

Hemorrhage — Traumatic  (e.  g.,  flea  bites),  typhus,  scurvy. 

Pigmentation — Syphilitic  maculae,  melasma,  chloasma,  icterus,  ephelis. 

Congenital  malformations — Ichthyosis,  cutaneous  nsevus. 

Neurosis— Pruritus  (diabetes,  jaundice). 

Anomalies  of  Secretion. — Increased,  diminished,  or  perverted — Seborrhea,  xeroderma, 
hyperidrosis,  anidrosis,  chromidrosis,  etc.  Obstructed  —  Comedo,  milium,  acne, 
sudamina. 

A  glance  at  the  above  outline  will  show  that  the  eruptions  which 
particularly  concern  us  belong  to  the  class  of  diseases  to  which  the  term 
erythema  is  applied. 

Erythema.  Classification.  Erythemata  may  be  divided,  •  in 
accordance  with  the  classification  of  Kaposi,  into  acute,  contagious, 
exudative  dermatoses,  represented  by  measles,  scarlatina,  rubella,  and 


136  GENERAL  DIAGNOSIS. 

smallpox  ;  and  the  acute,  non-contagious,  inflammatory  dermatoses, 
which  may  be  further  subdivided  into  :  (1)  typical  forms,  idiopathic  and 
toxic,  including  urticaria,  or  nettle-rash  •  (2)  varieties  of  herpes  ;  (3) 
erythemas  due  to  boils,  colds,  or  erysipelas.  The  first  group  of  the 
won-contagious  form  includes  the  class  which  should  always  be  consid- 
ered in  connection  with  the  diagnosis  of  fevers.  The  skin  inflamma- 
tions closely  simulate  in  their  symptoms  the  eruptive  fevers,  even  to 
the  affections  of  the  mucous  membranes.  Besnier  has  named  them  the 
pseudo-exanthems,  and  divides  them  into  rubeloids  and  scarlatinoids. 
Both  simulate  eruptive  fevers  throughout  their  course,  and  hence  both 
are  acute  and  febrile.  The  scarlatiniform  erythemas  are  febrile  at  the 
beginning,  subacute  in  course,  but  of  longer  duration  than  the  fever 
they  simulate.  They  are  the  most  common  forms,  and  arise  from  in- 
fectious diseases,  such  as  puerperal  fever,  septicaemia,  and  gonorrhoea, 
or  from  toxaemia  due  to  drugs  or  articles  of  food. 

Character  of  eruption  in  the  non-contagious  forms.  The  ery- 
themata  are  characterized  by  (a)  rose  rash  with  injection  of  the  surface, 
either  (6)  with  general  oedema,  or  with  circumscribed  local  oedema, 
forming  wheals  or  with  papules.  In  rare  cases  bullae  are  also  formed. 
(c)  The  rash  is  followed  by  a  branny  desquamation,  (c?)  The  exuda- 
tion that  attends  the  lesion  is  always  watery,  in  contradistinction  to  the 
sero-purulent  or  purulent  exudation  of  eczema  and  scabies.  Sometimes 
slight  hemorrhages  attend  the  lesion,  as  in  cases  of  purpura  or  of  urti- 
caria, (e)  The  course  of  the  erythema  is  of  diagnostic  significance.  It 
begins  quickly,  and  is  usually  attended  with  febrile  symptoms,  some- 
times mild,  again  very  intense.  (/)  The  duration  is  short ;  at  least  it 
is  not  indefinite.  The  erythemas  that  are  recurrent  must  not  be  con- 
sidered to  be  one  process  of  long  duration,  (g)  The  locality  of  the 
erythema  is  not  of  precise  diagnostic  significance.  The  eruption  is 
usually  symmetrical,  and  the  favorite  localities  may  be  defined  as  the 
extensor  surfaces  of  the  forearms  and  leg,  the  face,  cheeks,  neck,  and 
the  chest  and  abdomen.  True  erythema  does  not  attack  the  scalp,  the 
flexures  of  the  joints,  the  palms  (except  erythema  multiforme),  nor  the 
soles.  (A)  The  local  symptoms  that  attend  erythemata  are  mild.  Local 
tenderness  is  more  marked  than  in  eczema.  Smarting  and  tingling 
are  complained  of,  but  severe  pain  and  excessive  itching  are  rare.  Only 
when  wheals  are  present  do  we  find  pruritus.  The  rash  of  erythema 
does  not  spread.  Patches  occasionally  unite,  but  an  affected  area  never 
enlarges  its  borders. 

The  etiology  of  erythema  is  involved  in  obscurity.  Although 
the  frequent  associate  phenomena  are  not  of  etiological,  they  are  cer- 
tainly of  diagnostic  significance.  We  may  have  them  occur  under  the 
following  circumstances  :  1.  In  one  class  the  eruption  is  symptom- 
atic, depending  upon  dyspepsia  or  upon  rheumatic  fever.  2.  In  the 
eruptive  fevers,  especially  scarlatina  and  measles,  in  enteric  fever  and 
cholera,  and  in  syphilis,  there  is  an  early  erythema  preceding  the  later 
true  eruption.  3.  The  most  striking  instance  of  the  relationship  to 
internal  disorder  is  seen  in  the  rash  that  arises  after  the  administration 
of  medicine,  as  copaiba,  or  after  the  taking  of  certain  foods.  4.  The 
erythemata    occur    most    commonly   in   children    and    young   people. 


THE  DATA  OBTAINED  BY  OBSERVATION.  137 

They  are  very  frequent  in  men.  The  age  at  which  they  occur  coincides 
with  that  of  rheumatism. 

Varieties  of  non-contagious  erythemata  :  First,  erythema  multi- 
forme in  simple  form,  with  papules  or  with  exudation  ;  it  may  disap- 
pear in  a  few  hours,  or  persist  for  a  day  or  two  and  form  rings  (ery- 
thema fugax  or  erythema  annulatum).  With  the  fading  of  the  redness 
faint  desquamation  ensues,  and  there  may  be  a  few  pigment  marks. 
The  annular  form  is  observed  in  rheumatic  fever.  In  addition  to 
rheumatism  erythema  multiforme  may  be  found  associated  with  the 
following  affections  :  Typhoid  fever,  puerperal  fever,  gonorrhoea, 
cholera,  infectious  endocarditis  and  osteomyelitis,  syphilis,  leprosy, 
vaccination,  and  surgical  septicaemia.  Osier  has  called  attention  to  the 
visceral  complications  of  erythema  exudativa  multiforme  associated  with 
the  skin  lesions — viz.,  gastro-intestinal  crises,  endocarditis,  pericarditis, 
acute  nephritis,  and  hemorrhage  from  the  mucous  surfaces.  Arthritis 
is  also  seen  in  some  instances.  The  skin  lesions  range  from  simple 
purpura  to  local  oedema,  and  from  urticaria  to  large  infiltrating  hemor- 
rhages of  the  skin  and  subcutaneous  tissues.  The  gastro-intestinal 
crises  are  attended  by  colic,  with  vomiting  and  diarrhoea. 

Erythema  l,eve  often  appears  upon  the  tense  skin  of  dropsical 
parts.     It  may  be  the  result  of  acupuncture. 

Vesicular  and  Bullous  Erythema.  To  this  class  belong  the 
affections  known  as  herpes  and  erythema  bullosum. 

Herpes  zoster  is  seen  in  the  cutaneous  distribution  of  one  or  more 
nerves.  It  consists  of  vesicles  of  flattened  form,  ranged  in  clusters  of 
twenty  or  thirty,  lying  on  a  reddened,  slightly  swollen  bed  of  skin. 
The  number  of  clusters  varies  from  one  to  ten.  The  vesicles  develop 
in  quick  succession,  beginning  usually  near  the  roots  of  the  nerve  whose 
branches  they  follow.  A  short  papular  stage  precedes  the  vesicles,  and 
some  of  the  vesicles  abort.  The  eruption  tends  to  dry  up  in  five  or  six 
days.  The  crusts  form  in  yellowish  or  brownish  clusters,  which  fall 
off  in  the  third  week,  leaving  purple  stains. 

When  the  disease  attacks  the  face  it  follows  the  course  of  the  fifth 
nerve.  The  several  twigs  of  the  trifacial  are  traced  out  from  their 
points  of  emergence  from  the  bony  canals.  Great  swelling  of  the  eye- 
lids sometimes  takes  place  on  account  of  the  loose  tissue,  so  that  the 
lesion  may  be  mistaken  for  erysipelas.  Ulceration  of  the  cornea  and 
iris  sometimes  occurs,  and,  when  lower  divisions  of  the  trifacial  are 
affected,  vesicles  may  appear  in  the  mucous  membrane  of  the  mouth 
and  palate.  The  cervical  nerves  and  those  of  the  upper  extremity  are 
also  affected  in  their  distribution.  The  eruption  on  the  arm  rarely 
goes  below  the  elbow.  When  the  second  and  third  intercostal  nerves 
are  affected  the  intercostohumeral  branch  produces  an  eruption  down 
the  inner  side  of  the  arm.  The  eruption  occurs  frequently  on  the 
trunk.  Following  the  course  of  the  dorsal  nerves  it  slants  downward 
as  it  approaches  the  pubes. 

In  the  distribution  of  the  disease  in  the  lower  limbs  the  eruption 
rarely  extends  below  the  knee  or  buttocks.  It  follows  the  course  of 
the  external  cutaneous  or  anterior  crural  nerves,  or  that  of  the  small 
sciatic.     Some  of  the  branches  of  the  sacral  nerves  are  also  affected. 


138  GENERAL  DIAGNOSIS. 

The  disease  is  unilateral,  and  its  precise  limitation  to  one-half  of  the 
body  is  of  the  greatest  diagnostic  significance. 

While  fever  or  general  symptoms  do  not  usually  attend  its  course 
in  any  marked  degree,  insomnia  and  depression  are  likely  to  occur, 
probably  on  account  of  the  severe  neuralgic  pain.  Pain  is  the  most 
important  subjective  symptom.  It  is  localized  in  the  nerves,  hi  the 
distribution  of  which  the  eruption  takes  place.  It  is  not  so  likely  to 
be  present  in  the  young.  The  pain  may  precede  the  eruption  by 
several  days,  and  persist  long  after  the  eruption  subsides.  This  is 
particularly  the  case  in  old  people. 

Herpes  eabialis,  or  facialis,  consists  of  vesicles  arranged  in 
groups  or  clusters  upon  an  inflamed  surface.  They  appear  very  sud- 
denly upon  the  upper  lid  or  the  alae  of  the  nose,  sometimes  on  the 
cheek  or  chin,  and  they  may  appear  inside  the  mouth.  They  undergo 
some  changes,  as  in  herpes  zoster,  but  are  not  attended  by  severe 
neuralgic  pain.  They  are  also  symptomatic  of  an  internal  disorder, 
an  acute  catarrh  (cold),  or  follow  a  rigor,  as  in  intermittent  fever  or 
pneumonia.  They  may  be  present  in  epidemic  cerebro-spinal  menin- 
gitis, but  are  neyer  present  in  tuberculous  meningitis.  Diagnosis  of 
the  former  disease  is  confirmed  by  their  presence  (Klemperer).  Herpes 
iris  and  herpes  preputialis  have  no  diagnostic  significance  of  internal 
disease. 

Erythema  Nodosum.  With  the  erythema  there  is  great  oedema. 
The  spots  are  somewhat  painful  and  tender,  but  do  not  itch.  The 
redness  of  the  erythema  is  modified  by  the  hue  of  venous  congestion. 
Small  hemorrhages  may  be  seen.  The  patches  develop  on  the  legs, 
their  long  diameter  being  parallel  to  the  tibia.  They  rise  slowly  into 
hard  masses.  They  may  be  seen  on  the  ankles  or  the  calf,  and  some- 
times on  the  ulna.  They  occur  frequently  in  those  who  have  suffered 
from  rheumatic  fever. 

Urticaria  is  a  form  of  erythema  in  which  wheals,  sometimes  sur- 
rounded by  an  erythematous  blush,  are  seen.  It  is  an  acute  inflamma- 
tory oedema  of  the  cutis.  The  serous  exudation  fills  the  lymph-spaces 
and  expels  blood  from  the  venules.  It  takes  place  suddenly,  and  may 
be  excited  by  chemical  irritation  or  a  mechanical  irritant,  as  the  finger 
drawn  across  the  skin.  Small  patches,  or  large  white  areas,  are  seen, 
due  to  the  coalescence  of  smaller  ones  (giant  urticaria).  All  parts  of 
the  body  may  be  affected,  except  the  scalp,  face,  and  soles  of  the  feet. 
The  eruption  is  not  symmetrical.  Its  course  may  be  acute,  or  it  may 
be  chronic  and  transitory,  characterized  by  successive  attacks.  It  is 
the  form  of  erythema  in  which  intense  itching  is  the  most  pronounced 
symptom.  There  are  no  other  subjective  symptoms.  The  itching 
causes  restlessness  and  loss  of  sleep.  Urticaria  is  symptomatic  of  gas- 
tric or  intestinal  disturbance,  or  the  ingestion  of  drugs  or  poisons. 
Another  form  follows  the  tapping  of  a  hydatid  cyst.  It  occurs  some- 
times in  women  at  each  menstrual  period,  and  may  be  traced  to  ovarian 
disorder.  It  may  occur  after  severe  shock  to  the  nervous  system,  with 
high  fever.  It  is  not  an  infrequent  complication  of  rheumatic  fever. 
It  occurs  in  men  and  women  equally,  but  is  most  frequent  in  children 
and  adolescents. 


THE  DATA  OB  TAIN  ED  B  Y  OBSER  VA  TION.  139 

Medicinal  Rashes.  To  the  erythemata  belong  most  of  the  so-called 
medicinal  rashes. 

The  following  drugs  are  known  to  cause  erythema  :  potassium  bro- 
mide and  iodide,  copaiba,  cubebs,  the  essential  oils,  capsicum,  santonin, 
chloral,  opium,  morphine,  antipyrin,  salicylic  acid  and  its  compounds, 
iodoform,  belladonna  and  atropine,  tar,  carbolic  acid,  arsenic,  cannabis 
indica,  digitalis,  mercury,  silver,  copper,  and  antitoxin. 

Belladonna  produces  in  susceptible  persons,  or  when  administered 
in  poisonous  doses,  a  diffuse,  bright-red  erythema,  closely  resembling 
that  of  scarlet  fever,  but  without  the  darker  red  points  which  interrupt 
the  latter.  Atropine  also  produces  in  some  persons,  especially  on  the 
shoulders,  arms,  chest,  and  face,  an  eruption  of  disseminated,  small, 
hard  vesico-papules,  showing  no  tendency  to  pustulation.  They  are 
seated  on  an  inflammatory  base,  but  are  more  superficial  than  acne. 

The  bromides  produce  a  characteristic  pustular  eruption  which  is 
most  intense  upon  the  shoulders,  face,  chest,  and  arms.  Large  doses, 
or  long-continued  administration,  are  generally  required  to  bring  it 
out.     It  is  conspicuous  upon  the  face  of  some  epileptics. 

The  iodides  produce  an  eruption  which  is  not  often  pustular,  but 
an  erythematous  or  papular  rash  is  not  uncommon.  It  appears  chiefly 
about  the  forearms,  face,  and  neck.  Vesicles,  bullae,  and  purpuric 
spots  are  also  occasionally  seen. 

The  eruption  produced  by  quinine  is  generally  erythematous,  and  is 
attended  with  itching  and  burning  ;  the  face  and  neck  are  attacked 
first. 

Opium  and  its  alkaloid  also  produce,  in  susceptible  persons,  an 
erythematous  scarlatinoid  eruption  which  is  accompanied  by  intense 
itching.  Itching,  especially  about  the  nose,  is  much  more  common 
without  eruption. 

Copaiba  produces  a  vesico-papular  or  papular  eruption  which  resem- 
bles urticaria  and  erythema  multiforme.  It  is  itchy.  It  is  more  apt 
to  be  seen  on  the  extremities.     It  may  be  purpuric. 

The  eruption  of  cubebs  is  a  diffused  erythema,  with  millet-sized 
papules,  coalescent  here  and  there.  Unlike  the  eruption  of  copaiba, 
it  is  more  copious  over  the  face  and  trunk  than  over  the  extremities. 

Antipyrin  causes  a  measles-like  or  urticaria-like  eruption. 

Erythemata  of  Infectious  Diseases. 

The  inflammations  of  the  skin  which  are  symptomatic  of  a  specific 
infection  are  also  of  an  erythematous  variety.  The  term  exanthemata 
has  been  applied  to  the  latter,  but  the  eruptions  of  typhus  and  typhoid 
(enterica)  belong  to  the  same  class.  The  characteristics  and  distinc- 
tions of  the  various  forms  will  be  described  in  sections  devoted  to  the 
respective  diseases.  The  student  should  remember  the  associate  general 
phenomena,  particularly  fever,  the  onset  and  the  course  of  which  should 
be  carefully  observed. 

Roseola.  Roseola  is  of  a  deep  rose-color,  not  arranged  in  crescentic 
patches,  as  in  measles,  nor  scarlet  and  capable  of  being  resolved  into 
innumerable  red  points,  as  in  scarlatina.     It  is  not  so  diffuse  as  the 


140  GENERAL  DIAGNOSIS. 

latter.  It  precedes  smallpox,  scarlatina,  measles,  cholera,  typhoid  fever, 
syphilis,  diphtheria,  and  malaria.  In  smallpox,  in  cases  of  cholera,  and 
after  parturition  and  surgical  operations,  the  rash  is  copious,  but  is 
characterized  by  being  seated  over  the  lower  half  of  the  abdomen  and 
the  anterior  and  inner  aspects  of  the  thighs.  It  may  appear  elsewhere, 
but  is  usually  confined  to  that  portion  of  the  body. 

The  erythema  of  roseola  may  be  mistaken  for  rubella,  measles,  or 
scarlatina.  The  following  are  points  of  distinction  :  First,  it  is  neither 
contagious  nor  epidemic  ;  second,  there  are  no  prodromal  symptoms ; 
third,  the  rash  does  not  come  out  after  a  definite  period  of  fever ;  fourth, 
it  is  not  confined  to  any  special  locality ;  fifth,  the  fever  is  of  short 
duration  and  moderate  degree,  rarely  above  101°;  sixth,  there  is  no 
catarrhal  discharge  from  the  eyes  or  nose  or  in  the  pharynx  ;  the  fauces 
and  palate  are  reddened  without  swelling ;  seventh,  it  is  not  seen  in 
the  mouth,  like  the  eruptions  of  measles  or  scarlatina  ;  eighth,  if  pres- 
ent, the  fever  which  precedes  the  eruption  is  of  only  a  few  hours'  dura- 
tion (in  scarlatina  it  lasts  twenty-four  hours,  in  measles  seventy-two 
hours) ;  ninth,  the  rash  is  not  crescentic  as  in  measles,  nor  punctiform 
as  in  scarlatina,  though  it  must  be  admitted  that  severe  cases  of  the 
affection  cannot  be  easily  diagnosticated,  the  development  of  the  sequelae 
alone  concluding  the  diagnosis. 

To  add  to  the  confusion,  an  erythema  called  roseola  often  precedes 
the  eruption  of  a  particular  fever.  The  association  with  this  class  of 
fevers  has  been  indicated  before. 

Sufficient  reference  has  been  made  to  the  erythemata  that  attend  rheu- 
matism. A  few  other  internal  (infectious)  disorders  are  associated  with 
the  development  of  an  eruption.  In  cholera,  during  the  period  of  reac- 
tion, a  rose  rash  which  may  resemble  erythema,  urticaria,  or  scarlatina 
appears  comcidently  with  a  rise  of  temperature.  It  is  most  frequently 
seen  on  the  forearms  and  backs  of  the  hands,  but  may  cover  the  back 
and  limbs.  It  may  be  slisrhtlv  hemorrhagic  and  last  two  or  three  da  vs. 
A  slight  desquamation  usually  follows.  In  influenza  a  roseolous  erup- 
tion, covering  the  trunks  and  limbs  and  becoming  papular,  is  seen  in 
rare  cases. 

In  addition,  erythematous  eruptions  are  sometimes  seen  in  the  course 
of  B right's  disease.  Two  forms,  quite  distinct  from  the  previously 
mentioned  erythema  lseve,  are  observed  :  the  roseola  on  the  feet,  legs, 
and  hands — rarely  on  the  chest  and  abdomen  ;  and  the  papular  form 
on  the  thighs,  arms,  and  shoulders.  Itching  and  other  subjective 
symptoms  do  not  attend  the  eruption.  A  form  with  desquamation 
may  begin  on  the  limbs.  These  erythemata  are  common  in  the  later 
stages  of  Bright's  disease,  but  are  not  of  ill  omen.  In  acute  Bright's 
disease  a  transient  roseola  is  observed  very  rarely  ;  so  also  is  purpura. 
If  there  is  much  anasarca  in  tubal  nephritis,  erythema  is  more  common. 
The  eruptions  usually  appear  independently  of  ursemic  symptoms,  and 
disappear  during  their  continuance.  They  are  in  all  probability  allied 
with  the  inflammation  which  attacks  the  lungs  and  serous  membranes 
in  Bright's  disease. 

Sudamina.  Here  may  be  mentioned  another  eruption,  or  condition 
of    skin,   common  in   the  course  of  internal  diseases.      Sudamina,  or 


THE  DATA  OBTAINED  BY  OBSERVATION.  141 

miliaria,  are  small,  clear  vesicles  seen  in  large  numbers,  usually  on  the 
abdomen,  but  also  on  any  other  part  which  reflects  the  light  strongly. 
They  are  seen  during  and  after  the  subsidence  of  profuse  sweats. 
While  actual  perspiration  is  seen  on  the  forehead,  the  trunk  may 
appear  free  from  moisture.  When  the  hand  is  placed  over  it,  as  on 
the  abdomen,  the  dryness  is  noted,  but  at  the  same  time  a  roughened, 
nutmeg-grater-like  sensation  is  felt.  On  close  inspection  this  is  ob- 
served to  be  due  to  the  eruption  just  mentioned.  The  vesicles  are 
usually  of  good  prognostic  omen  in  the  course  of  febrile  diseases,  par- 
ticularly typhoid  fever.  They  are  due  to  the  accumulation  of  perspi- 
ration under  the  epidermis. 


General  Diagnosis  of  Skin  Affections. 

{Condensed  from  Pye-Smith.) 

I.  Factitious  Eruptions.  We  must  never  forget  the  possibility  of 
the  affection  before  us  being  artificial.  AH  kinds  of  dermatites,  eczema, 
erysipelas,  pemphigus,  impetigo,  may  be  simulated  by  the  application 
of  various  irritants.  Pigmentation  also  has  often  been  imitated  with 
success.  Such  artificial  lesions  will  generally  be  found  upon  the  arms, 
rarely  on  the  face,  and  scarcely  ever  beyond  reach  of  the  patient's 
hands.  Mustard,  cantharides,  and  some  other  irritants  can  be  distin- 
guished with  the  aid  of  the  microscope. 

II.  Traumatic  Eruptions.  In  all  cases  of  dermatitis  we  should 
seek  for  the  irritant,  and  sometimes  it  is  so  directly  the  cause  of  the 
disease  that  the  eczema  or  impetigo  in  question  may  be  considered 
purely  traumatic,  and  efficient  treatment  immediately  follows  accurate 
diagnosis  :  sublata  causa  tollitur  effectus. 

Pediculi  in  the  hair  should  be  carefully  looked  for  in  all  cases  of 
impetigo  in  children  ;  pediculi  vestimentorum  in  prurigo  of  old  people. 
The  acarus  of  scabies,  fleas,  bugs,  and  gnats  may  be  found.  In  adults, 
pediculi  pubis  may  sometimes  be  found  in  the  axillae  as  well  as  in  their 
proper  region,  and  when  they  have  been  destroyed  by  mercurial  oint- 
ment the  patient  is  at  once  relieved  from  pruritus. 

Frequently  the  irritant  must  be  sought  for  in  the  objects  which  the 
patient  habitually  handles.  The  coarser  kinds  of  brown  sugar  are  a 
frequent  cause  of  eczema  of  the  hands  (grocer's  itch).  So  with  many 
of  the  "  chemicals  "  used  in  a  variety  of  modern  handicrafts.  Constant 
washing  of  the  hands  in  washerwomen,  in  scrubbers,  in  potmen,  and 
many  others  produces  eczema  rimosum.  The  heat  of  the  sun  is  the 
cause  of  eczema  solare  and  ephelides  ;  the  heat  of  the  fire,  of  the  pig- 
ment spots  on  the  shins  of  elderly  people.  Sweat,  again,  is  a  very 
common  irritant,  producing  the  erythema  which  usually  accompanies 
sudamina  and  also  intertrigo  of  opposed  surfaces.  Scratching,  as  a 
cause  of  traumatic  dermatitis,  has  been  repeatedly  referred  to. 

III.  Febrile  Rashes.  We  must  never  forget  that  a  cutaneous 
eruption  may  possibly  be  part  of  an  acute  exanthem.  The  use  of  a 
clinical  thermometer  is  a  great  help  in  this  respect.  Variola  is  fre- 
quently mistaken  for  syphilis  and  other  affections. 


142  GENERAL  DIAGNOSIS. 

IV.  Medicinal  Rashes.  Other  cases  are  due  to  certain  kinds  of 
food  or  to  drugs.     They  have  been  described  above. 

V.  Syphilodermata.  When  we  have  satisfied  ourselves  that  the 
eruption  before  us  is  not  factitious,  nor  directly  traumatic,  nor  a  symp- 
tomatic eruption,  we  may  next  consider  whether  or  not  it  is  due  to 
syphilis.  In  this  inquiry  it  is  undesirable  to  ask  questions  the  answers 
to  which  are  as  apt  to  mislead  as  to  guide  aright. 

1.  We  should  first  consider  the  color  of  the  affected  skin,  remember- 
ing, however,  that  the  pigmentation  which  gives  the  so-called  coppery 
or  raw-ham  tint  to  a  syphilitic  eruption  is  the  same  which  is  sooner  or 
later  produced  by  all  forms  of  dermatitis.  Psoriasis,  chronic  eczema, 
lichen  planus,  and  prurigo  may  all  produce  shades  which  bear  the 
closest  resemblance  to  syphiloderma. 

2.  The  lesions  of  syphilis  are  multiform.  It  is  rare  in  any  but 
syphilitic  affections  to  find  mere  hyperemia  in  one  part  and  associated 
pustules,  papules,  scales,  or  ulcers  in  others;  and  it  is  not  often  that  a 
syphilitic  eruption  exhibits  only  a  single  elementary  lesion. 

A  pustular  eruption  in  an  adult  should  always  suggest  the  question 
of  syphilis  when  that  of  scabies  has  been  answered  in  the  negative. 

3.  Syphilitic  eruptions,  for  some  unknown  reason,  do  not  itch — the 
exceptions  to  this  rule  are  remarkably  few;  they  usually  occur  during 
the  stage  of  scabbing  of  pustular  rashes  or  during  the  healing  of 
tertiary  ulcers.  An  ordinary  secondary  syphilide  may,  however,  as  a 
rare  exception,  be  so  irritating  that  wheals  and  scratch-marks  are 
present.  On  the  other  hand,  psoriasis  is  often  free  from  irritation, 
while  the  degree  of  itching  of  eczema,  and  even  of  scabies  and  prurigo, 
varies  greatly. 

4.  The  local  distribution  of  syphilitic  disease  is  a  great  aid  in  diag- 
nosis. Specific  eruptions  are  certainly  not,  as  a  rule,  symmetrical;  the 
early  roseolous  rash  is  only  so  because  it  is  general,  and  therefore,  upon 
a  surface  like  the  human  body,  more  or  less  symmetrical.  Moreover,  as 
it  chiefly  affects  the  face,  chest,  and  trunk  generally,  it  is  near  the 
middle  line.  But  we  do  not  see  symmetrical  patches  of  syphilide  in 
corresponding  parts  of  both  sides  of  the  face,  both  sides  of  the  trunk, 
or  the  right  and  left  limbs.  In  all  but  the  earliest  syphilides  the 
affected  patches  are  very  decidedly  and  constantly  un symmetrical, 
irregularly  scattered  over  head,  trunk,  and  limbs,  and  chiefly  remark- 
able for  having  no  well-marked  seats  of  predilection. 

The  forehead,  especially  about  the  roots  of  the  hair,  is,  however, 
very  frequently  the  seat  both  of  the  early  and  middle  erythematous, 
scaly,  and  pustular  syphilides,  and  the  palms  of  the  hands  and  soles  of 
the  feet  are  frequently  symmetrically  affected  with  the  later  scaly  eruption. 

Practically,  when  we  find  a  disease  of  the  skin  occupying  some  un- 
usual position,  we  should  at  least  consider  the  question  of  syphilitic 
origin. 

5.  These  signs,  alone  or  in  combination,  serve  to  distinguish  early 
specific  roseola  from  erythema,  eczema,  scarlatina,  and  measles,  and  the 
later  eruptions  from  eczema,  lichen,  impetigo,  and  psoriasis. 

The  eruptions  of  congenital  syphilis  which  are  most  liable  to  be  mis- 
taken are  :  The  so-called  pemphigus  of  infants,  which  is  known  by  its 


THE  DATA  OBTAINED  BY  OBSERVATION.  143 

affecting  the  palms  and  soles  ;  rupia,  which,  by  the  form  of  the  crusts 
and  the  ulcerated  surface  beneath,  may  always  be  distinguished  from 
impetigo  ;  an  erythematous  rash  of  the  nates  and  genitals  of  infants, 
which  is  distinguished  from  eczema  of  the  same  parts,  also  common  at 
that  age,  by  its  coppery  color,  its  blotchy  distribution,  and  more  clearly 
defined  margin. 

The  tertiary  ulcers  of  syphilis  are  distinguished  by  their  presence  in 
unusual  places,  by  their  punched-out  edges,  circular  or  so-called  horseshoe 
shape,  and  by  the  fact  that  they  usually  give  little  pain  or  discomfort. 

Tertiary  ulcers  have  no  predilection  for  the  outer  side  of  the  leg,  but, 
inasmuch  as  the  part  above  the  inner  malleolus  is,  from  anatomical 
causes,  the  chosen  seat  of  varicose  ulcers,  most  ulcers  in  the  first  posi- 
tion will  be  syphilitic  and  in  the  latter  not.  Moreover,  the  age  helps 
in  the  diagnosis,  as  varicose  ulcers  rarely  occur  before  the  fortieth  year. 

Most  ulcers  on  the  arms  are  found  to  be  tertiary  syphilitic  ulcers. 

VI.  Tineae.  The  next  group  of  skin  diseases  includes  those  which 
are  due  to  vegetable  parasites — tinea  versicolor  of  the  trunk,  eczema 
marginatum  of  the  perineum  and  thighs,  tinea  circinata  of  the  neck 
and  other  parts,  tinea  sycosis  of  the  chin,  and  tinea  tonsurans  of  the 
scalp.     In  all  doubtful  cases  the  microscope  should  be  employed. 

Tinea  of  the  scalp  is  rare  in  adults,  and  tinea  circinata  still  more  so  ; 
tinea  marginata  occurs  only  in  adult  males. 

VII.  Primary  Superficial  Inflammations.  To  distinguish  the 
superficial  from  the  deeper  kinds  of  dermatitis,  we  should  notice 
whether  the  cutis  alone  is  infiltrated  and  thickened,  or  whether  it  is 
bound  down  by  adhesions  to  the  subcutaneous  tissues.  The  presence 
of  scars,  however  slight,  is  a  proof  that  the  process  has  gone  deeper 
than  the  papillae,  and  has  more  or  less  extensively  destroyed  the  papil- 
lary layer.  Superficial  inflammations,  excluding  those  due  to  acarus, 
to  pediculi,  and  to  other  direct  irritants,  and  excluding  also  those  which 
are  the  result  of  vegetable  parasites  and  of  syphilis,  fall,  with  respect 
to  their  treatment,  into  three  large  groups  : 

The  first  group,  represented  by  impetigo  and  most  forms  of  eczema, 
consists  of  inflammations  which  are  subacute,  and  accompanied  with 
burning,  itching,  and  pain,  sometimes  with  a  slight  degree  of  fever. 

The  second  group  of  superficial  inflammations  of  the  skin  is  typically 
represented  by  psoriasis,  but  includes  lichen  planus,  the  more  chronic, 
dry,  and  obstinate  forms  of  eczema,  and  true  prurigo.  These  affec- 
tions are  chronic,  with  little  irritation,  exudation,  pain,  or  active  signs. 

The  third  group  is  that  of  erythemata. 

VIII.  The  Acne  Group.  Acne,  both  in  its  pathology  and  etiol- 
ogy, differs  from  other  forms  of  dermatitis.  The  age  of  the  patient 
and  its  distribution  are  sufficient  for  diagnosis.  It  is  at  once  a  super- 
ficial and  a  deep  dermatitis,  and  is  often  followed  by  scars.  Its  treat- 
ment consists  entirely,  or  almost  entirely,  in  local  applications  directed 
to  the  correction  of  the  sebaceous  affection.  With  acne  may  he  classed 
sycosis  and  furunculus. 

IX.  Deep  Affections.  When  we  have  ascertained  that  the  affect  ion 
of  the  skin  is  deep,  that  is  to  say,  that  it  goes  below  the  papillary  layer, 
the  field  of  diagnosis  is  limited. 


144  GENERAL  DIAGNOSIS. 

Excluding  erysipelas,  which  is  distinguished  by  its  acute  character 
and  febrile  symptoms,  excluding  the  pustular  affections  which  affect 
the  skin  deeply  and  produce  scars  only  at  isolated  points,  such  as  acne, 
variola,  and  herpes  zoster,  and  excluding,  thirdly,  leprosy  and  other 
exotic  diseases,  we  have  to  distinguish  in  the  great  majority  of  cases 
which  come  before  us  in  this  country — first,  traumatic  and  varicose 
ulcers  ;  second,  gummata  and  syphilitic  ulcers  ;  third,  lupus  ;  fourth, 
rodent  ulcer  ;  and  fifth,  carcinoma  of  the  skin. 

With  regard  to  the  first  of  these,  we  must  not  assume,  because  a  sore 
upon  the  skin  is  said  to  be  the  result  of  a  blow  or  a  kick,  that  it  is 
purely  traumatic,  for  syphilitic  ulcers  often  arise  in  this  way.  Malig- 
nant ulcers  are  rare,  and  are  usually  obvious  from  the  age  of  the 
patient,  the  pain  they  occasion,  their  tumid  margins,  and  their  blood- 
stained secretions.  Moreover,  they  are,  with  few  exceptions,  confined 
to  the  neighborhood  of  the  orifices  of  the  body,  especially  the  lower 
lip,  the  urethra,  the  vulva,  and  the  anus.  Rodent  ulcer,  however,  is 
very  difficult  to  diagnose  with  certainty.  Its  locality,  its  slow  and 
painless  progress,  and  its  belonging  to  the  latter  half  of  life,  usually 
serve  to  distinguish  it  from  lupus  ;  and  its  being  single,  excessively 
chronic,  and  unaccompanied  by  nodes  or  other  syphilitic  lesions,  are 
the  best  characteristics  for  diagnosis  from  a  tertiary  ulcer. 

The  Nutrition  of  the  Skin. 

Palpation.  The  color,  as  determined  by  inspection,  is  a  fair  index 
of  the  nutrition  of  the  skin,  but  further  information  is  obtained  by  pal- 
pation. In  health  the  skin  is  smooth,  firm,  and  elastic.  When  pinched 
between  the  thumb  and  fingers  and  then  allowed  to  escape,  it  slips 
quickly  back  into  its  former  position.  When  pressed  or  squeezed,  it 
becomes  pale  from  expression  of  blood,  but  resumes  its  natural  hue 
immediately. 

The  readiness  with  which  the  blood  returns  after  pressure  shows  the 
character  of  the  capillary  circulation  of  the  skin.  This  is  active  in 
health  and  sluggish  in  serious  disease  of  the  lungs,  heart,  and  blood- 
vessels. In  the  eruptive  fevers,  especially  in  measles,  scarlet  fever, 
and  smallpox,  sluggish  capillary  circulation  with  dusky  eruption  is  a 
grave  sign.  In  measles  it  is  usually  due  to  pulmonary  complications, 
and  in  other  infectious  diseases  to  the  overwhelming  effects  of  the  poison. 

As  age  advances  the  skin  becomes  less  elastic,  and  in  old  persons 
may  lie  in  wrinkles.  When  pinched  between  the  fingers  the  skin  is 
more  inclined  to  remain  wrinkled.  Fat  persons  whose  skin  is  firm 
and  hard  are  in  much  better  condition  than  those  whose  skin  is  loose 
and  flabby.  The  latter  condition  is  frequently  met  with  in  babies, 
particularly  those  that  are  fed  on  artificial  foods.  When  the  skin  is 
thin  and  dry  and  loses  its  tone,  so  that,  when  pinched  into  folds,  it 
resumes  its  smoothness  but  slowly  and  sluggishly,  it  is  usually  evi- 
dence, in  a  person  under  fifty,  of  some  grave  cachexia,  as  carcinoma. 

Moisture  and  Dryness  of  the  Skin.  Moisture  and  dryness  are  in 
one  sense  correlated  with  the  nutrition  of  the  skin.  It  is  quite  certain 
that  when  the  skin  is  abnormally  dry  its  nutrition  is  impaired. 


THE  DATA  OBTAINED  BY  OBSERVATION.  145 

In  health  the  skin  is  not  perceptibly  moist,  except  as  the  result  of 
physical  exertion  or  under  heat,  or  as  the  immediate  result  of  imbibing 
a  hot  fluid  or  a  sudorific  drug.  There  is  considerable  individual  differ- 
ence, however,  within  the  limits  of  the  normal.  Rheumatic  and  stru- 
mous persons  may  have  a  perceptibly  moist  and  oily  skin  at  all  times, 
while  others  have  a  skin  which  perspires  very  little,  even  under  influ- 
ences which  usually  bring  about  perspiration. 

Pebspieation  Ijsfceeased.  Hyperidrosis.  It  may  be  general  or 
local. 

A.  General  increased  perspiration  is  seen — 1.  With  fever.  It  occurs 
in  the  course  of  rheumatism,  when  the  sweats  are  strong  in  odor  and 
acid  in  reaction.  It  is  seen  in  tuberculosis,  especially  the  miliary 
variety.  It  is  sometimes  marked  throughout  cases  of  typhoid  fever. 
General  perspiration  also  attends  the  violent  muscular  action  of  tetanus, 
but  is  not  seen  in  epilepsy.  An  example  of  general  sweating  is  seen  in 
that  curious  affection  to  which  the  term  "  sweating  sickness  "  has  been 
applied.  It  is  a  fever  the  nature  of  which  is  not  well  known,  but  in 
which  this  symptom  is  most  pronounced.  Sweating  is  extreme  in 
trichinosis. 

2.  AVith  normal  or  subnormal  temperature,  a.  Sudden,  temporary 
perspiration.  Sweats  occur  from  excitement  or  slight  exertion  in 
patients  during  convalescence.  A  general  profuse  perspiration  may  be 
of  short  duration  and  occur  suddenly  after  fright  or  shock  in  health. 
It  is  the  characteristic  perspiration  of  collapse.  The  forehead  is  cov- 
ered with  sweat,  large  drops  stand  out  on  the  face,  the  hands  and  feet 
are  moist  or  wet  with  perspiration,  and  the  whole  surface  of  the  body 
"  leaks."  It  is  attended  by  a  cold  and  clammy  skin.  In  the  collapse 
of  all  forms  of  shock,  or  after  hemorrhage  or  profuse  discharge,  as  in 
cholera,  this  form  of  perspiration  is  seen. 

More  striking  still  are  the  perspirations  that  suddenly  break  out  in 
the  course  of  acute  disease  coincidently  with  a  fall  of  temperature.  We 
have  (1)  the  critical  sweats  of  pneumonia  and  relapsing  fever ;  (2)  sweats 
which  terminate  a  paroxysm  of  intermitting  fever,  whether  of  malarial 
or  infectious  origin  (see  Fever) ;  (3)  the  profuse  perspiration  that 
attends  pyaemia,  breaking  out  with  each  fall  of  temperature  to  disappear 
as  it  rises  ;  (4)  the  night-sweats  that  attend  tuberculosis  and  other  ex- 
hausting diseases.  In  tuberculosis  and  in  pus-formation  or  accumula- 
tion the  oscillation  of  temperature,  with  or  without  chills,  followed  by 
sweating,  is  known  as  hectic.  Sudden  breaking  out  of  general  per- 
spiration, but  more  notably  seen  on  the  face,  attends  dyspnoea  of  pulmo- 
nary origin  and  the  attacks  of  dyspnoea  in  the  course  of  organic  heart 
disease.  These  perspirations  are  at  times  the  result  of  an  effort  at 
elimination,  on  the  part  of  the  skin,  to  relieve  the  kidneys  or  bowels, 
such  as  the  perspiration  of  urcemia,  which  is  attended  by  a  urinous 
odor.  At  times  it  may  also  occur  in  jaundice.  In  the  conditions  just 
mentioned  there  are  coolness  of  the  skin  and  cold  extremities. 

b.  Prolonged,  Perspiration.  In  exhausting  diseases,  general  and 
persistent  perspiration  may  occur,  particularly  in  the  later  stages,  as  in 
tuberculosis,  and  in  any  disease  attended  by  persistent  dyspnoea. 

10 


146  GENERAL  DIAGNOSIS. 

B.  Local  increased  perspiration  (hyperidrosis  localis)  occurs  when 
there  is  local  vasomotor  paresis.  Thus,  in  organic  diseases  of  the  brain 
and  hi  affections  of  the  peripheral  nerves,  in  some  forms  of  neuralgia, 
in  migraine  and  in  hysteria,  it  has  been  observed.  Sometimes  one 
side  of  the  body  alone  is  affected,  even  in  a  malarial  paroxysm  (hemi- 
drosis). 

Local  sweats  are  sometimes  significant.  This  is  the  case  particularly 
with  a  sweat  confined  to  the  head,  which  occurs  usually  in  children,  and 
is  one  of  the  striking  characteristics  of  rickets.  With  the  local  sweat- 
ing the  patient  rolls  his  head  at  night  from  discomfort.  The  hair  on 
the  back  of  the  head  is  rubbed  off. 

Unilateral  sweating  of  the  head  may  arise  from  destructive  pressure 
on  the  sympathetic  nerves,  causing  paralysis  of  the  dilator  fibres  of  the 
cilio-spinal  branches,  in  thoracic  aneurism,  and  in  caries  of  the  lower 
cervical  vertebrae.  There  are  usually  contraction  of  the  pupil  and  con- 
gestion of  the  face  on  the  same  side. 

Diminished  Peespieatiox.  Anidrosis.  The  skin  is  abnormally 
drv  in  the  early  stages  of  acute  disease  attended  by  fever,  particularly 
if  the  febrile  rise  takes  place  suddenly,  as  in  acute  digestive  disorders 
of  children.  In  adults,  when  the  disease  is  accompanied  by  high  fever, 
as  in  thermic  fever,  the  skin  is  dry.  In  the  first  day  of  the  eruption 
of  the  exanthemata  the  dryness  is  marked.  Dryness  of  the  skin  is  of 
frequent  occurrence  when  there  are  copious  discharges  of  water  from 
the  bowels  or  the  kidneys.  In  choleraic  diarrhoea  the  dryness  occurs 
suddenly.  In  some  affections,  as  diabetes  and  Bright's  disease,  the 
dryness  extends  over  a  long  period  of  time,  and  is  frequently  attended 
by  eruptions  or  desquamations  and  by  the  formation  of  boils.  When 
there  are  accumulations  of  serum  in  the  lymph-spaces  of  the  subcu- 
taneous connective  tissue,  or  changes  in  the  connective  tissue,  as  in 
dystrophies  or  myxoedema,  or  scleroderma,  the  skin  is  dry  because  of 
the  stretching  and  pressure  on  the  bloodvessels. 

Scars.  Scars  are  important  proofs  of  the  occurrence  of  previous 
disease,  especially  smallpox,  chickenpox,  and  syphilis.  Scars  of  the 
first  two  occur  in  the  form  of  circular  pits,  and  almost  always  on  the 
face.  Scars  of  syphilis  are  larger,  circular,  or  oval  in  shape,  and  seen 
usually  to  the  best  advantage  on  the  extremities,  but  the  single  scar  on 
the  forehead  is  strikingly  suggestive.  Scars  upon  the  legs  in  persons 
under  thirty  years  of  age,  when  not  traumatic,  are  almost  always 
syphilitic.  Scars  as  the  result  of  suppurating  glands  are  seen  most 
frequently  in  the  neck,  but  may  be  found  wherever  there  are  glands, 
especially  under  the  jaw  and  in  the  axilla  and  groin.  They  are  most 
liable  to  occur  in  tuberculous  persons,  either  spontaneously  or  as  the 
result  of  the  exanthemata,  erysipelas,  or  other  infectious  disease.  When 
such  scars  are  met  with  in  a  person  with  incipient  tuberculosis  the 
prognosis  becomes  more  anxious. 

The  appearance  of  the  scar  indicates  its  age  in  a  general  way,  and 
hence  throws  light  upon  the  patient's  previous  history,  and  also  serves 
as  a  check  upon  the  accuracy  of  his  statements. 

Scars  the  result  of  wounds,  injuries,  or  operations  may  be  seen  any- 


THE  DATA  OBTAINED  BY  OBSERVATION.  147 

where  ;  they  are  of  importance  only  so  far  as  they  may  furnish  a  clue 
to  the  cause  of  existing  disease.  Of  such  nature  are  the  scars  upon  the 
head  in  cases  of  brain  disease,  particularly  epilepsy. 

The  scars  of  pregnancy,  the  strise  seen  upon  the  lower  part  of  the 
abdomen  and  the  upper  part  of  the  thigh,  must  not  be  confounded 
with  similar  scars  that  occur  in  great  oedema,  and  which  are  some- 
times found  in  fat  persons.     They  are  also  seen  after  typhoid  fever. 


CHAPTER    XI. 

THE  DATA  OBTAINED  BY  OBSERVATION— {Continued). 

The  subcutaneous  connective  tissue.  CEdema — causes — mode  of  recognition — situation 
— feet,  face,  arms,  and  head — oedema  of  trichinosis — angioneurotic  oedema. 
Myxcedema.  Connective  tissue  dystrophies.  Scleroderma.  Sarcomata — cysti- 
cercus  cellulosae — brawny  induration.  Subcutaneous  nodules.  The  lymphatic 
glands.  Enlargements — local — general.  Adenitis.  Hodgkin's  disease.  Tuber- 
culosis and  leucaemia. 

THE  SUBCUTANEOUS  CONNECTIVE  TISSUE  AND 
LYMPHATIC  GLANDS. 

Enlargements  or  swellings  of  the  subcutaneous  connective  tissue, 
other  than  the  skin  tumors  and  papular  eruptions,  on  any  portion  of 
the  surface  of  the  body,  are  due  to  some  change  in  the  tissue  or  the 
structure  or  organs  directly  underneath  the  swollen  part.  CEdema, 
myxcedema,  subcutaneous  emphysema,  dystrophies,  scleroderma,  brawny 
induration,  and  local  subcutaneous  swellings  are  the  principal  ones  to 
be  considered. 

(Edema;  Dropsy. 

The  lymph-spaces  of  the  subcutaneous  connective  tissue  become  over- 
distended  with  sermn,  causing  an  accumulation  to  which  the  general 
term  dropsy  is  applied.  If  the  accumulation  is  local  and  confined  to 
small  areas  it  is  known  as  oedema.  If  it  is  general,  and  if,  in  addi- 
tion, the  large  lymph-cavities,  the  pleura,  the  peritoneum,  and  the 
pericardium  contain  fluid,  it  is  known  as  anasarca.  Accumulation 
occurs  because  more  fluid  is  poured  out  by  the  vessels  than  can  be 
removed  by  the  lymphatics  and  veins.  This  may  depend  either  upon 
obstruction  of  the  veins  and  lymphatics,  or  excessive  exudation  from 
the  bloodvessels,  or  both.  The  former  condition,  however,  is  rare, 
and  usually  local,  because,  unless  the  obstruction  is  very  great,  the 
veins  and  lymphatics  are  able  to  carry  away  more  fluid  than  is  effused 
from  the  capillaries. 

1.  Excess  of  fluid  transudes  when  there  is  local  capillary  change 
from  inflammation  or  the  effects  of  poisons.  The  change  must  be  in 
the  capillaries.  It  was  thought  that  this  general  process  was  of  an 
inflammatory  nature,  but  at  present  it  is  believed  to  be  due  to  the  in- 
fluence of  poisons,  probably  absorbed  from  the  intestinal  canal,  alter- 
ing the  nutrition  of  the  capillary  vessels.  Thus,  the  oedema  and 
general  dropsy  of  albuminuria,  particularly  in  the  early  stage  of  that 
affection,  are  thought  to  be  due  to  a  poison  circulating  in  the  blood 
which  also  causes  the  nephritis.     Mahomed  found  a  pre-albuminuric 


THE  DATA  OBTAINED  BY  OBSERVATION.  149 

stage  of  scarlet  fever,  in  which  lie  noted  a  peculiar  reaction  of  the 
urine,  which  gave  a  blue  color  with  guaiac.  A  brisk  purgative  admin- 
istered when  this  reaction  was  noticed  would  prevent  the  occurrence  of 
albuminuria,  whereas  if  the  drug  was  withheld  albuminuria  always 
followed.  The  purgative  removed  the  poison  which  caused  the 
nephritis  and  oedema. 

It  is  well  known  that  in  urticaria  there  is  marked  local  cedema. 
Brunton  thinks  that  some  poisons  circulating  in  the  blood  cause  paral- 
ysis of  the  secreting  power  of  the  sweat-glands,  on  account  of  which 
there  is  not  only  effusion  from  the  bloodvessels,  but  at  the  same  time 
such  changes  in  the  secreting-cells  take  place  as  to  produce  an  acid, 
the  local  irritative  action  of  which,  upon  the  capillaries,  causes  a 
further  transudation  of  fluid.  That  acids  circulating  in  the  blood  have 
the  power  of  creating  cedenia,  the  experiments  of  Cash  and  Brunton 
fully  demonstrate.  AVhile,  therefore,  in  the  oedema  of  Bright's  disease 
in  its  earliest  stage  and  in  urticaria  we  have  this  explanation  of  the 
phenomena,  other  factors  are  causal  in  other  forms  of  cedema. 

2.  Increased  transudation  and  obstruction  to  the  flow  of  lymph  are 
the  causes  of  some  forms  of  oedema.  It  may  be  of  local  origin,  as  in 
the  oedema  over  the  site  of  an  inflammation  or  the  oedema  of  an  arm 
or  leg  from  venous  occlusion,  or  it  may  be  of  general  origin,  as  in  car- 
diac disease.  The  obstruction  may  be  in  the  lymphatics  or  in  the 
veins.  In  the  former  it  may  occur  («)  from  want  of  muscular  action  ; 
(6)  from  want  of  inspiratory  action  of  the  thorax  ;  (c)  diminution  of 
the  diastolic  suction  of  the  heart ;  (d)  positive  pressure  on  the  veins. 
In  the  latter,  obstruction  of  the  veins  is  caused  by  conditions  similar  to 
those  affecting  the  lymphatics,  and  arises  from  (a)  want  of  muscular 
action  ;  (6)  want  of  movement  of  the  thorax  ;  and  (c)  feeble  action  of 
the  heart ;  and,  in  addition,  it  is  likely  to  be  caused  by  (d)  complete 
arrest  of  blood-flow  from  external  pressure  upon  the  vein  or  from 
plugging  of  the  vein.  It  can  readily  be  seen,  with  a  little  knowledge 
of  physiology,  how  the  above  factors  favor  the  development  of  cedenia 
due  to  disease  of  the  heart  and  to  venous  obstruction.  The  baneful 
factors  are  those  which  retard  the  flow  of  blood,  preventing  its  return 
to  the  right  heart.     Hence  it  is  called  the  oedema  of  passive  congestion. 

3.  A  third  form  of  oedema,  usually  slight,  is  that  which  is  seen  in 
anaemia.  Several  factors  combine  to  produce  it :  (a)  the  watery  con- 
dition of  the  blood  ;  (6)  the  condition  of  the  capillaries  ;  and  (o)  vaso- 
motor paresis  on  account  of  imperfect  nutrition  of  the  vasomotor 
centres.  It  may  be  diffused,  as  in  the  anasarca  that  attends  the 
anaemia  of  malaria. 

4.  (Edema  may  be  of  nervous  origin.  Such  is  the  oedema  that 
occurs  in  diseases  or  injuries  of  nerves.  To  it  possibly  belongs  the 
cedema  of  beri-beri.  It  may  be  a  trophoneurosis  with  secondary  alter- 
ations in  the  permeability  of  the  vascular  walls,  or  it  may  be  clue  to 
vasomotor  paralysis. 

Mode  of  Recognition.  Whether  the  accumulation  is  in  local  areas 
or  distends  the  entire  subcutaneous  tissue,  the  cedema  is  not  difficult  of 
recognition.  The  part  is  swollen  and  puffy,  the  surface  is  pale,  smooth, 
and  shiny,  the  temperature  is  usually  low,  and  the  affected  area  pits 


150  GENERAL  DIAGNOSIS. 

on  pressure.  Pitting  is  more  pronounced  if  the  finger  is  pressed  over 
a  part  which  is  seated  upon  a  firm  background,  as  bone.  CEdema  of 
the  ankle  or  over  the  tibia  is  more  readily  recognized  than  oedema  in 
the  calves. 

The  oedema  obliterates  normal  depressions  and  increases  the  rotundity 
of  the  affected  part,  It  causes  deformity,  as  of  the  face  and  neck 
or  of  the  penis,  when  the  accumulation  of  serum  is  considerable.  The 
swelling  appears  in  the  most  dependent  parts  if  the  oedema  is  diffuse 
or  the  cause  is  general,  as  in  cardiac  disease  ;  or  in  parts  made  up  of 
loose  connective  tissue,  as  the  eyelids  or  scrotum.  The  temporary  dis- 
appearance of  the  oedema,  either  entirely  or  from  one  part,  to  apj)ear 
in  another,  is  a  prominent  feature  of  it.  It  will  disappear  between 
morning  and  evening,  or  its  position  will  alter  with  change  in  the  posi- 
tion of  the  body.  The  presence  of  a  previously  existing  oedema  can 
often  be  told  by  the  scars  or  striae  that  resulted  from  overstretching  of 
the  skin,  as  of  the  abdomen  and  thighs. 

CEdema  is  to  be  distinguished  from — (1)  Inflammatory  swellings, 
by  the  absence  of  the  classical  signs  of  inflammation  :  pain,  heat,  and 
redness.  (2)  The  enlargement  of  myxoedema  differs  from  oedema  by 
the  absence  of  pitting  on  pressure,  the  occurrence  of  induration,  which 
resists  the  pressure  of  the  finger,  and  by  the  occurrence  of  anaesthesia 
or  analgesia.  (3)  The  swellings  of  connective-tissue  dystrophies  are 
hard,  localized  areas  that  do  not  pit  on  pressure,  and  are  not  seated  in 
dependent  parts  of  the  body.  They  are  found  on  the  arm,  for  instance, 
or  on  the  thigh,  or  about  the  flanks  and  in  the  axillae.  (4)  The  swell- 
ing of  subcutaneous  emphysema  differs  from  oedema  in  that  it  arises 
hi  the  course  of  some  disease  of  the  air-passages,  and,  on  palpation,  the 
crackling  sensation  of  air  under  the  finger  is  distinctly  felt,  while  there 
is  no  pitting  on  pressure.  In  the  cases  that  the  writer  has  seen  the 
parts  were  particularly  tender,  although  pain  in  subcutaneous  emphy- 
sema is  said  usually  to  be  absent, 

Diagnostic  Significance.  The  value  of  oedema  as  a  diagnostic  sign 
depends  upon  its  location,  its  mode  of  development,  and  its  association 
with  disease  of  other  organs  or  structures  of  the  body. 

Location.  The  oedema  may  be  limited  to  small  areas,  as  the  eyelids, 
the  face,  or  the  feet,  or  to  an  arm  or  leg  ;  it  may  involve  an  arm  and 
leg  of  the  same  side  ;  or  it  may  involve  the  extremities  and  trunk  and 
even  include  the  face.     We  therefore  have  local  and  general  oedema. 

Local  (Edema.  Local  oedema  occurs  when  there  is  pressure  on  a 
vein  or  occlusion  of  it  by  a  thrombus.  CEdema  of  the  arm  from  press- 
ure on  the  veins  by  enlarged  lymphatic  glands  in  the  axilla,  and  oedema 
of  the  leg  from  thrombosis  of  the  femoral  vein,  are  examples  of  this 
form  of  local  oedema.  Dropsy  of  an  arm  often  occurs  when  the  patient 
has  laid  upon  it.  Local  oedema  also  occurs  over  the  seat  of  inflamma- 
tion, and  is  a  valuable  diagnostic  sign.  It  is  an  indication  of  suppura- 
tion. It  is  known  as  "  inflammatory  "  or  "  collateral  oedema."  It  is 
due  to  obstruction  of  the  lymph  circulation.  It  is  seen  over  the  mas- 
toid when  its  cells  are  the  seat  of  inflammation  ;  over  the  parotid 
gland  under  the  same  circumstances  ;  over  parts  of  the  thorax  in  em- 
pyema ;  over  the  prsecordia  in  purulent  pericarditis  ;  over  the  surface 


THE  DATA  OBTA  IN  ED  B  Y  OBSEB  VA  TION.  151 

of  the  liver  in  some  cases  of  hepatic  abscess  ;  in  the  abdominal  parietes 
in  purulent  peritonitis,  but  more  marked  over  the  primary  focus  of  in- 
flammation, as  the  gall-bladder  region  or  the  region  of  the  appendix. 

The  Arms  and  Thorax.  Another  form  of  local  oedema  occurs 
when  there  is  pressure  upon  the  superior  vena  cava  from  aneurism  or 
disease  of  the  mediastinal  glands.  The  oedema  is  then  limited  to  the 
arms,  head,  neck,  and  thorax.  Such  oedema  is  usually  associated  with 
cyanosis  of  the  hands  and  arms.  There  is  also  marked  distention  of 
the  veins  of  the  upper  parts  of  the  body.  The  oedema  has  been  found, 
in  a  few  instances,  to  be  more  marked  on  one  side  than  on  the  other. 
This  has  occurred  in  cases  of  aneurism  which  communicated  with  the 
vena  cava.  Either  the  collateral  circulation  on  one  side  had  been 
established  or  pressure  was  greater  on  the  left  innominate  vein.  The 
oedema  is  sometimes  limited  to  the  head  and  arms.  If  the  obstruction 
of  the  superior  cava  is  situated  below  the  entrance  of  the  azygos  vein 
the  chest  shares  in  the  venous  congestion  and  resulting  oedema.  If, 
on  the  other  hand,  the  obstruction  is  above  the  azygos  vein  there  is 
no  oedema  of  the  chest-wall.  This  form  of  oedema,  as  a  rule,  is  easily 
recognized  by  the  presence  of  the  above-mentioned  symptoms,  with 
other  pressure-symptoms,  due  to  disease  of  the  mediastinum  and  by 
the  results  of  physical  examination,  which  reveals  the  presence  of  a 
tumor  in  the  thorax.  It  usually  develops  slowly,  hand-in-hand  with 
the  other  symptoms.  At  times,  however,  it  occurs  suddenly.  Sudden 
oedema  in  this  situation  is  always  due  to  an  aneurism  which  has  rup- 
tured into  the  vena  cava  (see  above).  The  sudden  onset  is  attended 
by  physical  signs  of  aneurism,  or,  if  they  are  not  present,  by  a  murmur 
characteristic  of  the  communication  between  an  artery  and  a  vein.  It 
must  be  confessed  that  often  the  physical  signs  are  not  precise  and  the 
murmur  is  absent.  The  suddenness  of  the  peculiar  localized  oedema  is 
the  chief  point  of  oliagnosis  in  favor  of  this  rare  form  of  aneurism. 

The  GEdema  of  Trichinosis.  (See  Face.)  (Edema  of  the  skin  over 
the  affected  muscles,  as  well  as  of  the  face,  occurs  in  trichinosis.  It 
begins  early  in  the  disease,  disappears  after  a  few  days,  to  return  again 
later.  It  is  localized  over  the  muscles,  and  is  associated  with  the 
growth  of  trichinae  in  them.  It  is  distinguished  from  cardiac  and 
renal  dropsy  by  its  course  and  situation  as  well  as  by  the  fact  that  the 
scrotum  and  labia  majora  are  never  cedematous. 

The  cause  of  the  above  forms  of  oedema  is  local  and  in  close  prox- 
imity to  or  in  intimate  anatomical  relation  with  the  dropsical  swelling. 
But  the  cause  of  local  oedema  may  be  central,  or  in  a  sense  general. 
It  then  develops  gradually  and  begins  in  special  localities,  as  in  the 
feet  or  face. 

The  Feet.  (Edema  of  the  feet  or  ankles  is  usually  due  to  disturb- 
ance of  the  circulation.  It  arises  in  heart  disease,  or  hi  the  course  of 
any  exhausting  and  debilitating  disease  in  which  the  heart  has  become 
weakened.  The  organic  change  which  takes  place  in  the  heart-muscle 
(dilatation)  in  the  course  of  obstructive  valvular  disease  and  in.  lung 
disease  is  often  attended  by  oedema  of  the  feet.  Later  a  general  dropsy 
may  ensue.  But  oedema  of  the  feet  may  occur  from  another  cause — 
i.  e.,  ancemia.     In  all  forms  of  this  affection  puffiness  of  the  ankles  may 


152 


GENERAL  DIAGNOSIS. 


be  seen.  An  explanation  of  the  cause  has  been  given.  Similar  local- 
ized oedema  in  individuals  of  relaxed  fibre  occurs  in  the  evening  after 
a  day  of  considerable  physical  exertion.  GEdeina  of  the  feet,  subse- 
quently becoming  diffuse,  occurs  in  beri-beri. 

(Edema  of  the  Face.  (Edema  may  begm  or  remain  localized  in 
the  face,  and  is  very  striking.  (See  Face  and  Eyelids.)  It  may  be 
limited  to  the  eyelids,  as  a  simple  puffiness,  or  may  spread  over  the 
entire  face,  causing  complete  *  obscuration  of  the  normal  outlines.  It 
is  the  oedema  of  renal  disease,  and  differs  from  oedema  of  the  feet  in 


Fig.  19. 


Face  of  a  patient  with  general  anasarca  due  to  chronic  parenchymatous  nephritis.    (Hare.) 

that  it  is  more  marked  in  the  morning  on  rising  and  disappears  toward 
nicht.  Of  all  forms  of  local  oedema  it  is  the  most  grave,  and  should 
at  once  call  attention  to  the  condition  of  the  urine,  particularly  if  the 
patient  has  just  had  an  attack  of  scarlatina,  or  if  it  occurs  in  a  woman 
who  is  pregnant. 

The  diagnostic  significance  of  primary  local  oedema  may  be  summar- 
ized as  follows  :  (1)  Eyelids  or  eyes  ("  Bright  "  eye,  "  tear  that  does  not 
fall  ")  in  nephritis  ;  (2)  faee,  nephritis  ;  (3)  forehead,  trichinosis;  (4) 
head,  pressure  upon  superior  vena  cava  above  the  azygos  vein  ;  (5)  one 
side  of  head,  pressure  upon  innominate  vein  ;  (6)  head  and  arms,  or 
head,  arms,  and  thorax,  pressure  upon  superior  vena  cava  ;  (7)  one 
arm,  pressure  upon  axillary  veins  ;  (8)  one  leg,  pressure  upon  femoral 
vein  ;  (9)  both  feet  or  legs,  pressure  upon  inferior  vena  cava  by  abdomi- 
nal tumor,  loss  of  vasomotor  tone,  heart  disease,  anaemia,  late  nephritis  ; 
(10)  the  loins,  "  lumbar  cushion,"  nephritis,  cardiac  disease  if  patient  is 
in  recumbent  posture  ;  (11)  the  scrotum,  nephritis  and  cardiac  disease  ; 


THE  DA TA  OB TAINED  B  Y  OBSER  VA  TION.  1 53 

(12)  local  oeclemas  over  inflammations  of  structures  underneath,  as 
bones,  the  gall-bladder,  the  appendix,  the  pleura,  peritoneum,  or  peri- 
cardium. 

General  (Edema.  Anasarca.  General  anasarca  is  due  to  heart  or 
to  kidney  disease  in  most  of  the  cases.  (Edema  of  the  face  and  feet 
may  become  general.  In  cases  in  which  the  face  is  first  oedematous  its 
extension  may  be  very  rapid,  so  that  twenty-four  to  forty-eight  hours 
after  the  swelling  is  noticed  the  whole  body  is  in  a  state  of  anasarca. 
Renal  disease.  The  extension  of  oedema,  primarily  seated  in  the  feet 
and  legs  (cardiac  dropsy),  throughout  the  rest  of  the  body  is  more 
gradual,  and  develops  with  other  signs  and  symptoms  of  weakness  of 
the  heart.  Hence  cyanosis  gradually  appears.  This  may  be  seen  first 
in  the  extremities.  Finally  the  face  and  lips  take  on  the  peculiar  hue. 
On  the  other  hand,  in  the  general  anasarca  that  follows  the  local 
oedema  of  the  face  in  Bright's  disease,  pallor  occurs,  and  as  the  oedema 
increases  it  becomes  more  and  more  of  a  waxy  hue,  while  the  extremi- 
ties beome  glistening  or  shining  in  appearance.  In  the  so-called  "  wet 
form  "  of  beri-beri  general  oedema  comes  on  rapidly. 

Angioneurotic  (Edema.  This  curious  affection  is  not  of  frequent 
occurrence.  It  may  be  present  in  the  individuals  of  several  genera- 
tions of  a  family.  The  attack  comes  on  suddenly.  The  swelling  is 
circumscribed.  It  may  appear  on  the  face,  on  the  brow,  the  lips,  or 
cheek.  The  eyelid  is  a  common  situation.  It  may  also  occur  on  the 
backs  of  the  hands,  the  legs,  or  in  the  throat.  It  remains  but  a  short 
time  and  disappears  as  quickly  as  it  came  on.  The  outbreaks  have 
exhibited  distinct  periodicity.  Local  symptoms  of  itching,  heat,  or 
redness,  or  general  urticaria,  may  precede  the  swelling.  The  sudden 
swelling  causes  great  deformity.  If  the  upper  lip  is  affected,  the 
mouth  cannot  be  opened  ;  if  the  hands,  the  fingers  cannot  be  bent.  In 
the  hereditary  cases  the  attack  recurs  every  three  or  four  weeks.  The 
danger  to  life  is  from  oedema  of  the  larynx,  which  caused  death  in  two 
of  Osier's  cases.  The  general  symptoms  that  attend  the  attack  are 
gastro-intestinal.    Nausea  and  vomiting  occur,  followed  by  severe  colic. 

It  must  not  be  confounded  with  simple  urticaria,  or  the  giant  form  of 
that  affection,  with  which  it  may,  however,  have  close  affinities.  It  is 
regarded  by  Quincke  as  a  vasomotor  neurosis,  which  leads  to  impair- 
ment of  the  permeability  of  the  vessels. 

Recapitulation.  From  what  has  been  said  the  student  will  observe 
that  oedema  may  be  local  or  general ;  that  local  oedema  may  be  uni- 
lateral or  bilateral ;  that  oedema  may  be  further  subdivided,  in  accord- 
ance with  the  cause,  into  inflammatory  dropsy,  oedema  or  dropsy  of 
passive  congestion,  hydrsemic  dropsy,  and  vasomotor  dropsy.  The 
forms  of  passive  dropsies  just  indicated  may  be  subdivided  into  cardiac 
dropsy,  hepatic  dropsy,  and  renal  dropsy,  according  to  anatomical 
causes. 

While  the  account  of  oedema  just  given  refers  more  particularly  to 
the  subcutaneous  accumulation  of  serum,  the  same  pathology  and 
etiology  apply  to  accumulations  in  the  large  lymph-cavities,  and  hence, 
in  addition  to  general  oedema,  we  may  have  ascites,  hydroperica;rdi '/u tin , 
hydrothorax,  hydrocele,  and  effusion  in  the  joints.      The   methods  of 


154 


GENERAL  DIAGNOSIS. 


recognition  of  dropsy  of  the  larger  cavities  will  be  deferred  until  dis- 
eases associated  with  these  particular  regions  are  discussed.  It  must 
be  remembered  that  oedema  or  accumulations  of  serum  in  cavities  may 
be  of  local  or  general  origin. 

It  must  not  be  forgotten  that  two  or  more  causes  may  combine  to 
produce  a  dropsy,  or  that  a  dropsy  of  one  cause  may  for  a  time  be 
dependent  upon  a  second  and  even  a  more  pronounced  factor  later  on 
in  the  development  of  the  disease.  Thus  (a)  the  dropsy  of  hydremia 
may  be  aggravated  by  that  of  (6)  weak  heart  which  arises  from 
ansemia,  to  which  may  be  added  later  the  dropsy  of  vasomotor  paresis. 
The  dropsy  in  Bright's  disease  is  clue  to  (a)  capillary  changes  pro- 
duced by  a  poison  circulating  in  the  blood,  and  (6),  later,  to  the  con- 
dition of  the  heart  if,  as  is  frequently  the  case,  it  undergoes  dilatation. 

Myxoedema. 

Enlargement  of  the  surface  of  the  body,  local  or  general,  is  also  seen 
in  myxoedema,  a  condition  which  simulates  dropsy,  as  already  stated. 
In  myxoedema  the  swelling  is  general.     The  face  is  involved.     The 

Flo.  20. 


A  typical  case  of  myxcedema.    (Starr.) 


arms  are  more  markedly  swollen,  however,  than  the  fingers  ;  the  legs 
more  than  the  feet.  Usually  the  swelling  of  the  legs  and  arms  is 
irregular.     In  some  cases  supraclavicular  paddings  are  marked.     These 


THE  DATA  OBTAINED  BY  OBSERVATION.  155 

paddings  must  not  be  confounded  with  the pseudo-lipomata,  described  by 
Verneuil,  occurring  in  these  situations.  The  swelling  is  due  to  the 
infiltration  of  mucin  into  the  connective  tissue,  and  arises  from  some 
affection  of  the  thyroid  gland.  The  gland  is  absent,  functionally  or 
actually.  The  hard,  indurating,  non-pitting  swelling  is  associated 
with  striking  change  in  the  appearance  of  the  face,  particularly  the 
nose  and  forehead.  The  nose  becomes  thickened,  the  forehead  more 
prominent  and  overhanging.  The  outline  of  the  face  is  rounded,  so 
that  the  term  "  full-moon  "  is  applied  to  it.  The  skin  is  thickened, 
dry,  and  rough,  somewhat  translucent  in  appearance,  pale  or  yellow  in 
color,  and  of  a  doughy  consistence,  but  with  a  moderate  degree  of  elas- 
ticity. The  perspiration  is  diminished.  The  hands  change  in  shape, 
they  become  square  or  spade-shaped,  and  the  fingers  clubbed.  The 
appendages  of  the  skin  change.  The  nails  become  brittle  and  dis- 
torted, the  hair  dry,  harsh,  and  brittle,  and  it  may  fall  out.  With 
these  remarkable  changes  in  the  exterior  marked  nervous  and  mental 
symptoms  arise.  Speech  is  thick  and  hesitating,  the  memory  feeble. 
The  intellect  is  dull  and  irresponsive,  the  temper  irritable.  Sensibility 
is  impaired,  particularly  the  loss  of  sensation  to  pain.  Patients  have 
been  burned  without  their  knowledge.  This  happened  in  one  of  the 
writer's  cases.  Abnormal  sensations  of  heat  and  chilliness  are  com- 
plained of,  as  well  as  other  paresthesias.  The  patient  is  anaemic,  the 
temperature  is  subnormal,  the  heart's  action  weak,  the  respiration  slug- 
gish. Breathlessness  on  slight  exertion  is  pronounced,  and  exertion 
itself  is  very  difficult,  while  there  is  a  greater  sense  of  fatigue  than  the 
exertion  and  the  condition  of  the  organs  would  warrant.  The  mus- 
cularity is  enfeebled.  There  are  impairment  of  appetite,  indigestion, 
and  flatulency.  The  urine  may  become  albuminous,  but  for  a  long 
time  is  not  characteristic  save  in  amount  and  specific  gravity.  The 
former  is  increased,  the  latter  lowered. 

As  the  case  advances  mental  and  physical  failure  become  more  pro- 
nounced, the  patient  is  subject  to  hallucination,  and  is  extremely  irrita- 
ble. Stupor  sets  in  ;  death  may  take  place  in  coma  or  from  uraemia. 
It  is  a  disease  of  mature  life,  and  occurs  most  frequently  in  women. 

The  following  varieties  are  seen  :  (1)  Spontaneous  myxoedema  of 
the  adult ;  (2)  infantile  myxoedema  ;  (3)  operative  myxoedema  ;  and 
(4)  endemic  myxoedema  or  cretinism.  In  infantile  myxoedema  the 
functions  of  the  thyroid  body  are  suppressed  during  the  period  of  the 
development  of  the  individual.  Typical  cases  justify  the  name  of 
myxoedematous  idiocy. 

Subcutaneous  Emphysema. 

Enlargement  or  swelling  of  the  surface,  either  local  or  general, 
may  occur  on  account  of  air  underneath  the  skin.  The  skin  is  pale 
and  quite  distended,  and  hence  depressions  are  filled  up,  as  the  axil- 
lary, clavicular,  and  intercostal  spaces.  The  primary  seat  of  the  swell- 
ing is  in  close  proximity  to  the  air-passages,  and  occurs  because  of 
communication  between  them  and  the  subcutaneous  connective  tissue. 
It  may  occur  in  ulcerations  of  the  upper  passages,  as  the  larynx  or 


156 


GENERAL  DIAGNOSIS. 


Fig.  21. 


trachea  ;  in  ulcerations  of  the  oesophagus  into  the  mediastinum  ;  in  the 
ulceration  and  rupture  of  phthisical  cavities  into  the  chest-wall ;  and 
in  rupture  of  the  lungs  from  hard  coughing,  sharp  crying,  severe 
exertions,  such  as  blowing  of  wind  instruments.  The  air  may  escape 
under  the  pleura  to  the  mediastinum  and  thence  to  the  neck,  or,  when 
the  pleura  is  adherent,  air  will  pass  from  the  lung  into  the  connective 
tissue.  The  swelling  gradually  spreads  over  the  entire  body  from  the 
seat  of  rupture  or  in  close  proximity  to  it.  In  a  case  of  laryngeal 
phthisis  under  the  writer's  care  it  encircled  the  neck  and  spread  uni- 
formly over  the  anterior  and  posterior  portion  of  the  thorax.  Thence 
it  extended  downward  until  it  met  a  corresponding  infiltration  of  the 
lymph-spaces  in  the  thighs,  due  to  serum.     The  distinction  between 

cedematous  swelling  and  subcutaneous 
emphysema  could  thus  be  made  :  the 
latter  offered  no  resistance,  did  not 
pit  on  pressure,  crackled  under  the 
finger,  and  was  quite  tender  on  press- 
ure. Spontaneous  pain  was  not  pres- 
ent ;  but  any  position  was  painful  in 
which  the  weight  of  the  body  pressed 
upon  the  part  affected. 

Connective-tissue  Dystrophies. 

Enlargements  of  the  surface  -are 
seen  in  the  so-called  dystrophies. 
The  dystrophy  is  usually  due  to  a 
localized  anomalous  overgrowth  of 
connective  tissue,  probably  of  trophic 
origin.  It  can  easily  be  distinguished 
from  oedema  by  the  absence  of  the 
signs  of  cedema,  or  from  local  inflam- 
matory swelling  by  the  absence  of 
pain,  heat,  and  redness.  The  swell- 
ing occurs  on  the  arms  and  legs, 
usually  on  the  outer  aspects,  and  may 
occur  in  various  portions  of  the  trunk. 
In  one  of  the  writer's  cases  the  swell- 
ings were  periodical ;  or,  rather,  the 
persistent  swellings  increased  in  size 
at  irregular  intervals. 

Dercum  and  Henry  have  described 
cases  of  dystrophy  in  which  the  en- 
largements had  been  attributed  to 
accumulations  of  fat.  The  patients 
presented  marked  subjective  nervous 
phenomena,  paresthesias  of  all  kinds, 
with  flushings  and  sensations  of  sinking  and  depression.  There  were 
areas  of  anaesthesia,  pain,  and  tenderness  in  the  nerve-trunks.  Pain 
preceded  the  advent  of  the  swellings. 


Note  accumulations  on  back  and  on  ex- 
tremities. See  knees  and  elbows ;  wrists  and 
ankles  unusually  small.  Patient  aged  56. 
Second  attack  of  insanity.    (Original.) 


THE  DA  TA  OB  TAINED  B  Y  OBSER  VA TION.  \  57 

Herpes  zoster  occurred  in  Dercum's  case,  and  other  symptoms  of 
neuritis  were  marked.  The  irregularity  in  the  distribution  of  the 
swellings,  their  character  and  mode  of  development,  the  occurrence  of 
neuritis,  and  the  absence  of  perspiration,  distinguished  dystrophy  from 
lipomatosis  or  excess  of  fat.  The  patients  were  of  a  neurotic  type,  and 
mental  impairment  usually  resulted  in  the  course  of  the  disease.  The 
general  nutrition  failed,  particularly  as  gastro-intestinal  disorders 
ensued. 

Scleroderma. 

Scleroderma  is  a  hyperplasia  of  the  subcutaneous  connective  tissue 
with  swelling  and  induration.  It  is  brawny.  As  the  tissues  are  almost 
immovable,  the  term  "hide-bound  "  is  applied  to  this  condition  There 
are  marked  stiffness  and  also  pain. 

In  localized  scleroderma,  or  morphcea,  the  skin  has  a  waxy  or  dead- 
white  appearance,  is  brawny  and  inelastic.  There  may  be  preliminary 
hyperemia  of  the  skin.  Subsequently  pigmentation  of  the  hypersemic 
area  takes  place,  causing  changes  in  color,  or  the  pigment  may  atrophy, 
causing  leucoderma.  The  secretion  of  sweat  is  diminished  or  entirely 
abolished.  In  the  diffused  form  the  affection  begins  in  the  extremities 
or  face,  and  is  accompanied  by  a  sense  of  stiffness  or  tension  ;  the  skin 
is  usually  hard  and  firm,  and  gradually  a  diffuse,  brawny  induration 
develops.  The  skin  cannot  be  picked  up  in  folds.  It  may  appear 
normal,  but  is  generally  very  smooth,  glossy,  and  dryer  than  usual, 
rarely  pigmented.  Scleroderma  may  be  confined  to  a  limb  or  may 
become  universal.  The  appearance  of  the  face  is  characteristic.  It  is 
expressionless,  and  the  lips  cannot  be  moved,  while  mastication  is  im- 
possible ;  the  eyes  and  the  nose  are  deformed ;  the  hands  become  fixed 
and  the  fingers  immobile  and  contracted,  on  account  of  induration 
about  the  joints,  the  deformity  being  called  sclerodactyle.  It  is  thought 
to  be  due  to  a  trophoneurosis,  or  to  fibrosis  of  the  arteries  of  the  skin, 
with  connective-tissue  overgrowth  in  the  adjacent  areas. 

Brawny  Induration. 

(Edema  must  not  be  confounded  with  the  brawny  induration  of  the 
calves  of  the  legs  in  scurvy,  probably  from  deep-seated  hemorrhage. 
It  must  be  remembered,  however,  that  oedema  of  the  ankles  is  very 
common  in  this  affection.  Brawny  induration  may  also  be  found  in 
syphilis.  In  a  patient  recently  under  the  writer's  care,  in  the  Presby- 
terian Hospital,  a  brawny  induration  of  the  thigh,  with  painless  swell- 
ing and  stiffness  of  the  leg,  appeared  to  be  due  to  syphilis.  It  disap- 
peared rapidly  under  treatment  with  potassium  iodide. 

Localized  Subcutaneous  Nodules. 

Sarcomata.  The  subcutaneous  nodules  seen  in  these  affections  are 
rarely,  if  ever,  confounded  with  oedema  or  other  swellings.  In  sar- 
coma the  subcutaneous  tumor  becomes  attached  to  the  skin  and  may 
change  its  color.     It  is  usually  secondary  to  sarcoma  in  some  other 


158  GENERAL  DIAGNOSIS. 

organ  of  the  body.  When  primary,  or  secondary  to  organs  in  which 
there  is  normal  pigmentation,  as  the  eye,  they  become  blue  or  bluish- 
black.  On  palpation  the  surface  is  found  to  be  rough  and  uneven  if 
the  tumors  are  numerous. 

Primary  melanotic  sarcomata  of  the  skin  can  always  be  distinguished 
by  their  color.  In  both  forms  of  sarcomata  the  general  symptoms  of 
this  affection  daily  become  more  and  more  pronounced,  and  subcuta- 
neous hemorrhages  are  commonly  associated  with  the  local  phenomena. 

The  first  external  evidence  of  lymphosarcoma  may  be  subcutaneous 
nodules  in  unusual  situations.  Thus,  in  a  case  under  my  observation, 
a  lymphoid  nodule  was  first  observed  in  the  third  interspace  on  the 
right  side.     Subsequently  the  glandular  involvement  followed. 

Carcinomata.  Subcutaneous  lymphatic  glands  may  be  the  seat  of 
secondary  carcinoma,  and  from  their  location  may  indicate  the  primary 
source  of  the  disease.  The  glands  above  the  left  clavicle  are  some- 
times secondarily  affected  in  cancer  of  the  stomach.  In  similar  dis- 
eases of  abdominal  organs  glands  in  the  abdominal  wall  are  enlarged. 
The  subcutaneous  nodules  should  be  removed  and  examined  microscop- 
icall  y.  The  structures  of  the  umbilicus  (skin  and  subcutaneous  tissues) 
enlarge,  become  nodulated,  and  sometimes  the  seat  of  fungoid  ulcera- 
tion in  abdominal  carcinoma,  particularly  of  the  stomach.  It  must 
not  be  forgotten  that  primary  sarcoma  or  carcinoma  of  the  skin,  lim- 
ited to  one  area,  and  simulating  an  intra-abdominal  growth,  may  occur, 
as  in  a  case  under  my  care  in  the  Philadelphia  Hospital,  operated  on 
by  Horwitz. 

Cysticercus  Oellulosse.  The  nature  of  the  subcutaneous  nodules 
of  cysticercus  are  recognized  by  microscopic  examination.  They  are 
usually  associated  with  the  larvae  in  other  tissues,  hence  the  patient 
complains  of  great  soreness  and  stiffness,  and  may  become  helpless. 

Rheumatic  Nodules.  Subcutaneous  nodules  are  seen  in  rheumatic 
patients  in  the  course  of  the  disease,  or  after  the  attacks.  They  are 
common  in  the  young.  They  are  particularly  frequent  in  cases  of 
rheumatic  endocarditis.  They  may  occur  independently  of  the  articu- 
lar symptoms.  They  may  occur  in  large  numbers,  and  vary  in  size 
from  a  small  shot  to  a  large  pea.  They  are  of  fibrous  structure. 
They  are  attached  to  the  tendons  and  fasciae,  particularly  on  the  fingers, 
hands,  and  wrists,  but  may  be  found  over  the  elbows,  knees,  the 
scapulae,  and  the  spines  of  the  vertebrae. 

Syphilitic  Nodes.  Gummata  are  observed  in  the  tertiary  periods 
of  syphilis.  They  must  not  be  confounded  with  the  enlarged  glands. 
They  are  attached  to  the  skin,  and  may  from  time  to  time  ulcerate. 
They  may  be  seen  on  the  back  or  buttocks  ;  less  frequently  on  other 
parts. 

The  Lymphatic  Glands. 

Information  of  diagnostic  value  may  be  obtained  from  the  condition 
of  the  lymphatic  glands.  (See  Chapter  VII.)  Enlargement  may  be 
general  or  local. 

Enlargement  of  the  cervical  glands,  and  of  the  axillary  and  inguinal 
glands  attended  by  fever,  occurs  in  that  obscure  infection  described  by 


THE  DATA  OBTA  IN  ED  B  Y  OBSER  VA  TION.  159 

Dawson  Williams  and  others  called  glandular  fever.  Similar  glandu- 
lar enlargement  is  quite  characteristic  of  German  measles  or  rotheln. 
(See  the  Infections.) 

Enlargement  of  the  post-cervical  glands,  the  epitrochlear  glands,  and 
lymphatic  glands  in  other  portions  of  the  body  points  to  syphilis.  In 
the  two  first-mentioned  localities  the  enlargement  is  of  great  diagnostic 
importance,  as  it  is  less  likely  to  be  due  to  any  other  causes.  Suppu- 
rating glands  do  not  here  concern  us. 

Inguinal  and  Axillary  Enlargement.  With  or  without  suppuration, 
enlargement  always  points  to  an  irritation  or  lymphatic  invasion  in 
the  area  drained  by  the  affected  lymphatic  gland.  When  in  the  groins 
the  feet  are  affected,  and  when  in  the  axilla?  the  hands.  Great  enlarge- 
ment in  either  situation  causes  oedema  of  the  corresponding  extremity 
if  the  veins  are  pressed  upon.  The  axillary  glands  are  early  affected 
and  enlarged  in  mammary  cancer.  The  breast  should  always  be 
examined  in  oedema  of  the  arm. 

The  Supraclavicular  Glands.  These  glands  are  often  enlarged 
and  indurated,  and  may  cause  pressure-symptoms.  The  only  local 
enlargement  that  is  of  special  diagnostic  significance  is  that  which  is 
seen  above  the  clavicle  on  the  left  side.  They  often  point  to  carci- 
noma of  the  stomach,  as  Troisier  announced.1  Indeed,  there  are  cases 
of  this  disease  in  which  only  the  general  symptoms  of  carcinoma  are 
present.  Local  symptoms  are  wanting  and  the  locality  of  the  cancer 
cannot  be  made  out  by  the  symptoms.  The  enlarged  glands  above  the 
clavicle  are  a  fair  indication  that  the  stomach  is  the  seat  of  the  disease. 
The  enlargement  is  probably  due  to  transmission  of  the  infection 
along  the  thoracic  duct  and  its  lodgement  in  the  associated  glands. 

The  Cervical  and  Submaxillary  Glands.  Enlargement  of  the 
submaxillary  and  cervical  glands  points  to  affections  of  the  mouth 
and  throat  or  of  the  jaw  and  teeth.  It  is  caused  particularly  by  infec- 
tious disorders  in  these  localities.  They  are  often  the  seat  of  nodular 
enlargement  in  actinomycosis.     (See  "  collar  "  in  adenitis  of  leukaemia.) 

Scars  at  the  site  of  former  glands  point  to  tuberculous  destruction 
or  former  bubo,  and  are  suggestive. 

The  glands  are  enlarged  in  simple  adenitis,  tuberculosis,  Hodgkin's 
disease,  leucocythcemia,  sarcoma,  and  cancer.  The  moderate  enlarge- 
ment of  syphilis  and  the  local  enlargement  from  irritation  in  the  area 
of  lymph-drainage  have  been  mentioned.  Adenitis  is  usually  local. 
The  gland  is  tender  and  the  connective  tissue  around  it  is  affected. 
There  are  local  heat  and  pain.  At  first  the  gland  is  hard,  later  it 
softens  in  the  centre,  and  finally  it  exhibits  fluctuation.  In  tuberculosis 
more  than  one  gland  is  affected.  Usually  the  glandular  involvement 
is  bilateral  (as  in  the  neck).  At  first  the  glands  are  isolated.  Later 
they  become  matted.  The  local  symptoms  are  not  marked  and  the 
process  is  very  indolent.  Thick,  cheesy  pus  is  discharged  which  may 
contain  tubercle  bacilli.  It  causes  tuberculosis  when  inoculated  in 
lower  animals — a  method  of  diagnosis  necessary  to  be  resorted  to  fre- 
quently.    The  tuberculin  test  must  be  used.     Fever  and  "  decline " 

1  Bulletin  et  Memoires  de  la  Soci£te  Medicale  des  Hopitaux,  January  13,  1888. 


160 


GENERAL  DIAGNOSIS. 


occur  later,  but  often  not  until  other  structures,  as  the  lungs,  are  in- 
fected.    (See  Leucocytheniia.) 

Lympho  Sarcoma  is  an  infection  of  the  glandular  structures  of  ob- 
scure origin.  A  local  group  of  glands  may  be  involved  or  the  glands 
throughout  the  body  may  be  the  seat  of  the  overgrowth.  When  the 
infection  is  general  the  deep-seated  glands,  as  the  mediastinal  and 
retroperitoneal,  may  be  the  first  involved.  Anaemia,  fever,  and  signs 
of  intrathoracic  and  abdominal  pressure  may  be  present  without  decisive 
indications  of  the  nature  of  the  disease.  In  a  short  time,  however,  a 
superficial  gland  may  enlarge,  and  from  thence  rapidly  other  glands  be 
involved.  The  occurrence  of  an  enlarged  gland  in  any  part  of  the 
body  may  be  suggestive  of  the  nature  of  a  deep-seated  process.  Posi- 
tive diagnosis  can  be  established,  and  the  method  should  be  resorted 
to  by  removal  of  the  gland  and  its  examination  microscopically.  A 
case  of  this  character  seen  with  Hare  showed  the  first  evidence  of 
glandular  infection  in  the  enlargement  of  a  small  gland  over  the  third 
interspace  on  the  right  side  of  the  chest  in  front. 


Hodgkin's  Disease. 

Hodgkin's  disease  (pseudoleukemia,  lymphadenoma,  or  lymphatic 
anemia)  is  characterized  by  enlargement  of  the  lymphatic  glands  and 

other  adenoid  tissue  ;  bv  pro- 
gressive  oligocythemia  with- 
out, in  most  cases,  much  in- 
crease of  leucocytes ;  and  by 
the  development  of  lymphatic 
tumors  in  unusual  situations. 

The  disease  is  most  frequent 
in  the  first  half  of  life,  three- 
fourths  of  the  cases  being  in 
males. 

The  first  symptom  noted  is 
enlargement  of  the  glands  of 
the  neck  ;  but  sometimes  the 
inguinal,  less  frequently  the 
axillary  glands,  are  first  en- 
larged ;  rarely  the  tonsils  are 
the  first  to  be  affected.  The 
enlargement  is  painless  and 
progressive,  appearing  first  on 
one  side  of  the  neck  and  ex- 
tending under  the  jaw  to  the 
opposite  side.  The  tumors  at 
first  are  distinct  and  movable 
under  the  skin.  The  swollen 
glands  may  remain  in  this  condition  indefinitely  for  months  or  years  ; 
but  eventually  they  begin  to  enlarge  very  rapidly,  lose  their  separate 
identity,  and  coalesce  into  large  masses.  Other  glands  in  remote  parts, 
as  the  axilla  and  groin,  retroperitoneum,  and  arm,  are  affected.     They 


Hodgkin's  disease.    Glands  in  right  axilla  and  neck 
much  enlarged. 


THE  DATA  OBTAINED  BY  OBSERVATION.  161 

may  be  soft  and  fluctuating,  or  very  dense  and  hard,  but  heat,  tender- 
ness, suppuration,  and  other  evidences  of  inflammation  are  absent. 

The  spleen  becomes  very  much  enlarged,  but  rarely  attains  the 
dimensions  common  in  leucocythsemia. 

Other  adenoid  tissue  in  the  intestine,  tonsil,  and  posterior  nares, 
and  even  the  thymus,  may  enlarge  and  give  rise  to  pressure  symptoms. 

Fever  is  a  very  constant  symptom,  but  the  type  is  not  constant.  The 
onset  of  the  disease  may  be  marked  by  fever  and  constitutional  symp- 
toms, and  the  glandular  enlargement  appears  later.  On  the  other 
hand,  in  three  cases  reported  by  J.  Dreschfeld,1  all  the  patients  enjoyed 
good  health  and  were  able  to  follow  their  work  until  a  few  weeks 
before  death.  In  all  symptoms  appeared  suddenly,  and  consisted  of 
pain,  weakness,  pallor,  loss  of  appetite,  and  pyrexia. 

Coincident  with  the  rapid  and  extensive  enlargement  of  the  glands, 
anaemia  becomes  pronounced  and  is  accompanied  by  the  usual  symp- 
toms. Cough  is  often  associated  with  anaemic  dyspnoea,  and  in  women 
menstruation  may  cease. 

Along  with  the  general  symptoms  there  are  numerous  local  ones, 
due  to  the  pressure  or  impairment  of  function — cerebral  anaemia  from 
pressure  on  the  carotids  ;  cerebral  congestion  from  pressure  on  the 
veins  of  the  neck ;  disturbance  of  the  heart  from  pressure  on  the 
pneumogastric  ;  deafness  ;  difficulty  in  deglutition  and  mastication  ; 
and  pleural,  peritoneal,  and  pericardial  effusions. 

The  most  frequent  complications  are  nephritis,  fatty  degeneration  of 
the  heart,  pleurisy,  and,  less  frequently,  pneumonia  and  pericarditis. 

The  duration  of  the  disease  is  from  six  to  eighteen  months.  Two- 
thirds  of  fifty  fatal  cases  referred  to  by  Gowers2  ended  in  less  than  two 
years.  It  is  difficult  to  determine  accurately  the  beginning  of  the 
disease  ;  sometimes  a  long  period  of  latency  follows  the  early  glandular 
swelling  ;  sometimes  a  general  anaemia  precedes  any  noticeable  swelling 
of  the  glands  ;  and  sometimes  the  disease  runs  an  acute  course,  ending 
fatally  in  two  or  three  months. 

Death  results  most  frequently  from  exhaustion  ;  but  pressure  upon 
the  trachea  producing  asphyxia  is  not  uncommon,  and  death  has 
occurred  from  starvation,  the  result  of  occlusion  by  pressure  of  the 
oesophagus.  The  complications  already  mentioned  are  the  immediate 
causes  of  death  in  other  cases. 

The  diagnosis  is  not  difficult  with  blood  examination.  By  this  means 
leucocythaemia  is  excluded.  It  may  be  distinguished  from  tuberculosis 
in  the  early  stages  when  local  by  the  site  of  the  enlargement.  In  the 
former  the  submaxillary  glands  are  involved ;  in  the  latter  the  glands 
in  the  anterior  and  posterior  cervical  triangles.  The  tuberculin  test  is 
required,  as  insisted  upon  by  Otis,  to  establish  tuberculous  adenitis. 

Lymphangitis  or  Angioleucitis.  The  streaked  redness  over  the 
surface  of  the  skin,  with  tenderness  along  the  course  of  the  lymphatics 
and  oedema,  is  characteristic  of  inflammation  of  the  lymphatic  vessels, 
and  need  not  be  further  mentioned.     The  glandular  and  dermal  changes 

1  British  Medical  Journal,  April  30,  1892. 

2  Reynolds'  System  of  Medicine,  Philadelphia,  1880,  vol.  iii.  549. 

11 


162  GENERAL  DIAGNOSIS. 

of  elephantiasis,  with  chyluria,  with  or  without  lymph  scrotum,  are 
unmistakable  ;  the  disease  is  due  to  the  Jilaria  sanguinis  hominis. 

Lymphatism.  Poor  physical  development  has  recently  been  ob- 
served with  lymphatic  overgrowth,  or  the  constitutio  lymphatieo.  In 
this  state  sudden  death  is  liable  to  occur.  It  is  believed  that  one  of 
the  causes  of  death  from  anaesthesia  and  from  antitoxin  of  diphtheria  is 
a  condition  known  as  status  lym/phaticus.  Hyperplasia  of  the  lym- 
phatic glands,  the  spleen,  the  thymus,  and  the  bone  marrow  are  rarely 
found  in  patients  with  rhachitis,  and  in  hypoplasia  of  the  heart  and 
aorta.  The  internal  lymphatic  glands  and  the  lymphatic  structures  of 
the  alimentary  tract  are  more  frequently  involved  than  the  more 
external  glands.  With  this  overgrowth  of  lymph-tissue  the  spleen 
and  the  thymus  gland  are  enlarged,  and  red  marroAV  replaces  the  yellow 
marrow  in  young  adults.  The  hypoplasia  of  the  vascular  system  is 
not  easily  recognized.  The  left  ventricle  may  be  dilated  and  the 
peripheral  arteries  diminished  in  size. 


CHAPTER    XII. 

THE  DATA  OBTAINED  BY  OBSERVATION— {Continued). 

The  muscles — idiopathic  muscular  atrophy — pseudohypertrophy — Thomsen's  disease — 
paramyoclonus  multiplex.     Myositis — myalgia — muscular  rheumatism. 

THE  MUSCLES. 

The  Nutrition.  The  nutrition  of  the  muscles  is  observed  by  the 
hand  of  the  examiner  while  the  muscles  are  made  to  relax  and  contract 
alternately.  We  compare  corresponding  muscles  of  the  two  sides. 
Measurement  of  the  limbs  at  corresponding  situations  makes  the  obser- 
vation more  accurate.  The  muscles  may  atrophy  or  hypertrophy. 
Either  condition  may  be  local,  unilateral,  bilateral,  or  general. 

Myoidema  is  a  local  contraction  of  the  muscle  which  occurs  upon 
striking  it  with  a  pleximeter  or  the  finger,  as  in  percussion.  It  is  more 
particularly  seen  in  thin  subjects,  usually  tuberculous,  and  elicited  by 
tapping  the  pectoral  muscles.  The  fasciculi  raise  in  little  humps,  which 
persist  for  a  short  time  and  gradually  subside.  At  one  time  they  were 
thought  to  be  diagnostic  of  tuberculosis.  They  are  of  no  special 
significance. 

Atrophy. 

There  are  several  varieties  of  atrophy:  1.  The  atrophy  of  disuse. 
2.  Myopathic  atrophy.  3.  Myelopathic  atrophy,  or  the  atrophy  of 
degeneration.  It  follows  lesions  of  the  motor  path,  of  the  cortex, 
medulla,  or  spinal  cord  ;  and  neuritis.     (See  Nervous  Diseases.) 

The  Atrophy  of  Disuse.  It  is  also  known  as  the  atrophy  of  inac- 
tivity. The  muscles  are  slightly  lessened  in  volume.  The  atrophy 
takes  place  very  sloAvly ;  it  supervenes  in  cases  of  paralysis  and  in 
the  joint-diseases  which  cause  immobility.  It  occurs  also  in  joint- 
disease  from  reflex  influences.  The  electrical  reactions  of  the  muscles 
are  qualitative  and  unchanged.  By  this  reaction  atrophy  from  disuse 
and  atrophy  from  disease  of  the  muscles  can  be  distinguished  from  myelo- 
pathic atrophy,  due  to  disease  of  the  nerves  (neuritis),  or  to  degeneration 
of  motor  nerves  and  ganglia. 

Myopathic  Atrophy.  Muscular  Dystrophy.  In  this  form  of 
atrophy  the  muscle  is  diseased.  It  diminishes  in  volume  and  finally 
becomes  completely  shrunken.  Complete  paralysis  rarely  ensues,  but 
the  reaction  of  degeneration  cannot  be  determined. 

Idiopathic  Muscular  Atrophy.  Dystrophia  muscular  is  pro- 
gressiva (Erb).  In  this  affection  muscular  wasting  takes  place  with  or 
without  initial  hypertrophy.     Three  forms  are  seen  : 

1.  Atrophy  with  Pseudohypertrophy.  It  usually  begins  in 
childhood,  and  is  often  of  congenital  origin,  being  transmitted  through 


164  GENERAL  DIAGNOSIS. 

the  mother.  It  is  first  noticed  just  as  the  child  is  learning  to  walk. 
The  extensors  of  the  leg,  the  glutei,  the  lumbar  muscles,  the  deltoids, 
and  the  triceps  and  infraspinati  muscles  are  involved,  but  the  first 
change  takes  place  in  the  muscles  of  the  calves.  The  muscles  of  the 
face,  neck,  and  forearm  are  not  usually  affected  in  this  form  of  the 
disease  ;  the  muscles  of  the  hand  are  not  involved.  While  hypertrophy 
progresses  hi  certain  muscles  others  waste.  The  calves  may  hypertro- 
phy, for  instance,  while  the  extensors  of  the  leg  waste  away  and  become 
weak.  Attitude  and  gait  are  characteristic.  (See  page  73.)  The  patient 
stands  erect,  with  the  legs  apart,  the  shoulders  thrown  back,  the  spine 
curved,  and  the  abdomen  prominent.  The  waddling  gait  is  character- 
istic, and  the  method  of  getting  up  from  the  floor  is  pathognomonic. 
The  course  of  the  disease  is  slow,  wasting  follows  the  hypertrophy,  but 
the  weakness  is  greatest  in  the  muscles  first  atrophied.  Contractures 
and  distortions  of  the  spine  and  of  the  bones  of  the  leg  take  place. 

2.  Primary  Atrophy.  This  is  likewise  congenital  or  manifests 
itself  in  early  life.  It  is  divided  into  different  types,  according  to  the 
groups  of  muscles  that  are  affected.  The  same  process  occurs  as  in 
the  former,  except  that  pseudohypertrophy  is  not  primary.  There 
may  be  several  forms  in  different  members  of  the  same  family.  Of 
these  we  have  the  juvenile  form  of  Erb.  The  upper  arm  and  shoulder 
and  the  thigh  muscles  are  first  involved.  Later  the  muscles  of  the 
gluteal  region  and  calf  may  become  enlarged  and  hard.  The  back 
muscles  are  gradually  affected,  inducing  the  attitude  previously  men- 
tioned. The  reaction  of  degeneration  is  not  present.  There  is  also  an 
infantile  type,  first  described  by  Duchenne,  or  the  fascio-seapulo-humeral 
type,  Erb's  form  begins  about  puberty.  The  other  forms  usually 
begin  in  childhood,  but  may  be  delayed.  The  face  is  involved  ;  it  is 
expressionless,  and  in  laughing  the  muscles  move  slowly  ;  the  child 
cannot  whistle,  as  the  lips  are  thick  and  everted.  The  eyes  remain 
partlv  open.  The  muscles  of  the  group  waste  ;  later  the  thighs  become 
involved.  Erb  has  given  a  useful  test  to  determine  the  strength  of  the 
shoulder  and  girdle  muscles.  When  the  child  is  lifted  by  the  armpits, 
if  the  scapulohumeral  groups  are  weak,  the  shoulders  are  forced  up  to 
the  child's  ears  without  resistance. 

3.  Peeoxeal  Ateophy.  A  peroneal  type  of  muscular  atrophy  has 
been  described  by  Charcot.  The  extensors  of  the  great  toe  and  after- 
ward the  common  extensors  and  peronei  muscles  are  affected  ;  club- 
foot results.  The  muscles  of  the  thigh  may  become  involved  later. 
When  the  disease  occurs  hi  childhood  it  gradually  spreads  to  the  upper 
extremities  and  affects  the  muscles  of  the  hand,  differing  in  this  respect 
from  other  forms  of  muscular  atrophy.  The  thenar,  hypothenar,  and 
interossei  muscles  are  symmetrically  involved,  producing  the  claw-hand. 
Unlike  the  other  forms  of  atrophy  embraced  under  this  heading,  the 
peroneal  type  is  attended  by  disturbances  of  sensation,  and  by  pain,  fibril- 
lary contractions,  and  vasomotor  changes.  The  reactions  of  degeneration 
may  be  present.  It  is  thought  by  competent  observers  to  be  simply  a 
form  of  neuritis  ;  and  it  is  also  called  progressive  neural  muscular  atrophy. 

Diagnostic  Featuees  of  Myopathic  Ateophies.  The  disease 
is  characterized  by  gradual  progression  of  the  wasting  and  weakness  in 


THE  DATA  OBTAINED  BY  OBSERVATION. 


165 


various  groups  of  muscles  not  specially  related.  We  never  see  wasting 
of  the  intrinsic  muscles  of  the  hands,  as  in  the  spinal  forms  of  muscular 
atrophy,  or  of  the  tongue,  pharynx,  larynx,  and  eye.  Electrical  irri- 
tability is  lessened  and  reaction  of  degeneration  is  not  present.  Fibril- 
lary twitching  is  not  seen.  Sensation  is  not  affected.  The  reflexes  are 
diminished  and  later  may  be  lost.  The  sphincters  are  not  involved  ; 
deformities  about  the  joints  or  in  the  spinal  column  may  occur. 

The  diagnosis  of  idiopathic  muscular  atrophy  is  not  difficult  if  the 
above-mentioned  facts  are  borne  in  mind.  The  fact  that  it  occurs  in 
family  groups  is  an  important  point  in  the  diagnosis.  In  cerebral 
atrophy  there  is  primary  loss  of  power.  In  chronic  anterior  poliomy- 
elitis (spinal  atrophy)  wasting  begins  in  the  muscles  of  the  hands  ;  in 
both  the  simple  and  spastic  form  there  are  reactions  of  degeneration, 
fibrillary  twitching,  and  increase  in  the  reflexes,  and,  in  the  latter, 
spastic  contraction  of  the  legs.  The  myopathies  occur  early  in  life,  and 
are  hereditary. 

In  neuritis  the  paralysis  is  proportionately  greater  than  the  atrophy. 
Sensory  symptoms  are  often  present.  The  cause  is  distinct.  There  is 
no  family  history. 

General  Atrophy.  In  cachexias  the  muscles  as  well  as  the  tissues 
undergo  atrophy.  Even  in  nervous  disease  the  atrophy  of  the  muscles 
markedly  increases  when  general  wasting  takes  place. 


Circumscribed  atrophies 


Progressive  atrophies    . 


Diffuse  atrophies 


Facial  hemiatrophy  . 


Progressive  myopathic  . 


Raymond's  Table  of  Atrophies. 

Atrophy  from  compression. 

Atrophy  in  inflammatory  conditions  (pleurisy,  joint-disease,  etc.). 

Atrophy  from  injury  or  inflammation  of  individual  nerves. 

Progressive  spinal  muscular  atrophy  ;  type  Aran-Duchenne. 

Pseudohypertrophic  muscular  paralysis. 
Type  Leyden-Mobius. 
Type  Zimmerlin. 
atrophy     ."."*.    .    .  ■  Type  Erb. 

I  Type  Landouzy-Dejerine. 
I  Type  Charcot-Marie. 

f  Infantile  form. 
Acute  of  adults :  spinal  paralysis,  with 
rapid  course  and  curable  (Landouzy- 
Dejerine)  ;  subacute  and  chronic  form  ; 
chronic  mixed  form  (Erb);  diffuse 
subacute,  general  spinal  paralysis 
(Duchenne). 


Anterior   poliomyelitis 


I  Syringomyelia. 


r  Lead  paralysis. 


J  Multiple  neuritis 

■~\      .  .       ..    .       .  -I  Leprous  neuritis. 

I      (amyotrophic  form)  1    .,    .    ,. 

v  '  v.  Alcoholic  neuritis. 


Muscular  atrophies  of  cere-  j  with  secondary  degeneration  involving  the  anterior  cornua. 
bral  origin (  Without  secondary  degeneration  involving  the  anterior  cornua. 

Muscular  atrophy  in  hysteria  1    .  ,  . 

,,         .         .        *    ,        .        L  Amyotrophic  sclerosis. 
Muscular  atrophy  from  sys-  f  -,,         ,  T-    ,  ,  ,     . 

temic  disease  of  the  cord   .  Wosso-labio- laryngeal  paralysis. 

1  Atrophy  in  myelitis. 
Atrophy  in  compression  of  the  cord. 
Atrophy  in  multiple  sclerosis. 
Atrophy  in  tabes  dorsalis. 


166  GENERAL  DIAGNOSIS. 

Hypertrophy. 

Hypertrophy  of  individual  muscles  occurs  from  overuse,  as  when  an 
extremity  or  a  portion  of  the  trunk  is  used  in  excess.  General  hyper- 
trophy of  muscles  occurs  in  Thomsen's  disease.  True  hypertrophy  is 
recognized  by  increased  volume,  great  hardness,  and  increased  vigor  of 
the  muscle. 

Pseudo-hypertrophy  (see  under  Muscular  Atrophy)  is  associated 
with  increased  volume  of  muscle  but  diminished  power. 

Thomsen's  Disease  (Myotonia  congenita).  This  is  an  hereditary 
disease  and  may  occur  in  several  generations  of  a  family.  Tonic 
cramps  take  place  in  the  muscles  when  voluntary  movements  are 
attempted.  The  disease  begins  in  childhood,  rarely  after  puberty. 
The  muscles  become  rigid  and  fixed  when  put  in  action.  The  lack  of 
voluntary  control  of  the  muscles  is  shown  by  the  slow  contraction  and 
relaxation  when  voluntary  efforts  are  made.  The  rigidity  may  wear 
off  and  the  limb  can  then  be  used.  It  is  particularly  noticeable  when 
walking  is  attempted.  As  the  leg  is  advanced  slowly  it  may  remain 
stiff  for  a  second  or  two,  but  after  it  becomes  limber  the  patient  can 
walk  for  hours.  If  he  stops  walking  the  same  difficulty  is  experi- 
enced when  he  starts  again.  Both  arms  and  legs  are  affected.  Patients 
are  usually  well  nourished,  however.  There  are  no  atrophies.  The 
muscles  are  irritable,  so  that  mechanical  stimulus  or  pressure  causes 
tonic  contraction.  Movement  and  cold  aggravate  it.  Sensation  and 
the  reflexes  are  not  affected,  and  there  is  no  evidence  of  disease  of  the 
cerebro-spinal  system,  save  the  occurrence  of  hypochondriasis  in  some 
cases.  The  myotonic  reaction  described  by  Erb  is  induced.  (See 
electrical  diagnosis — Diseases  of  the  Nerves.) 

Paramyoclonus  Multiplex.  In  this  affection  there  is  clonic  con- 
traction of  the  muscles.  It  is  usually  confined  to  the  extremities  and 
occurs  in  paroxysms.  It  may  have  been  caused  by  sudden  twitching 
or  violent  motion.  The  clonic  spasms  at  first  do  not  interfere  with 
the  patient's  occupation,  but  gradually  they  increase.  Both  legs  are 
affected,  and  the  number  of  contractions  varies  from  50  to  150  a  minute. 
The  contractions  may  be  rhythmical.  In  severe  cases  the  muscles  of 
the  back  and  abdomen  contract  violently.  Tremor  of  the  muscles 
may  be  present  in  the  intervals.  (For  paralysis,  spasm,  tremor,  contrac- 
tion, etc.,  see  Nervous  System.) 

Myositis.  Inflammation  of  the  muscles.  (See  also  Trichinosis.)  In 
inflammation  of  the  muscles  there  is  pain,  swelling,  and  loss  of  power. 
In  universal  myositis  the  inflammation  begins  in  the  lower  extremities 
and  gradually  involves  other  muscles  of  the  body.  They  are  swollen, 
hard,  and  painful  on  pressure.  Atrophy  supervenes  in  groups  of 
muscles.  The  muscles  may  become  more  or  less  rigid.  Local  oedema 
of  the  skin  over  the  muscles  occurs.  The  progress  is  gradual,  and 
death  ensues  when  the  respiratory  muscles  are  involved. 

The  three  cardinal  symptoms  that  attend  the  disease  as  described  by 


THE  DATA  OBTAINED  BY  OBSERVATION.  167 

Loenfeld  are  :  (1)  Swelling  of  the  extremities  due  to  subcutaneous 
oedema  and  swelling  of  the  muscle,  causing  functional  disturbance  ;  (2) 
extension  to  the  muscles  of  respiration  and  deglutition  ;  (3)  a  more  or 
less  extensive  eruption.  The  latter  is  erythematous,  its  distribution  is 
usually  general  but  irregular,  and  may  be  followed  by  pigmentation. 
The  disease  must  not  be  confounded 'with  trichinosis.  In  the  latter 
examination  of  a  small  portion  of  muscle  reveals  the  trichinae. 

Progressive  ossification  of  the  muscles  is  rare.  The  muscle-tissues 
undergo  gradual  ossification,  either  in  localized  spots  or  in  wide-spread 
areas.  Inflammation  of  the  muscle  precedes  the  ossification.  As  the 
inflammatory  swelling  subsides  the  muscles  become  hard  and  are  grad- 
ually converted  into  bony  tissue.     The  disease  lasts  many  years. 

Myalgia  is  an  inflammation  of  the  muscles  produced  by  cold  or 
trauma.  There  is  pain  on  movement  and  spontaneous  pain  in  the 
muscle  ;  it  is  tender  on  pressure.     It  may  be  the  seat  of  spasm. 

Muscular  Rheumatism.  In  this  variety  of  rheumatism  there  is  pain 
in  the  affected  muscles,  which  often  comes  on  suddenly  in  the  night, 
or  is  first  noticed  when  the  patient  attempts  to  rise  in  the  morning. 
The  pain  when  the  patient  is  at  rest  may  be  inconsiderable,  rarely 
amounting  to  more  than  a  dull,  aching,  sore  feeling  ;  on  attempting  to 
move,  to  bend,  or  twist,  or  straighten  himself,  however,  the  patient 
catches  himself  suddenly  on  account  of  the  agonizing,  tearing,  or  burning 
pain.  When  the  muscles  are  relaxed  the  patient  is  fairly  comfortable. 
Sudden  movement  is  the  most  painful.  The  affected  muscles  are 
tender  to  the  touch  and  to  sharp  blows.  Muscular  rheumatism  may  be 
acute  or  chronic.  In  the  latter  the  symptoms  are  very  much  like  those 
of  chronic  articular  rheumatism,  except  that  the  muscles  and  not  the 
joints  are  affected.  There  is  the  same  proneness  to  recur  in  unfavor- 
able weather  and  in  cold,  damp  seasons. 

The  disease  receives  different  names  according  to  the  muscle  affected. 
The  most  common  subvarieties  are  :  lumbago,  in  which  the  muscles 
of  the  small  of  the  back  are  affected  ;  'pleurodynia,  in  which  the  inter- 
costal muscles  suffer  ;  and  torticollis,  in  which  the  sternomastoid  and 
trapezius  are  painfully  contracted. 

In  lumbago  the  patient  holds  himself  rigid  and  is  unwilling  to  rotate 
the  trunk  upon  the  vertebra?.  Often  the  most  comfortable  position  is 
that  in  which  he  sits  and  bends  slightly  forward  over  another  chair. 
Motion  is  painful,  but  pressure  is  not.  Fever  is  absent.  There  is 
a  history  of  repeated  attacks,  or  of  exposure,  such  as  lying  upon 
damp  ground.  Lumbago  needs  to  be  distinguished  from  disease  of 
the  spinal  membranes,  from  disease  of  the  vertebras,  aneurism,  abdomi- 
nal abscess,  and  diseases  of  the  uterus  and  ovaries.  The  diagnosis  of 
rheumatism  is  arrived  at  by  exclusion. 

In  pleurodynia  there  is  usually  tenderness  upon  pressure  as  well  as 
upon  motion  and  deep  inspiration.  The  pain  is  of  the  same  sore,  burn- 
ing character,  aggravated  by  coughing  and  sneezing.  The  patient 
breathes  as  little  as  possible,  and  often  bends  over  toward  the  affected 
side  to  lessen  the  motion.     Pleurodynia  is  distinguished  from  pleurisy 


168  GENERAL  DIAGNOSIS. 

by  the  absence  of  fever,  cough,  and,  above  all,  of  friction-sounds.  In 
intercostal  neuralgia  there  are  painful  points  upon  pressure,  whereas  in 
pleurodynia  firm  pressure  is  grateful,  though  tapping  is  painful. 

In  torticollis  the  head  is  drawn  to  one  side  and  fixed  in  that  position. 
The  sternomastoid  especially  is  rigid  and  tender  on  pinching.  In 
spinal  affections  the  head  is  retracted,  and  there  are  antecedent  symp- 
toms, as  headache  and  darting  pains  with  fever. 

Fibrous  Tissues.  Intimately  associated  with  rheumatic  affections 
of  the  muscles  is  that  of  the  fibrous  tissues  or  fascia.  Pain,  fixation, 
and  tenderness  are  noted,  and  if  with  them  other  rheumatic  manifesta- 
tions are  foimd  the  diagnosis  is  established  ;  especially  is  the  above  true 
of  trauma. 


CHAPTER    XIII. 

THE  DATA  OBTAINED  BY  OBSERVATION— (Continued). 

The  bones — general  examination.  Enlargement — acromegaly — osteitis  deformans — pul- 
monary osteo-arthropathy — Diminution — rhachitis  osteomalacia.  Local  examination 
— position  and  shape — nodes — inflammation — osteomyelitis. 

THE  BONES  AND  JOINTS. 

Method  of  Examination.  When  the  bones  and  joints,  especially 
the  spinal  column,  are  to  be  examined,  the  patient  should  be  stripped, 
and  after  the  movements  and  position  in  the  upright  or  semi-upright 
position  have  been  noted,  he  should  be  made  to  lie  down  on  a  hard, 
smooth  surface,  and  the  trunk  and  joints  examined  in  that  position. 
Anterior,  posterior,  and  lateral  movements  of  the  spinal  column  must 
be  made  to  determine  its  flexibility.  In  this  manner  deformities, 
changes  in  the  length  of  the  bones,  and  abnormal  posture  can  be  care- 
fully observed.  In  addition  we  must  note  muscular  wasting,  the  pres- 
ence of  local  tenderness  and  swelling,  changes  in  the  movements  of  the 
joints,  and  loss  of  other  functional  activity  causing  lameness  or  joint- 
disability. 

To  distinguish  joint  lesions  from  abnormal  flexions  or  extensions, 
the  result  of  spasm  of  muscles,  anaesthesia  must  be  employed. 

The  Bones. 

The  bones  are  fixed  landmarks  by  which  the  location  of  organs  is 
determined.  The  student  should  familiarize  himself  with  the  shape  of 
the  bones  and  the  location  of  normal  tuberosities. 

The  bones  may  be  the  seat  of  nutritive  changes  which  involve  the 
skeleton  in  whole  or  in  part,  causing  enlargement  or  diminution  of  the 
osseous  system,  and  hence  of  the  body.  Local  changes  are  traumatic 
(periostitis)  or  infectious,  giving  rise  to  nodes  or  to  swellings. 

General  Examination.  Enlargements.  Nutritive  changes  giving 
rise  to  enlargement  of  the  bones  occur  in  acromegalia,  osteitis  defor- 
mans, and  pulmonary  osteo-arthropathy. 

Acromegalia. 

Marie  first  described  acromegaly,  a  skeletal  change,  characterized 
by  hypertrophy  of  the  bones  of  the  hands,  feet,  and  face.  The  tibro- 
cartilages  of  the  ear  and  larynx  are  also  enlarged.  The  enlargement 
of  the  inferior  maxillary  and  frontal  bones  causes  the  face  to  assume  a 
peculiar,  elongated,  elliptical  outline.     The  nasal  bones  are  enlarged, 


170 


GENERAL  DIAGNOSIS. 


and  the  nose  thickened  ;  the  temporal  fossae  are  deepened,  on  account  of 
enlargement  of  the  malar  bones.  The  forehead  retreats  because  of  the 
enlargement  of  the  frontal  sinuses  and  projection  of  the  superciliary 
ridges  ;  the  chin  is  prominent  and  the  lower  teeth  project  beyond  the 
plane  of  the  upper  ;  the  lips  and  eyelids  may  be  thickened  ;  the  tongue 
is  enlarged  and  thickened.  The  hair  is  coarse  and  dry ;  the  face  dry 
and  pigmented. 

^  The  hands  are  peculiar  ;  they  are  much  broader,  the  fingers  are 
sausage  shaped,  and  the  hand  spade-like  in  shape  ;  the  nails  are  flat, 

striated,  and  too  small.  There  is  usually 
spinal  curvature  ;  the  abdomen  is  prom- 
inent, and,  as  before  intimated,  the 
height  is  increased.  The  muscles  be- 
come weak  and  may  atrophy ;  the  skin 
is  often  pigmented ;  varicose  veins  have 
been  observed,  and  the  patient  complains 
of  hemorrhoids.  The  thyroid  gland  may 
be  atrophied  or  hypertrophied.  It  may 
be  well  to  state,  in  passing,  that  with 
these  appearances  nervous  phenomena 
are  observed  and  disorder  of  special 
senses  complained  of.  Hemianopsia, 
limitation  of  the  visual  field,  and  blind- 
ness or  deafness  arise. 


Osteitis  Deformans. 


Another  remarkable  change  is  seen 
in  the  skeleton,  and  has  been  described 
by  Sir  James  Paget ;  in  this  there  is 
marked  change  in  the  contour  of  the 
patient  and  a  peculiarity  in  the  mode 
of  locomotion.  It  is  known  as  osteitis 
deformans.  The  head  is  advanced  and 
lowered,  so  that  the  neck  is  very  short, 
and  the  chin,  when  the  head  is  at 
ease,  is  more  than  an  inch  below  the 
top  of  the  sternum.  The  chest  becomes 
contracted,  narrow,  flattened  laterally, 
deep  from  before  backward,  and  the 
movements  of  the  ribs  and  spine  are 
lessened ;  the  arms  appear  unnaturally  long ;  the  shafts  of  each  tibia 
and  femur  are  bent  so  that  the  patient  becomes  bow-legged.  There  is 
some  stiffness,  but  no  loss  of  power  and  not  a  great  deal  of  pain.  The 
skull  is  increased  considerably  in  thickness. 

These  changes  in  the  bones  cause  a  dwarfed  appearance  of  the  trunk 
in  comparison  with  the  legs  and  arms,  and  the  posterior  lateral  curva- 
ture necessitates  a  characteristic  attitude.  The  skeletal  changes  are 
noted  particularly  in  the  long  bones.  As  a  result  of  the  enlargement 
of  the  cranial  bones,  the  face  presents  a  triangular  outline,  with  the  base 


Case  of  acromegaly.    (Osborne.) 


THE  DATA   OBTAINED  BY  OBSERVATION. 


Ill 


above  and  the  apex  below  (see  Fig.  24,  outline  3),  thus  differing  in 
appearance  from  the  outline  in  acromegaly  (Fig.  24,  outline  2). 


Fig.  24. 


Outline  of  face  in 
myxcedema. 


Outline  in  acro- 
megaly. 


Outline  in  osteitis 
deformans. 


Pulmonary  Osteo-arthropathy. 

Marie  distinguishes  acromegaly  from  another  skeletal  change  in 
which  there  is  hypertrophy  of  the  bones  of  the  extremities,  including 
enlargement  of  the  shafts.  In  this  form  of  arthropathy  the  bones  of 
the  head  and  face  are  not  affected.  The  hands  and  feet  are  enlarged, 
and  the  patellae  and  other  bones  of  the  knee-joints  increased  in  size. 

Fig.  25. 


Pulmonary  osteo-arthropathy.    Female,  aged  eleven.  Tuberculous  vertebral  caries  and  pulmonary 
tuberculosis.    Enlarged  clubbed  fingers  and  thickened  ulna  and  radius.    Private  patient,  1885. 

Curvature  of  the  spine  is  present.  The  appearance  of  the  fingers  is 
different  from  that  seen  in  acromegalia.  The  ends  are  enlarged  and 
bulbous,  and  the  nails  are  too  large  and  are  curved  in  a  transverse  and 


172 


GENERAL  DIAGNOSIS. 


longitudinal  direction,  like  the  clubbed  fingers  of  phthisis,  although  the 
chief  enlargement  of  the  fingers  is  not  terminal,  and  there  is  no  cyanosis, 
as  in  phthisical  clubbing.  The  change  seemed  to  be  associated  with  pul- 
monary affections,  and  Marie  called  it  osteo-arthropathie  pneumonique. 

Diminution.  Small  development  of  the  bones  is  seen  in  idiots  and 
cretins  ;  later  in  life  diminution  in  size  may  occur  from  rhachitis  and 
osteomalacia. 

Rhachitis. 

In  this  affection  the  size  of  the  body  is  lessened.  For  its  recognition 
it  is  important  to  know  how  rapidly  the  osseous  deposits  in  childhood 
have  formed.  The  fontanelles  and  the  epiphyses  must  be  examined. 
If  the  fontanelles  are  open  beyond  their  period  of  closure  in  health,  or 
if  the  epiphyses  are  enlarged  and  lack  firmness,  the  condition  points 
either  to  simple  malnutrition  or  to  rhachitis. 

In  rhachitis  late  development  of  the  teeth  is  observed.  If  the  ribs  are 
examined,  nodules  will  be  detected  at  the  junction  of  the  bone  with 

Fig.  26.  Fig.  27. 


■Br                         ^sH 

ffik                         9 

■k                     M 

Rhachitis;  attitude  in  sitting;   one  hand  raised 
to  exhibit  swelling  at  the  wrist.    (Williams.) 


Rhachitis  in  moderate  degree  in  a  hoy  aged 
fifteen  months ;  showing  backward  escurvation 
of  the  spine.    (Williams.) 


the  cartilage.  These  may  be  seen,  as  wrell  as  felt,  if  the  child  is  thin. 
Thev  form  the  so-called  rhachitie  rosary.  The  thorax  also  is  changed 
in  shape.  At  the  junction  of  the  cartilages  and  ribs  a  depression  takes 
place  which  is  continuous  with  a  groove  which  passes  out  from  the 
ensiform  cartilage  toward  the  axilla.  This  transverse  curve  is  known 
as  Harrison's  groove.  It  may  deepen  with  inspiration.  The  sternum 
projects,  forming  the  so-called  "  pigeon-breast."     (See  Thorax.)     Such 


THE  DA  TA  OB  TA INED  B  Y  OB  SEE  VA  TION.  173 

deformity  must  not  be  confounded  with  a  similar  one  seen  in  adenoid 
disease.  Changes  at  the  lower  end  of  the  radius  and  ulna,  and  some- 
times at  the  end  of  the  humerus,  are  noticed.  The  parts  are  enlarged 
at  the  junction  of  the  shaft  and  epiphyses.  There  may  be  thickening 
of  the  clavicles  at  the  sternal  ends.  In  the  legs  the  lower  end  of  the 
tibia  becomes  enlarged,  and  at  times  the  upper  end,  or  even  the  shaft, 
becomes  thickened.  The  child  becomes  bow-legged,  or  the  tibia?  and 
femora  may  arch  forward.  Knock-knee  sometimes  occurs.  The 
bones  of  the  vertebral  column  and  of  the  pelvis  are  also  affected.  The 
spine  is  usually  curved  posteriorly,  but  the  lateral  curvature  may  also 
be  produced  with  it.  The  contraction  of  the  pelvis  is  such  as  to 
narrow  its  outlet — a  matter  of  much  importance  for  the  future  of 
female  children. 

The  head  of  the  child  with  rickets  is  quite  characteristic.  It  has 
been  mentioned  that  the  fontanelles  remain  open  for  a  long  time,  and 
areas  of  ossification  are  imperfect,  so  that  the  bone  yields  to  the  press- 
ure of  the  finger.  This  occurs  particularly  at  the  side,  and  the  term 
■craniotabes  is  applied  to  it.  The  large  head  is  square  in  shape,  not 
globular,  when  seen  from  above  downward.  It  gives  the  face  a  pecu- 
liar appearance.  It  is  proportionately  very  small,  especially  in  the 
lower  two-thirds,  while  the  forehead  is  broad  and  square. 

Rhachitis  is  usually  developed  in  childhood,  and  is  most  common  in 
children  with  bad  hygienic  surroundings,  who  have  lived  upon  a 
starchy  diet  and  have  taken  cow's  milk  for  too  long  a  period  of  time. 
A  child  that  has  been  nursed  during  the  mother's  pregnancy  is  liable 
to  have  the  disease. 

In  addition  to  changes  in  the  bones  a  child  presents  other  evidences 
of  defective  nutrition.  There  is  marked  pallor  ;  the  muscles  are  flabby  ; 
the  child  is  feeble  ;  and  the  weakness  of  the  muscles  results  in  an  inac- 
tion which  resembles  paralysis. 

The  disease  usually  progresses  slowly,  and  is  eminently  chronic.  A 
form  is  seen,  however,  in  which  the  progress  of  the  symptoms  is  more 
acute.  With  some  gastro-intestinal  disturbances  there  are  mild  fever, 
considerable  weakness,  and  great  restlessness.  Sleep  is  disturbed,  and 
pain  is  complained  of  if  the  child  is  of  an  age  to  make  such  com- 
plaint. Soreness  of  the  body  is  observed  on  handling  the  child ;  and 
of  its  own  accord,  on  account  of  the  pain  and  soreness,  it  avoids  all 
customary  movements.  The  child  lies  on  its  back  and  shrinks  from 
any  attempts  to  disturb  it.  The  pain  is  not  only  caused  by  handling 
of  the  muscles,  but  the  bones  also  are  sore  and  tender.  Sometimes  the 
most  marked  manifestations  of  the  more  acute  forms  are  the  gastro- 
intestinal symptoms.  It  may  often  happen  that  vomiting  and  diar- 
rhoea have  as  an  underlying  basis  this  rhachitic  condition. 

With  the  above  symptoms,  and  also  in  chronic  cases,  perspirations 
about  the  head  are  common.  There  is  usually  more  heat  of  the  head 
than  is  natural,  hence  in  sleep  the  child  rolls  the  head.  This .  rolling 
causes  the  hair  on  the  back  of  the  head  to  be  worn  off.  This  sign  is 
most  characteristic  of  rhachitis  when  observed  along  with  changes  in 
the  skeleton. 

In  the  acute  and  chronic  forms  enlargement  of  the  liver  and  spleen  is 


174  GENERAL  DIAGNOSIS. 

observed.  The  enlargement  is  not  only  actual,  but  also  a  false  enlarge- 
ment may  be  seen  from  distortion  of  the  organs,  on  account  of  changes  in 
the  vertebrae  and  ribs.  The  abdomen  is  prominent,  usually  on  account 
of  flatulency,  although  the  enlarged  organs  contribute  to  the  swelling. 

Nervous  phenomena  are  common  in  the  course  of  rhachitis.  Tetany, 
limited  to  the  upper  extremities,  and  laryngismus  stridulus  are  the  most 
frequent.  Either  of  these  complications  may  occur  before  the  disease 
is  otherwise  suspected. 

Diagnosis.  The  possible  presence  of  rhachitis  must  not  be  over- 
looked in  cases  of  chronic  vomiting  in  childhood.  The  acute  form  of 
the  disease  must  not  be  confounded  with  scurvy,  as  often  happens  in 
the  case  of  children.  It  must  not  be  forgotten  that  scurvy  may  set  in 
in  the  course  of  rhachitis.  In  scurvy  the  pain,  tenderness,  and  weak- 
ness are  limited  to  the  lower  extremities.  The  immobility  of  the 
extremities  may  go  on  to  pseudoparalysis.  The  tenderness,  however, 
is  great ;  oedema  is  more  pronounced,  and  local  areas  of  periostitis  are 
more  common.  In  scurvy  the  gums  are  swollen  and  may  be  spongy, 
or  may  be  the  seat  of  ecchymoses.  The  most  decisive  diagnostic  crite- 
rion is  the  therapeutic  test,  scurvy  rapidly  yielding  to  a  proper  regimen. 

Osteomalacia. 

Among  the  general  affections  of  the  skeleton  which  may  cause  lessened 
size,  osteomalacia  must  not  be  forgotten.  As  the  lime  salts  are  dis- 
solved the  bones  become  preternaturally  soft,  break  on  the  slightest 
provocation,  or  bend  in  various  directions,  depending  upon  the  external 
pressure  and  the  direction  of  the  muscular  force.  The  ribs  are  drawn 
in  by  inspiratory  force  until  the  cavity  of  the  thorax  is  lessened  to  a 
degree  incompatible  with  life.  The  pelvis  is  deformed  so  that  labor  is 
impossible.  (It  occurs  frequently  in  pregnancy.)  All  sorts  of  fixed 
contortions  are  assumed.  If  the  patient  is  able  to  be  up  the  body 
shortens,  the  back  becomes  rounded,  the  neck  flexed,  so  that  the  chin  is 
brought  close  to  the  sternum.  On  palpation  the  bones  can  be  indented 
with  the  finger,  and  crepitate  like  egg-shells. 

Osteomalacia  is  easily  distinguished  from  carcinoma  or  sarcoma  of 
the  bones.  In  the  latter  spontaneous  fracture  occurs  in  various  parts 
of  the  skeleton,  but  is  generally  preceded  by  pain  and  swelling  at  the 
seat  of  fracture.  Then,  in  sarcoma,  subcutaneous  hemorrhages  are 
present.  When  a  single  joint  is  affected  in  osteosarcoma  the  same  egg- 
shell crackling  is  observed. 

Local  Examination.  The  Position  and  Shape  of  Bones. 
The  peculiar  position  (falling  downward)  of  the  scapula  in  paralysis  of 
the  serratus  magnus  is  diagnostic  of  that  affection,  and  indicates  disease 
of  the  posterior  thoracic  nerve.  In  examination  of  the  clavicles  frac- 
tures must  not  be  mistaken  for  disease  of  the  bones,  such  as  rickets. 
The  examination  of  the  spinal  column  is  of  the  greatest  importance. 
(See  Spinal  Joints.)  A  study  of  the  diseases  of  the  spinal  column  due 
to  caries  from  tuberculosis  is  not  within  the  province  of  this  work ; 
no  physical  examination,  however,  is  complete  without  an  investigation 


THE  DATA  OBTAINED  BY  OBSERVATION.  175 

of  the  movability  of  the  spine  and  the  presence  or  absence  of  curvature. 
I  refer  to  the  curvature  due  to  weakness  of  groups  of  spinal  muscles. 
Functional  disorders  of  the  gastro-intestinal  tract  and  of  the  uterus 
are  undoubtedly  intensified  by  the  presence  of  curvature,  which  leads 
to  deformity  of  the  body,  and  hence  to  the  assuming  of  abnormal  posi- 
tions when  sitting  or  walking.  The  recognition  of  lateral  or  anterior 
curvature  leads  to  the  adoption  of  lines  of  treatment  which  otherwise 
would  not  be  followed,  but  without  which  weak  muscles,  improper 
aeration  of  the  blood,  and  sluggish  circulation  would  persist.  Pain  in 
the  distribution  of  nerves,  or  at  their  termination,  is  often  due  to  spinal 
caries  pressing  on  them  as  they  pass  through  the  foramina.  The  most 
noticeable  is  the  pain  about  the  umbilicus  in  children  due  to  Pott's 
disease. 

The  bones  and  cartilages  connected  with  the  thorax  will  be  consid- 
ered under  Diseases  of  the  Lungs. 

Inflammation.  The  discovery  of  a  slight  change  may  lead  to  the 
recognition  of  a  grave  general  process.  Simple  local  inflammation  or 
periostitis  may  be  due  to  syphilis,  and  is  recognized  by  local  pain,  swell- 
ing, and  slight  oedema.  It  may  be  diffuse.  It  is  seen  most  frequently 
on  the  tibia,  sternum,  and  clavicle.  It  not  infrequently  follows  typhoid 
.fever. 

Nodules  or  nodes  are  usually  due  to  syphilis.  They  form  on  vari- 
ous portions  of  the  skeleton,  but  are  most  frequently  seen  on  the  skull, 
especially  on  the  forehead  ;  they  are  also  found  on  the  shafts  of  the 
long  bones,  preferably  the  tibia,  ulna,  and  clavicles.  They  are  usually 
multiple  or  bilateral.  They  are  painful  and  tender  on  pressure,  and 
may  be  the  seat  of  heat  and  redness.  They  are  not  so  hard  and  dense 
as  exostoses.  The  latter  are  situated  on  the  outer  aspects  of  the  bone 
and  in  relation  with  the  strongest  tendons  or  muscles. 

As  an  illustration  of  the  importance  of  recognizing  nodes  the  writer 
recalls  a  case  of  persistent  headache,  the  true  nature  of  which  was  only 
ascertained  by  finding  a  small  node  on  the  skull.  The  headache  had 
been  of  long  (five  years)  duration,  and  treatment  for  it  had  been 
sought  in  many  countries. 

Tenderness  of  the  sternum  upon  pressure  is  often  of  diagnostic  signifi- 
cance and  is  usually  indicative  of  syphilis.  The  pain  and  tenderness  just 
noted,  however,  must  not  be  confounded  with  local  tenderness  due  to 
necrosis,  which  often  arises  in  convalescence  from  fevers,  notably  those 
of  an  infectious  nature. 

Osteomyelitis.  The  occurrence  of  high  fever,  with  or  without 
chills,  but  usually  with  pysemic  symptoms,  without  recognized  cause, 
should  lead  to  an  examination  of  the  bones.  A  spot  of  tenderness 
followed  by  local  redness  and  swelling — on  the  tibia,  for  instance — 
would  indicate  the  seat  of  suppuration  in  osteomyelitis. 

The  Joints. 

The  Data  Obtained  by  Inquiry.  Careful  observation  of  the  bones 
enables  us  largely  to  discern  the  nature  of  the  diseased  process,  as  has 
just  been  indicated.     It  is  true  osteomyelitis  is  less  likely  of  recognition 


176  GENERAL  DIAGNOSIS. 

than  any  other  process,  but  when  the  patient  has  been  exposed  to  an 
infection,  and  fever  is  present,  this  condition  must  always  be  sought, 
for  in  the  absence  of  any  other  infectious  area. 

Such  is  not  true,  however,  of  joint-disease.  By  observation  we  deter- 
mine the  joint  affected  and  in  part  the  nature  of  the  morbid  process. 
Other  data  are  needed.  Hence  we  collect  the  usual  data  obtained  by 
inquiry.  The  social  history  is  not  productive  of  valuable  data.  Acute 
rheumatism  is  more  common  in  early  life,  rheumatoid  arthritis  in  the 
middle  periods,  and  cnronic  rheumatism  in  late  life.  Females  are 
more  commonly  attacked  than  males  in  rheumatoid  arthritis,  and  this 
affection  is  more  common  in  the  poorer  classes.  Males  and  the  well- 
to-do  are  the  victims  of  gout. 

In  the  family  history  one  learns  of  the  transmission  of  gout  from 
generation  to  generation  and  of  the  occurrence  of  rheumatism  or  of 
its  various  allied  processes  in  members  of  the  same  or  previous  genera- 
tions. Previous  diseases  elicited  are  those  of  an  infectious  nature  or  an 
intoxication,  as  of  lead.  Such  diseases  must  be  sought  for  if  the  true 
nature  of  an  arthritis  is  to  be  discovered.  The  history  of  the  present 
disease  is  often  that  of  recent  infection  or  intoxication. 

The  subjective  symptoms  of  joint-affections  are  worthy  of  note.  Pain 
is  the  most  prominent.  This  may  be  spontaneous,  or  may  arise  upon, 
pressure,  or  follow  attempts  at  movement.  Spontaneous  pain  with  ten- 
derness is  more  pronounced  in  rheumatic  and  gouty  inflammations  of 
the  joints.  The  pain  is  usually  worse  at  night.  This  is  particularly 
the  case  in  tuberculous  joints,  and  is  due  to  removal  of  the  apprehen- 
sive spasm  of  the  muscles  whereby  the  joints  had  been  protected. 

Pain  in  the  joints  must  not  be  confounded  with  that  of  local  or  mul- 
tiple neuritis.  I  have  seen  the  pains  of  neuritis  attributed  to  rheuma- 
tism of  the  phalanges,  tarsus,  and  ankle  until  paralysis  of  the  exten- 
sors took  place.  I  have  seen  the  pain  of  neuritis  of  the  circumflex 
mistaken  for  shoulder-joint  disease.  Multiple  neuritis  is  attended  by 
pains  that  may  be  located  in  the  joints  by  the  patient ;  but  neither  in 
local  nor  in  general  neuritis  are  the  joints  ever  swollen,  tender,  or 
painful  on  passive  movement. 

Inspection.  The  size,  shape,  and  color,  the  degree  of  movability  and 
the  position  of  the  joints  are  observed. 

The  Size  aistd  Shape.  The  joints  may  be  enlarged.  The  enlarge- 
ment may  be  due  to  infiltration  of  the  tissues  about  the  joints,  to  effu- 
sion within  the  joints,  serous  or  purulent,  or  to  inflammation  of  the 
ends  of  the  bones. 

1.  When  the  enlargement  is  due  to  infiltration  about  the  joint  the 
tissues  are  previously  thickened,  as  shown  by  palpation,  and  the  out- 
line of  the  joint  is  changed.  The  normal  contour  is  lost  entirely,  and, 
instead,  there  is  a  globular  swelling  beginning  above  and  extending 
below  the  joint.  2.  When  the  enlargement  is  due  to  effusion  it  may 
be  detected  by  palpation,  as  this  secures  fluctuation.  This  is  particu- 
larly so  in  the  large  joints.  If  the  joint  involved  is  the  knee  the 
patella  will  float.  The  effusion  changes  the  normal  contour,  but, 
in  the  earlier  stages,  may  cause  local  swellings  where  the  synovial 
.sacs  are  near  the  surface  ;  hence,  at  the  articulation  of  the  tibia  and 


THE  DATA  OBTAINED  BY  OBSERVATION.  177 

fibula  with  the  tarsus,  on  the  inner  and  outer  side,  a  boggy  swelling  is 
observed.  At  the  knee  the  swelling  is  on  each  side  above  and  below 
the  patella.  When  the  effusion  is  great  the  joint  becomes  immobile, 
and  may  be  flexed  from  distention  of  the  sac.  3.  When  enlargement 
of  the  joints  is  due  to  hypertrophy  of  the  bones  the  latter  are  thick- 
ened and  very  hard.  There  may  or  may  not  be,  and  usually  is  not, 
fixation,  and  movement  is  but  moderately  interfered  with. 

Changes  in  the  outline  of  the  joint  are  also  seen  in  rheumatoid  arth- 
ritis. The  loss  of  the  cartilaginous  substance  of  the  joint,  with  the 
secondary  osteophytic  changes,  causes  deformity,  so  that  in  the  case  of 
the  small  joints  of  the  finger  subluxation  is  seen  ;  similar  subluxations 
are  seen  in  larger  joints.    The  ends  of  the  phalangeal  bones  are  thickened. 

The  Color  Change  in  the  color  is  usually  noticed  in  inflamma- 
tions.    The  surface  is  either  bright  red  or  dusky. 

The  Position.  The  position  assumed  is  of  diagnostic  importance. 
Flexion  of  the  limb  of  the  affected  joint  occurs  in  over-distention.  It 
must  be  remembered  that  the  hip-joint  is  flexed  in  appendicitis  and  in 
psoas  abscess  or  other  affections  in  proximity  to  the  psoas  muscles. 
In  rheumatoid  arthritis  there  is  subluxation.  Immobility  is  observed. 
(See  Palpation.) 

Palpation.  By  palpation  we  determine  the  degree  of  movability  of 
the  joints,  the  presence  of  fluctuation  and  of  crepitation. 

1.  The  movability  of  the  joint  is  learned.  Movement  is  inhibited  in 
inflammation  on  account  of  the  pain.  A  reflex  muscular  spasm  takes 
place  if  osteitis  and  cartilage-destruction  are  present.  The  spasm  pre- 
vents movement.  In  effusion  there  is  less  movability  or  even  none  at 
all.  In  rheumatoid  arthritis  movement  is  prevented  by  the  osteophytic 
growths  which  surround  the  joint. 

2.  Fluctuation  is  revealed  by  palpation,  pointing  to  liquid  effusion 
within  the  joint.  (Edema  of  the  surrounding  tissues  occurs  in  puru- 
lent effusions. 

3.  A  crepitus  or  grating  sensation  is  observed  in  rheumatoid  arth- 
ritis and  other  destructive  diseases. 

The  Morbid  Process.  The  processes  which  give  rise  to  change  in 
the  joints  are  inflammatory  and  degenerative,  and,  curiously,  neurotic 
or  neuropathic.  When  a  single  joint  is  the  seat  of  disease  the  process 
may  be  local,  as  in  traumatic  synovitis.  But  tuberculosis  and  other 
infections,  gout  and  rheumatism  or  rheumatoid  arthritis,  may  be  local- 
ized to  one  joint — the  latter  rarely,  however.  Multiple  joint-disease, 
polyarticular,  is  infectious  or  systemic  (intoxication)  usually. 

Much  information,  therefore,  is  learned  by  noting  if  the  process  is 
limited  to  one  joint,  monarticular;  or  to  many  joints,  polyarticular ;  if 
to  large  joints  or  to  small  joints  ;  if  it  is  fixed,  as  in  synovitis,  or  fugi- 
tive, as  in  rheumatic  fever.  Monarticular  inflammation  of  small  joints 
points  to  gout ;  of  large  joints,  to  gonorrhoeal  rheumatism  or  pyaemia. 
Polyarticular  inflammation  of  small  joints,  to  rheumatoid  arthritis ;  of 
large  joints,  to  rheumatism.  Lesions  may  be  unilateral  or  bilateral, 
symmetrical  or  asymmetrical.  Bilateral  joint  lesions  are  characteristic 
of  rheumatoid  arthritis.  Asymmetrical  and  fugacious  lesions  are  seen 
in  rheumatic  fever. 

12 


178  GENERAL  DIAGNOSIS. 

It  must  always  be  remembered  that  joint-lesions  or  processes  may  be 
expressions  of  general  infections,  as  septicaemia,  influenza,  cerebro-spinal 
meningitis,  scarlet  fever,  and  dysentery  ;  or  blood  diseases,  like  purpura 
or  hemophilia  or  scurvy ;  or  of  nervous  diseases,  like  tabes  dorsalis. 

W  e  have  to  consider  synovitis  or  arthritis  single  and  multiple,  trau- 
matic, toxic,  or  infectious,  of  which  gonorrheal  and  tuberculous  infec- 
tions are  the  most  common  monarticular  causes.  We  will  then  consider 
rheumatism  and  gout,  rheumatoid  arthritis,  and  follow  with  the  neuro- 
pathic joints. 

Synovitis.  The  inflammation  is  recognized  by  pain,  heat,  redness, 
and  swelling.  Effusion  is  present,  and  its  physical  signs  are  readily 
elicited.  It  is  both  periarticular  and  intra-articular.  It  may  be  due 
to  traumatism,  but  we  are  chiefly  concerned  with  inflammations  due  to 
internal  morbid  processes.  When  single  joints  are  affected  the  most 
common  causes  are  tuberculosis,  pyemia,  and  gonorrheal  infection. 
A  mild  degree  of  inflammation  may  be  limited  to  one  joint  in  subacute 
rheumatism.  When  many  joints  are  affected  the  cause  is  an  infectious 
one,  as  rheumatism,  septicemia,  pyemia,  epidemic  cerebro-spinal  men- 
ingitis, scarlet  fever,  and  dysentery,  rarely  gonorrhea. 

The  Tuberculous  Joint.  In  'tuberculosis  the  joint  is  swollen  and 
the  neighboring  tissue  edematous.  Effusion  may  be  detected.  There 
is  fever.  The  hip,  the  knee,  the  elbow,  the  wrist,  and  the  ankle  are 
most  frequently  affected.  Cheesy  material  may  be  withdrawn  by  tap- 
ping. Destruction  ultimately  takes  place,  with  subluxations  and  sub- 
sequent fixation  of  the  joint.  With  fever,  wasting,  and  local  signs  of 
tuberculosis  in  other  portions  of  the  body  the  true  nature  of  the  affec- 
tion is  indicated.  The  tuberculous  process  may  be  limited  to  the 
affected  joint,  extend  to  the  tendinous  sheaths,  or  secondary  tuberculosis 
of  internal  organs  may  supervene. 

The  Joint  of  Gonorrhceal  Rheumatism.  The  knee-joint  is  usually 
affected.  Signs  of  acute  or  subacute  inflammation  are  present,  with 
edema  and  effusion.  The  patient  is  a  male  in  whom  an  acute  or 
chronic  urethral  discharge  is  found.  The  pam  is  worse  at  night.  The 
process  is  of  long  duration.  Metastasis  does  not  take  place.  Destruc- 
tion rarely  occurs,  but  anchylosis  may.  General  pyemic  svmptoms 
may  ensue,  and  gonorrheal  endocarditis  supervene.  The  micro-organ- 
isms (gonococci)  can  be  found  in  the  blood  and  in  the  pus  of  the 
affected  joint.  There  is  entire  absence  of  heart-symptoms  from  simple 
endocarditis.  The  general  and  local  signs  of  rheumatism  or  of  a  rheu- 
matic diathesis,  and  changes  in  the  urine,  skin  eruptions,  cardiac 
lesions,  etc.,  are  wanting.  In  certain  cases  many  joints  are  affected, 
but  the  temperature  is  not  so  high  or  the  sweats  so  profuse  as  in  acute 
rheumatism.     Tendo-synovitis  is  not  infrequent. 

Rheumatic  Fever. 

An  acute,  general,  febrile,  non-contagious  disease,  characterized  by 
specific  inflammation  of  thejomfc  and  their  contiguous  structures,  hence 
called  acute  articular  rheumatism.  It  is  further  characterized  by  a  ten- 
dency of  the  inflammation  to  involve  the  larger  joints  successively,  to 


THE  DA  TA  OB  TAIN  ED  B  Y  OBSEB  VA  TION.  \  7  9 

skip  from  one  joint  to  another,  and  to  be  associated  with  endocarditis 
or  pericarditis. 

The  predisposing  causes  of  rheumatic  fever  are  heredity,  which  is 
operative  in  25  or  30  per  cent,  of  the  cases  ;  age — 81  per  cent,  of  first 
attacks  occur  between  the  eleventh  and  thirtieth  years  (Pye-Smith)  ; 
sex — in  childhood  girls  are  more  frequently  affected  than  boys,  but  after 
that  period  sex  appears  to  have  no  influence.  Polyarticular  inflamma- 
tions, sometimes  rheumatic  hi  nature,  are  met  with  during  convales- 
cence from  scarlatina  and  dysentery.  They  also  occur  in  association 
with  the  puerperal  state  and  gonorrhoea,  in  which  they  are  probably 
pyaemia  The  nature  of  the  polyarthritis  which  occurs  in  connection 
with  dengue,  and  haemophilia  is  obscure. 

Symptoms.  The  onset  of  the  disease  is  not  characterized  by  con- 
stant symptoms.  Sometimes  the  fever  and  joint-inflammations  are 
preceded  a  day  or  two  by  debility,  wandering  pains  in  the  joints  or 
muscles,  and  loss  of  appetite.  In  other  cases  there  is  a  chill  or  repeated 
attacks  of  chilliness,  followed  in  a  day  or  two  by  fever  and  inflamma- 
tion of  the  joints.  In  rare  cases  the  onset  may  be  followed  not  by  in- 
flammation of  the  joints  but  by  inflammation  of  the  serous  membranes, 
particularly  those  of  the  heart  and  its  sac. 

The  temperature  may  rise  a  day  or  two  before  there  are  any  joint- 
symptoms,  or  fever  and  arthritis  may  begin  almost  simultaneously. 
The  temperature  rises  rapidly  to  102°,  103°,  or  104°  F.,  and  one  or 
more  of  the  larger  joints,  generally  the  knee  and  ankle,  become  painful, 
tender,  swollen,  and  hot. 

The  Joixt.  There  may  be  great  pain  on  motion  before  there  is 
evident  swelling  or  much  local  tenderness.  The  pain  varies  from  mere 
discomfort  to  the  most  excruciating  suffering.  It  is  always  aggravated 
by  motion  or  pressure,  and  is  at  times  so  exquisite  that  the  slightest 
touch,  the  weight  of  the  bedclothing,  or  the  jar  of  the  bed  from  a  heavy 
step  in  the  room  makes  the  patient  cry  out.  It  may  extend  beyond 
the  joint  to  neighboring  tendons  and  nerves.  The  swelling  like- 
wise varies  greatly ;  sometimes  there  is  only  slight  puffiness  with 
increased  distinctness  of  the  cutaneous  veins,  increased  heat  in  the  part, 
but  no  general  redness  ;  in  other  cases  there  is  considerable  swelling 
about  the  joint,  so  that  the  bony  prominences  are  obliterated,  the  sur- 
face being  tense,  red,  and  very  hot  to  the  touch.  There  is  often  effu- 
sion into  the  joint.  Swelling  is  most  marked  in  the  wTrist  and  ankle, 
and  less  so  in  the  shoulders,  hips,  elbows,  and  knees. 

Multiplicity  of  Joints  Affected.  A  characteristic  peculiarity  of  rheu- 
matism is  its  tendency  to  involve  one  joint  after  another.  One  or 
several  joints  may  be  affected  at  first ;  it  is  very  common  for  the 
right  ankle  to  be  affected,  and  then  in  a  short  time  the  opposite  ankle, 
followed  by  the  left  knee  and  right  knee,  and  so  on  with  the  other 
joints.  The  inflammation  usually  lasts  in  each  joint  from  two  to  four 
days.  The  process  may  subside  in  one  articulation  and  begin  .  in 
another  with  startling  rapidity.  At  one  visit  of  the  physician  the 
patient's  right  ankle  may  be  swollen,  hot,  and  unbearably  painful,  and 
on  the  next  day  the  right  ankle  maybe  quite  well  again  and  the  patient 
be  found  suffering  acute  pain  in  the  right  knee  or  left  ankle. 


180 


GENERAL  DIAGNOSIS. 


The  pulse  in  the  early  stages  of  rheumatism  is  moderately  accelerated 
(99  to  110) ;  it  is  regular,  of  good  volume,  often  bounding,  and  some- 
times hard.  The  urine  is  scanty,  high-colored,  abnormally  acid,  and 
deposits  on  cooling  a  copious  precipitate  of  urates,  resembling  red  sand 
in  appearance.  The  skin  does  not  feel  so  hot  as  one  would  expect  from 
the  temperature.  It  is  continuously  covered  with  a  copious,  acid,  and 
somewhat  pungent  perspiration.  Nervous  symptoms  are  not  marked. 
There  may,  however,  be  slight  nocturnal  delirium.  Sleeplessness  from 
pain  is  very  common. 

The  temperature  in  rheumatic  fever  is  not  usually  very  high  ;  it  is 
much  oftener  under  than  over  103°.  In  rare  cases,  however,  espe- 
cially when  the  fever  is  complicated  with  pericarditis,  pneumonia,  or 

Fig.  28. 


May 


Rheumatic  fever.    Admitted  fourth  day  of  disease. 


some  disturbance  of  the  heat-regulating  apparatus,  the  temperature 
may  attain  the  extraordinary  range  of  106°-112°  F.  Such  high  tem- 
peratures may  occur  suddenly  or  gradually,  and  are  sometimes  attended 
with  marked  brain-symptoms  (so-called  cerebral  rheumatism). 

Endocarditis  and  pericarditis  may  occur  at  any  period  of  rheumatic 
fever  ;  they  may  even  precede  any  joint-inflammations.  They  are  most 
common,'however,  in  the  first  two  weeks  of  the  disease.  The  younger 
the  patient  and  the  more  severe  the  attack  the  greater  the  liability  to 
heart-complications.  They  occur  in  about  one-fourth  of  all  cases. 
Endocarditis  is  most  common  ;  often  it  is  the  only  lesion,  but  some- 
times it  is  associated  with  pericarditis  and  more  rarely  with  myocar- 
ditis. These  complications  usually  give  rise  to  no  symptoms  at  first. 
Hence  the  heart  should  be  examined  daily.  A  sense  of  constriction 
in  the  prsecordia  or  pit  of  the  stomach,  an  anxious  expression  of  the 
face,  with  pallor,  a  change  in  the  frequency,  but  especially  in  the 
rhythm  of  the  pulse,  and  the  occurrence  of  cough  or  dyspnoea,  should 
attract  attention  to  the  heart.  The  physical  signs  of  the  respective 
lesions  have  been  described  fully  under  Diseases  of  the  Heart. 

The  setting  in  of  convalescence  from  rheumatic  fever  is  marked  by 
cleaning  of  the  tongue,  which  also  becomes  less  red,  and  increase  in 
the  secretion  of  urine,  which  remains  of  high  specific  gravity.  The 
fever  subsides  gradually,  the  joints  cease  to  be  red,  swollen,  and  tender, 


THE  DATA  OBTAINED  BY  OBSERVATION.  181 

the  acid  sweats  lessen,  and  the  appetite  improves.  In  proportion  to 
the  duration  of  the  case  and  its  severity  the  patient  is  left  with  debility 
and  marked  anaemia,  both  red  cells  and  haemoglobin  being  diminished. 
In  anaemic  cases  a  haamic  murmur  may  be  heard  over  the  base  of  the 
heart.  In  some  cases  acute  dilatation  has  been  observed,  with  a  tri- 
cuspid murmur. 

Complications  and  Sequelae.  Apart  from  heart  complications  which 
have  been  mentioned,  pleuritis,  pneumonia,  and  bronchitis  occur  in  from 
10  to  15  per  cent,  of  the  cases.  They  are  frequently  bilateral,  and  are 
very  much  more  common  in  rheumatic  fever  with  pericarditis  or  endo- 
carditis than  in  simple  rheumatic  fever.  Moreover,  the  pulmonary 
complications  are  frequently  latent,  and  would  be  overlooked  but  for 
the  daily  physical  examination  of  the  chest.  On  the  other  hand  they  may 
develop  with  great  suddenness,  and  what  appeared  to  be  a  full-blown 
pneumonia  may  subside  suddenly  as  a  fresh  joint  is  affected.  They 
behave  more  like  sudden  active  congestions  than  true  pneumonias. 
Rheumatic  pleurisies  are  characterized  by  the  rapidity  with  which  effu- 
sion takes  place,  the  persistence  of  pain  in  the  side  during  effusion,  the 
tendency  to  involve  both  sides  in  succession,  the  readiness  with  which 
the  effusion  is  absorbed,  and  their  acute  course. 

Nervous  System.  The  most  common  complication  of  the  nervous 
system  is  delirium,  which  is  generally  associated  with  insomnia  and 
hyperpyrexia,  but  the  latter  is  not  constant.  These  brain-symptoms 
generally  appear  in  the  second  week  of  illness,  and  about  the  time  of 
convalescence,  or  while  the  joints  are  still  inflamed.  The  delirium 
may  be  low  and  muttering,  accompanied  by  ataxic  symptoms  or  even 
by  tremors  and  spasms  of  muscles  ;  or  it  may  be  furious.  In  favorable 
cases  a  deep  sleep  ushers  in  recovery  ;  or,  in  unfavorable  cases,  the 
delirium  persists  with  adynamia,  the  patient  dying  hi  collapse  or  coma, 
preceded  or  not  by  convulsions. 

Chorea  sometimes  occurs  as  a  complication,  but  it  is  more  common 
as  a  sequel  of  mild  cases  in  children.  Cerebral  meningitis  occurs  occa- 
sionally, especially  when  there  is  ulcerative  endocarditis.  Cerebral 
embolism  is  another  rare  complication. 

Various  spinal  symptoms  occur  in  some  cases,  at  times  with,  and  at 
times  without,  demonstrable  lesion  of  the  cord  or  its  membranes. 
Tetanus,  myelitis,  and  spinal  meningitis  may  all  be  simulated.  Per- 
haps these  symptoms  are  due  to  high  temperature  ;  but  very  high  tem- 
peratures are  met  with  without  the  occurrence  of  any  cerebral  or  spinal 
symptoms. 

Nephritis  is  rare,  but  sometimes  hemorrhage  into  the  kidney  occurs 
with  its  usual  symptoms.     Peritonitis  is  extremely  rare. 

Various  erythematous  skin-eruptions  are  seen  from  time  to  time, 
and  occasionally  purpura.  Subcutaneous  nodosities  have  been  described 
by  several  writers.  They  are  attached  to  the  tendons,  fascia,  and  peri- 
osteum, and  are  most  frequent  on  the  back  of  the  elbow,  the  ankles, 
and  patella.  They  are  painless,  and  may  occur  in  any  form  of  rheu- 
matism. 

Diagnosis.  Rheumatic  fever  is  distinguished  from  gout  by  the 
profuse  acid  and  acrid  sweating,  the  tendency  to  involve  a  number 


182  GENERAL  DIAGNOSIS. 

of  joints,  and  particularly  the  larger  ones,  by  the  greater  intensity  of 
constitutional  symptoms,  by  the  great  liability  to  heart-complications, 
and  by  the  absence  of  uric  acid  from  the  blood. 

It  is  distinguished  from  pycemia  by  the  wandering  character  of  the 
inflammation  ;  the  acid  sweats  ;  the  absence  of  any  antecedent  condi- 
tion which  would  develop  purulent  foci — such  as  injuries,  abscesses,  or 
specific  eruptive  fever  ;  the  absence  of  chills,  and  the  fact  that  in  rheu- 
matic fever  the  sweats  are  constant,  whereas  in  pyeemia  they  follow  a 
fall  in  the  temperature.  Cutaneous  abscesses  do  not  occur  in  rheuma- 
tism, and  after  its  subsidence  the  joint's  usefulness  is  not  impaired. 
:  v  Acute  synovitis  resembles  rheumatic  fever,  because  in  both  occur 
symptoms  of  pain,  tenderness,  and  swelling  in  connection  with  a  joint. 
Usually,  however,  in  synovitis  but  one  joint  is  involved,  and  there  is 
a  history  of  exposure  to  cold  or  injury.  The  effusion  is  limited  to  the 
synovial  sac  of  the  joint,  is  frequently  abundant,  and  fluctuation  can 
easily  be  detected.  The  constitutional  symptoms  are  much  less  marked 
than  in  rheumatism. 

Milk-leg,  or  phlegmasia  alba  dolens,  differs  from  rheumatism  in  that 
it  usually  occurs  in  women  after  confinement,  or  as  a  complication  or 
sequel  of  fever,  as  typhoid  fever.  Usually  one  leg  is  affected,  or  part 
of  the  leg,  especially  the  calf.  This  becomes  tense,  tender,  uniformly 
swollen,  and  the  seat  of  great  pain.  The  leg  is  moved  with  much  diffi- 
culty. The  femoral  vein  may  be  found  to  be  knotted  and  tender. 
There  is  almost  always  evidence  of  antecedent  disease. 

Acute  periostitis  when  close  to  a  joint  simulates  rheumatism.  But 
the  tenderness  and  heat  are  not  in  the  joint  itself ;  they  are  superficial, 
and  are  associated  with  less  swelling.  Pitting  on  pressure  is  common  ; 
and  circumscribed  fluctuation  usually  discloses  the  presence  of  suppu- 
ration. Pyaemic  symptoms  are  added  to  the  local  symptoms,  particu- 
larly if  osteitis  or  osteomyelitis  is  present. 

The  articular  symptoms  of  glanders  are  to  be  distinguished  by  the 
occupation  of  the  patient,  the  mode  of  onset,  the  associated  symptoms, 
especially  one  or  more  pustules,  and  the  fact  that  the  painful  joints  are 
not  so  apt  to  be  swollen  and  red  as  in  rheumatic  fever. 

In  syphilis  joint-pains  frequently  occur,  but  their  character  is  made 
out  by  the  fact  that  the  joints  are  not  inflamed,  and  that  the  pain  is 
much  worse,  or  occurs  only  at  night,  and  by  the  history  of  the  patient 
and  the  therapeutic  test. 

In  some  diseases  of  the  brain  and  spinal  cord  joint-inflammations  of 
trophic  origin  occur.  They  are  distinguished  by  the  coexistence  of 
some  lesion  of  brain  or  cord,  with  hemiplegia  or  other  palsy,  and  of 
other  trophic  changes,  such  as  bed-sores,  atrophied  muscles,  loss  of 
hair,  shiny  skin,  and  defective  growth  of  nails. 

Subacute  Articular  Rheumatism. 

In  some  instances  the  joint-inflammation  is  less  severe,  and  is 
accompanied  by  only  slight  fever.  One  or  more  joints  may  be  affected. 
It  differs  from  the  ordinary  form  in  being  milder  in  degree  and  more 
persistent,  lasting  sometimes  for  months.     It  is  generally  subacute  from 


THE  DATA  OB  TA  IN  ED  BY  0  BSER  VA  TION.  183 

the  beginning,  but  may  be  the  type  present  in  those  who  have  had 
several  attacks  of  rheumatic  fever  and  have  been  left  in  a  very  sensi- 
tive condition.  Rheumatic  fever  is  usually  subacute  in  children,  and 
often  only  one  joint  is  involved.  Cardiac  complications  are  more  fre- 
quent than  in  adults,  and  chorea  may  occur  as  a  sequel.  Erythema 
nodosum  and  subcutaneous  nodosities  are  more  common  in  children. 

Chronic  Articular  Rheumatism. 

In  this  form  the  patient  has  pain  and  stiffness  in  one  or  more  joints, 
or  in  the  contiguous  tissues.  The  joints  most  frequently  affected  are 
the  shoulder  and  knee.  The  pain  is  more  or  less  constant,  but  worse 
in  damp  weather  or  on  the  approach  of  a  storm,  and  worse  also  at 
night  in  many  cases.  Conversely,  it  is  better  in  warm,  dry  weather. 
There  is  not  much  if  any  tenderness,  and  rarely  any  swelling  or  ele- 
vation of  temperature.  The  joints  very  frequently  crack  and  grate  on 
motion.  In  the  interval  between  the  attacks  there  is  no  impairment 
of  the  usefulness  of  the  joints.  In  very  chronic  cases  there  may  be 
some  atrophy  of  muscles  and  permanent  stiffness,  even  fibrous  anchy- 
losis. 

In  some  cases  there  are  repeated  attacks  of  subacute  articular  rheu- 
matism, accompanied  by  the  usual  symptoms  and  joint-effusions. 

Chronic  articular  rheumatism  is  distinguished  from  chronic  gout  by 
the  fact  that  there  is  no  special  tendency  to  involve  the  great  toe,  by 
the  absence  of  the  deformities  resulting  from  gout,  and  the  absence  of 
deposits  of  sodium  urate  in  the  ears,  fingers,  and  around  the  joints. 

Gout. 

A  disease  characterized  by  specific  arthritis,  associated  with  uric 
acid  in  the  blood  and  the  deposit  of  sodium  urate  in  the  joints,  or 
manifesting  itself  as  a  diathesis  in  which  occur  other  inflammations  of 
non-articular  tissues  and  various  disturbances  of  functions  of  organs, 
the  blood  also  containing  uric  acid. 

Gout  is  common  in  Europe,  particularly  in  England,  but  in  its  ar- 
ticular form  is  rare  in  this  country.  There  is  an  hereditary  predispo- 
sition in  from  50  to  60  per  cent,  of  the  cases.  It  results  from  over- 
eating of  rich  foods  and  the  drinking  of  malt  liquors,  associated  with 
insufficient  exercise  and  excretion.  Garrod  has  called  attention  to  its 
association  with  lead-poisoning.  Paroxysms  are  induced  by  indiscre- 
tions in  eating  or  drinking,  by  nervous  shock  or  great  mental  strain, 
by  exposure  to  cold  or  injury,  or  by  overwork  and  sexual  excesses. 

The  characteristic  phenomena  of  gout  are  preceded  for  a  variable 
time  by  acid  flatulent  dyspepsia,  colicky  pains  in  the  stomach  and 
bowel,  constipation  alternating  with  diarrhoea,  and  scanty,  heavily 
loaded  urine.  Accompanying  these  dyspeptic  symptoms  often  are 
impairment  of  physical  and  mental  vigor,  irritability  of  temper,  and 
hypochondriasis. 

In  other  cases  the  premonitory  symptoms  are  palpitation  of  the  heart, 
or  dyspnoea  resembling  asthma,  or  various  nervous  symptoms,  as  drow- 
siness, insomnia,  or  headache. 


184  GENERAL  DIAGNOSIS. 

In  acute  articular  gout  the  onset  is  often  sudden,  especially  in  the 
first  attack.  The  patient  may  go  to  bed  in  apparent  health,  but  wake 
up  early  in  the  morning  with  a  feeling  of  discomfort  or  uneasiness, 
usually  in  the  great  toe.  In  some  cases  the  pain  is  agonizing  from  the 
first.  The  patient  finds  he  is  unable  to  step  upon  the  foot  without 
torturing  pain.  The  ball  of  the  great  toe  is  hot,  swollen,  red,  and 
exquisitely  resentful  of  the  slightest  touch  or  jar  of  the  bed.  The 
veins  are  swollen  and  the  joint  stiff.  There  is  slight  fever,  perhaps 
chilliness,  thirst,  coated  tongue,  constipation ;  scanty,  high-colored  urine, 
depositing  urates  on  cooling  ;  the  skin  is  warmer  than  normal,  and 
there  is  slight  perspiration.  The  pain  usually  abates  during  the  day 
and  increases  at  night.  It  is  aggravated  by  motion  and  attended  by 
painful  muscular  cramps.  By  the  end  of  the  first  day  or  two  the  swell- 
ing increases  and  the  pain  lessens,  owing  to  diminished  tension  of  the 
part.  Pain  on  motion  is  still  great,  however,  and  without  treatment 
may  continue  for  a  week  or  two  ;  under  treatment  the  paroxysm  sab- 
sides  in  four  or  five  days. 

Both  great  toes  may  be  attacked  in  the  first  seizure,  more  often 
alternately  than  simultaneously,  and  sometimes  other  joints  than  those 
of  the  toes  are  affected. 

After  the  subsidence  of  an  attack  the  urine  contains  a  larger  quan- 
tity of  uric  acid,  and  the  patient  feels  better  in  health  and  spirits  than 
for  some  time.  A  second  attack  may  be  postponed  for  several  years, 
but  usually  after  that  the  intervals  between  them  steadily  dimmish, 
until  an  attack  recurs  every  few  weeks  or  months,  and  the  patient 
may  be  scarcely  ever  free  from  it.  Other  joints  than  the  toes,  particu- 
larly those  of  the  fingers,  become  involved  in  subsequent  attacks. 

The  Blood.  Neusser  has  attributed  to  gout  and  the  uric-acid  diath- 
esis the  presence  of  granules,  observed  after  staining,  in  the  white 
corpuscles,  but  they  have  been  found  in  other  affections,  and  are  not 
diagnostic.  The  nature  of  many  otherwise  obscure  gouty  manifesta- 
tions or  arthritic  changes  may  be  determined  by  an  examination  of  the 
serum  of  the  blood.  Collect  the  serum  which  accumulates  in  a  blister 
and  examine  for  uric  acid.     (See  Blood.) 

Chronic  gout  results  from  repeated  acute  attacks.  It  is  characterized 
by  deformity  of  the  affected  joints,  around  which  are  deposited  chalk- 
stones  (tophi)  of  sodium  urate.  Similar  deposits  occur  in  the  helix  of 
the  ear.  The  first  appearance  is  that  of  a  clear  vesicle  under  the  skin, 
which  subsequently  becomes  chalky-white  and  solid.  The  deposits  of 
sodium  urate  occur  not  only  in  the  cartilages  of  the  joints  but  in  the 
ligaments  and  bursas  also,  resulting  in  great  impairment  of  motion  and 
deformity.  "  In  extreme  cases  an  appearance  is  presented  by  the 
hand  very  closely  resembling  a  bundle  of  French  carrots  with  their 
heads  forward,  the  nails  appearing  to  take  the  place  of  the  stalks" 
(Garrod). 

Gouty  abscesses  consist  of  collections  of  liquid  and  solid  sodium  urate, 
which  discharge,  with  or  without  pus,  through  the  skin.  A  patient 
may  have  a  number  of  them  with  but  very  little  impairment  of  the 
general  health.     They  may  even  act  as  a  helpful  vent  to  the  system. 

In  so-called  retrocedmt  gout  the  external  joint-manifestation  is  sup- 


THE  DATA  OBTAINED  BY  OBSERVATION.  185 

pressed  or  replaced  by  an  internal  inflammation,  as  one  of  the  serous 
membranes. 

Gout  attacks  the  nervous  system,  causing  headache,  delirium,  and 
sometimes  apoplexy,  apoplectiform  seizures,  epilepsy,  mania,  various 
neuralgias,  and  spinal  symptoms. 

It  also  affects  the  heart  and  bloodvessels,  causing  valvulitis  and  chronic 
arteritis. 

The  symptoms  presented  by  the  digestive  organs  have  been  men- 
tioned.    They  are  often  premonitory  of  an  attack. 

The  kidneys  may  be  affected,  causing  typical  contracted  kidney,  or 
there  may  be  chronic  cystitis  and  urethritis. 

Rheumatoid  Arthritis. 

Rheumatoid  arthritis,  or  rheumatic  gout,  is  an  affection  characterized 
by  acute  or  chronic  inflammation  of  the  joints,  of  progressive  charac- 
ter, and  resulting  in  deformities.  It  is  attended  with  very  little  fever, 
and  occurs  apart  from  any  known  systemic  disease. 

It  may  be  acute  or  chronic.  The  acute  form  differs  but  little  in  its 
manifestations  from  acute  rheumatic  fever.  Several  joints  are  en- 
larged, tender,  and  painful.  Constitutional  symptoms,  such  as  fever, 
loss  of  appetite,  frequent  pulse,  thirst,  and  furred  tongue,  occur  as  in 
rheumatism.  Profuse  acid  sweats,  however,  are  absent,  and  so  is  the 
tendency  to  serous  inflammations.  Moreover,  while  the  larger  joints,  as 
in  rheumatism,  may  be  affected,  the  smaller  ones  also,  especially  of  the 
fingers  and  toes,  are  inflamed  and  often  the  seat  of  serous  effusions. 
Furthermore,  the  inflammation  persists  in  the  affected  joints  and  does 
not  jump  from  one  to  another.  Instead  of  disappearing  in  a  few 
weeks,  it  drags  on  for  a  much  longer  time.  The  pain  subsides,  but 
the  swelling  persists,  and  permanent  deformity  results  in  at  least  some 
of  the  joints.  The  muscles  of  the  arms  and  legs  waste  and  are  affected 
with  painful  spasms. 

The  disease  is  most  common  in  young  women  exhausted  by  repeated 
pregnancies  or  prolonged  lactation,  and  is  favored  by  poverty,  priva- 
tion, and  cold. 

The  chronic  form  is  much  more  common.  It  also  attacks  most  fre- 
quently young  women  who  are  exhausted  or  are  subjected  to  great 
fatigue.  There  is  pain,  numbness,  or  formication  in  a  joint,  as  the 
knee.     The  joint  becomes  tender,  painful,  and  may  be  slightly  swollen. 

This  subsides  after  a  while,  but  sooner  or  later  the  same  joint  or 
another  one  becomes  affected,  the  process  is  persistent,  one  joint  after 
another  is  attacked,  and  gradually  all  the  joints  may  become  greatly 
distorted,  enlarged,  and  the  seat  of  contractions.  There  may  be  no 
impairment  of  general  health,  or,  at  most,  only  dyspeptic  symptoms. 
The  progress  is  interrupted  by  remissions  from  time  to  time.  Pain 
may  be  severe  and  subject  to  nocturnal  exacerbations.  The  shape  of 
the  joints  is  altered  by  the  effusion  into  the  joints  and  adjacent  bursa?, 
by  thickening  of  the  tissues  around  the  joints,  growths  of  new  bone  on 
the  joint-extremity  of  the  bones,  absorption  of  the  articular  cartilages, 
and  growths  of  new  cartilage  in  the  synovial  sheaths,  relaxation  of 


186  GENERAL  DIAGNOSIS. 

ligaments,  muscular  contractures,  and  luxation  of  the  joints.  The 
joints  crack  and  creak  like  rusty  hinges,  are  sore  and  stiff,  and  the 
attached  muscles  are  affected  with  painful  cramps.     (See  Fig.  29.) 

Fig.  29. 


Rheumatoid  arthritis. 


Great  enlargement  of  the  joints  at  times  occurs  from  the  causes 
already  mentioned  and  from  infiltration  of  the  overlying  tissues.  The 
enlargement  is  rendered  more  conspicuous  by  the  atrophy  of  adjacent 
muscles.     (See  Fig.  14.) 

In  addition  to  the  articular  symptoms  other  phenomena  attend  the 
process.  One  of  the  more  common  is  increased  frequency  of  the  pulse. 
Although  the  patient  is  afebrile,  the  average  pulse-rate  is  100  to  120, 
or  even  more.  Moreover,  the  pulse  is  soft  and  compressible,  in  con- 
tradistinction to  the  pulse  of  gout  and  rheumatism.  It  is  worth  noting 
that  a  return  to  the  normal  frequency  of  pulse  is  a  sign  that  the  pro- 
cess of  the  disease  is  arrested,  although  the  joint-lesions  remain. 

The  skin  is  characteristic.  It  is  soft  and  often  much  freckled,  while 
the  complexion  is  fair.  C.  T.  Griffiths  has  observed  the  pigmentary 
cutaneous  changes,  along  with  neural  symptoms,  prior  to  the  joint- 
manifestations,  and  describes  two  forms  :  a  diffuse  melasmic  discolora- 
tion, and  dark-brown  spots  resembling  moles,  but  not  raised.  Moist- 
ure of  the  skin  with  clamminess  is  common.  It  is  limited  to  the  palms 
of  the  hands,  or  may  occur  in  the  distribution  of  certain  nerves.  The 
sweats  are  not  acid  ;  they  are  usually  local,  but  may  be  profuse.  Pain 
independent  of  the  joint-lesion  is  due  to  neuritis,  and  may  precede  the 
joint-trouble.  It  is  not  merely  confined  to  the  nerve-trunks,  but  affects 
the  smaller  branches  which  are  distributed  to  muscles,  as  the  base  of 
the  thumb.     Numbness  and  tingling  are  often  present. 

The  progress  of  the  disease  is  pretty  steadily  worse.  In  extreme 
cases  not  only  are  the  limbs  crippled,  deformed,  and  helpless,  but  there 
is  fixation  of  the  cervical  spine  and  of  the  articulations  of  the  jaw,  so 
that  the  patient  cannot  move  the  head  or  masticate  food. 


THE  DATA  OBTAINED  BY  OBSERVATION.  187 

The  following  describes  the  characteristic  deformity  of  the  hand  : 
The  first  phalanx  of  the  fingers  is  either  flexed  upon  the  metacarpus  or 
extended,  and  the  terminal  phalanx  in  like  manner  is  either  markedly 
flexed  or  extended  upon  the  second,  or  these  two  phalanges  are  kept 
at  a  straight  line,  while  the  first  phalanx  is,  as  usual,  decidedly  flexed 
upon  the  metacarpus.  The  hand  is  pronated  and  the  fingers  turn 
toward  the  ulnar  side  (Palmer  Howard  and  Charcot).     (See  Fig.  29.) 

The  foot  is  abducted  and  flattened,  and  the  great  toe  abducted  across 
and  above  the  other  toes.  Rarely  it  may  be  beneath  the  other  toes. 
The  metatarso-phalangeal  joint  is  enlarged. 

.  A  variety  of  the  disease  is  sometimes  met  with,  chiefly  in  old  persons 
(senile  arthritis),  in  which  the  tendency  is  to  involve  one  or  two  joints, 
particularly  the  hip,  or  hip  and  knee.  It  is  of  slow  progress,  and  is 
otherwise  attended  with  the  same  deformities  as  the  usual  polyarticular 
form. 

Rheumatoid  arthritis  is  distinguished  from  gout  by  the  absence  of 
heredity  and  by  its  development  under  the  exhausting  influences  of 
repeated  pregnancies,  lactation,  poverty,  and  malnutrition.  Rheuma- 
toid arthritis  is  progressive,  with  occasional  remissions  ;  gout  occurs 
in  successive  attacks,  with  intermissions.  Uric  acid  is  absent  from  the 
blood  in  the  former  and  is  present  in  gout.  Rheumatoid  arthritis  in 
the  vast  majority  of  cases  is  subacute  or  chronic.  The  acute  form  is 
distinguished  from  acute  gout  by  the  duration  of  the  paroxysm  and  the 
absence  of  intermissions  ;  by  there  being  less  heat,  swelling,  and  red- 
ness of  the  joints,  and  less  infiltration  of  the  soft  parts  ;  by  the  fact 
that  large  and  small  joints  are  involved,  and  that  there  is  no  special 
tendency  to  inflammation  of  the  great  toe. 

From  chronic  gout  rheumatoid  arthritis  is  distinguished  by  the 
absence  of  hereditary  predisposition,  of  repeated  acute  attacks,  and  of 
the  causes  of  gouty  paroxysms — indulgence  in  sugars,  acids,  malt 
liquors,  etc.  Moreover,  rheumatoid  arthritis  most  frequently  begins 
in  the  hands,  and  is  symmetrical  and  bilateral.  Gout  has  a  predilec- 
tion for  the  great  toe,  and  is  unilateral,  x^gain,  gout  attacks  well-fed 
males  most  frequently  after  the  age  of  thirty  years,  while  rheumatoid 
arthritis  tends  to  attack  women  under  the  depressing  influences  already 
mentioned.  It  may,  however,  occur  in  both  sexes,  and  even  be  asso- 
ciated with  gout. 

Rheumatic  fever  is  distinguished  from  acute  rheumatoid  arthritis  by 
its  tendency  to  involve  the  larger  joints,  its  erratic  course,  acid  sweats, 
and  heavy  deposits  of  urates  from  the  urine,  its  shorter  course,  its  ten- 
dency to  heart-complications,  and  its  subsidence  without  impairment  of 
the  usefulness  of  the  joints. 

Chronic  articular  rheumatism  is  distinguished  by  the  preceding  his- 
tory, the  tendency  to  seasonal  exacerbations,  by  its  involving  fewer 
joints,  and  not  being  so  symmetrical  in  the  joints  affected.  It  does  not 
produce  so  great  deformity  as  is  common  in  rheumatoid  arthritis,  nor  is 
it  so  likely  to  affect  the  vertebra?  and  jaws.  The  existence  of  valvular 
heart  disease  or  a  history  of  antecedent  chorea  is  in  favor  of  rheumatism. 

The  joint-affections  of  locomotor  ataxia  are  distinguished  by  the  asso- 
ciated  symptoms   of    incoordination   and    absent    knee-jerk,   by   their 


188  GENERAL  DIAGNOSIS. 

sudden  onset  without  pain  or  fever,  by  the  occurrence  of  large  effusion 
into  the  joint,  with  subsequent  disorganization,  fractures,  and  dislo- 
cations. 

■  Gonorrhoea!,  arthritis  is  distinguished  by  the  history  of  gonorrhoea 
or  the  existence  of  a  discharge  from  the  urethra,  by  the  tendency  of 
the  disease  to  attack  the  larger  joints,  particularly  the  knee  or  shoul- 
der, and  to  become  fixed  in  one,  not  wandering  from  one  to  another. 
The  affected  joint  suffers  effusion,  and  the  synovial  membranes  and 
bursse  are  inflamed.  The  process  is  very  chronic  but  indolent,  and 
the  heart  rarely  becomes  affected. 

Scurvy. 

The  joints  are  swollen,  painful,  and  tender  in  about  one-third  of  all 
cases  of  scurvy.  When  to  these  joint-symptoms  the  spongy  gums,  the 
hemorrhages,  the  anaemia,  and  cachexia  are  added,  scurvy  may  be' 
suspected. 

Scorbutus,  or  scurvy,  is  a  constitutional  condition  brought  about 
by  a  long-continued  diet  deficient  in  fresh  vegetables.  It  is  character- 
ized by  pallor,  great  physical  weakness  and  mental  sluggishness, 
dyspnoea,  subcutaneous  and  submucous  hemorrhages,  a  swollen,  spongy 
condition  of  the  gums,  and  a  brawny  induration,  especially  of  the  calves 
and  hams. 

The  onset  of  the  disease  is  gradual,  and  is  marked  by  a  peculiar 
dirty-yellow  or  greenish  pallor  of  the  face,  associated  soon  with  an 
apathetic  expression  of  the  face,  physical  iveakness,  and  decided  lack  of 
customary  energy.  The  appearance  is  so  characteristic  that  patients 
are  said  to  detect  it  readily  in  others,  though  unaware  of  it  themselves. 
Sleep  and  digestion  are  good,  but  rheumatoid  pains  may  be  complained 
of.  Other  prominent  subjective  symptoms  are  fatigue  on  slight  exer- 
tion, dyspnoea,  faintness,  and  despondency.  In  the  course  of  a  week 
or  two  petechia)  appear  upon  the  lower  extremities,  especially  around 
a  hair  as  the  centre.  (See  page  128.)  Depending  upon  the  severity  of 
the  case  there  are  also  bulla?,  vibices,  and  ecchymoses.  Brawny  indu- 
ration, due  to  deep  effusion  of  blood,  occurs,  especially  in  the  calves 
and  hams,  producing  considerable  pain  on  flexure  of  the  knees. 

There  is  no  fever  apart  from  complications.  The  pulse  is  frequent, 
weak,  and  small,  and  the  first  sound  of  the  heart  and  the  impulse  may 
be  very  faint. 

The  face  is  swollen  and  of  a  dirty,  possibly  greenish-yellow  color, 
according  to  Bird,  Buzzard,  and  others  ;  in  some  cases  the  eye  and  its 
surroundings  are  the  only  parts  exhibiting  signs  of  scurvy  at  this  time. 
"  The  integument  around  one  or  both  orbits  is  puffed  up  into  a  bruise- 
colored  swelling.  The  conjunctivae  covering  the  sclerotic  is  tumid  and 
of  a  brilliant  red  color  throughout,  and  about  an  eighth  of  an  inch  in 
thickness  or  elevation  above  the  cornea,  leaving  the  cornea  at  the 
bottom  of  a  circular  trench  or  well."  l  The  condition  is  not  inflam- 
matory.    These  cases  often  terminate  fatally. 

1  Buzzard:  Reynolds'  System  of  Medicine,  1880,  vol.  i.  p.  451. 


THE  DATA  OB  TAINED  B  Y  OB  SEE  VA  TION.  189 

The  gums  swell  almost  always,  become  spongy,  and  bleed  upon  the 
slightest  irritation.  They  are  dark  cherry-red  in  color  and  look  not 
unlike  a  split  cherry.  Sometimes  they  swell,  so  as  almost  to  hide  the 
teeth  completely  and  even  to  protrude  the  lips.  The  breath  has  a 
heavy,  sickening  odor,  and  the  teeth  sometimes  drop  out  of  their  sockets. 

In  addition  to  the  cutaneous  and  gingival  hemorrhages,  hemorrhages 
occur  from  the  nose  and  other  mucous  surfaces,  and  effusions  take  place 
into  the  lungs,  intestines,  pericardium,  and  pleura,  associated  with  in- 
flammatory products.  There  may  be  no  physical  signs  on  the  part  of 
the  lungs  to  account  for  the  dyspnoea,  or  some  dulness  and  bronchial 
breathing,  or  a  few  rales,  may  be  detected. 

A  very  peculiar  symptom,  and  sometimes  the  earliest,  is  hemeral- 
opia,  nyctalopia,  or  night-blindness,  in  which  the  patient  can  see  during 
the  day  but  not  by  moonlight,  and  apart  from  artificial  light  is  totally 
blind  at  night. 

So-called  scurvy-rickets  is  more  or  less  common  in  infants  fed  on  arti- 
ficial food  exclusively  or  on  sterilized  milk.  It  is  therefore  limited 
to  the  first  four  or  five  years.  The  symptoms  of  scurvy  are  added  to 
those  of  rhachitis.  In  the  eight  cases  I  have  seen,  the  most  pronounced 
features  were  those  of  weakness,  ansemia,  polyuria,  restlessness,  the 
scorbutic  gums,  local  periostitis,  particularly  of  the  tibia,  sometimes 
periarticular  inflammation,  and  always  a  general  tenderness  of  the 
body,  as  in  rhachitis. 

The  Tabetic  Joint.  In  forms  of  nervous  diseases,  particularly  in 
sclerosis  of  the  posterior  columns,  secondary  joint-involvement  some- 
times occurs.  The  change  in  the  large  joints  is  preceded  by  pain, 
stiffness,  and  inability  to  use  them.  Gradually  nutritive  changes  take 
place.  At  first  there  is  boggy  swelling.  The  cartilages  become  eroded, 
the  heads  of  the  bone  waste,  the  ligaments  ossify,  and  irregular  bony 
growths  project.  Wasting  of  the  head  of  the  femur  is  followed  by 
dislocation.  Sometimes  an  effusion  takes  place  in  the  joints,  and  there 
may  be  periarticular  oedema.  The  large  joints  are  most  commonly 
affected — the  knee,  hip,  ankle,  and  elbow.  Injury  excites  the  abnor- 
mal atrophic  process.  When  the  tarsal  bones  and  the  articulations  are 
affected  the  foot  becomes  flat,  and  the  tarsal  and  metatarsal  articulation 
and  the  tarsal  bones  project  forward  or  backward.  This  is  called  the 
tabetic  foot. 

The  Joint  of  Hysteria.  Symptoms  of  joint-disease  are  seen  in 
hysteria.  Pain  and  fixation  of  the  joint  are  sometimes  complained  of. 
The  joint  rarely  undergoes  organic  changes,  but  sometimes  a  plastic 
infiltration  of  the  connective  tissue  outside  of  the  capsule  does  occur. 
The  hysterical  nature  of  the  pain  and  immobility  are  recognized  by 
the  absence  of  a  cause  for  joint-lesion,  the  absence  of  fluctuation,  or  of 
signs  due  to  erosion,  by  the  association  of  the  local  symptoms  with  the 
phenomena  of  hysteria,  but,  more  particularly,  by  the  fact  that  con- 
traction and  even  wasting  precede  the  joint-symptoms.  In  true  affec- 
tions of  the  joint  both  occur  after  the  joint  has  become  diseased  ;  in 
hysteria  muscular  contraction  will  take  place  first. 

The  knee  is  the  joint  usually  affected.  Care  must  be  taken  not  to  be 
deceived  by  local  vasomotor  changes  of  hysterical  origin  which  may 


190  GENERAL  DIAGNOSIS. 

be  observed  under  the  surface  of  the  joint.  This  local  increased  tem- 
perature is  not  associated  with  general  fever,  however,  while  the  vaso- 
motor changes  indicated  by  the  swelling  of  the  skin,  increased  tension, 
and  the  shining  appearance,  with  increased  sensibility,  are  not  per- 
sistent, but  occur  once  or  twice  in  the  twenty-four  hours.  In  a 
remarkable  case  of  Mitchell's  the  local  vasomotor  change  took  place 
at  night.  The  temperature  of  the  knee  which  was  affected  increased 
three  or  four  degrees,  while  the  pulse  remained  at  80.  The  local  symp- 
toms of  heat,  redness,  swelling,  tension,  and  increased  pain  passed 
away  by  three  o'clock  in  the  morning.  The  fact  that  the  same  symp- 
toms could  be  brought  on  by  handling  the  knee,  or  by  pressure  upon 
the  patella,  pointed  to  its  vasomotor  origin. 

In  joint-cases  of  hysterical  origin  the  reflexes  must  be  studied. 
They  do  not  change,  and  the  electrical  reactions  are  normal,  although 
there  may  be  atrophy  from  disuse,  but  not  to  the  degree  that  occurs 
in  organic  disease.  The  muscles  may  be  contracted,  but,  as  previously 
noted,  the  contracture  is  primarily  a  relaxation,  which  takes  place  if 
the  tension  is  removed.  Concerning  these  vasomotor  changes,  Sir  James 
Paget's  expression,  "  A  joint  which  is  cold  by  day  and  hot  by  night 
is  not  an  inflamed  joint,"  is  a  safe  guide  to  the  recognition  of  an  hys- 
terical joint.  When  the  joint  becomes  hysterical  after  injury  it  is  most 
difficult  to  ascertain  its  true  nature. 

Special  Joints.  The  three  joints  that  should  concern  the  student 
more  particularly  are  the  shoulder,  hip,  and  knee.  When  symptoms 
are  referred  to  either  of  these  joints  they  should  not  be  passed  over 
lightly.  Grave  consequences  have  followed  the  attributing  of  hip- 
joint  inflammation  to  rheumatism  when  it  was  of  tuberculous  origin. 
Not  only  has  hip-joint  disease  been  mistaken  for  rheumatism,  but  the 
mistake  has  even  been  made  of  considering  the  process  to  be  going  on 
in  the  knee  instead  of  in  the  hip.  This  is  because  there  is  often  flexion 
of  the  leg,  and  because  pain  is  so  often  referred  to  the  knee-joint. 

On  the  other  hand,  cases  of  hip-joint  disease  have  been  mistaken  for 
suppuration  in  the  pelvis  or  in  the  iliac  fossa.  Typhlitis  or  appendi- 
citis has  frequently  been  mistaken  for  hip-joint  disease. 

In  the  case  of  the  shoulder- joint  there  is  danger  of  confounding 
neuritis  of  the  circumflex  nerve,  and  consequent  paralysis  of  the  del- 
toid, with  affections  of  the  joint.  Although  the  patient  is  unable  to 
move  the  joint,  it  is  still  readily  moved  by  the  physician,  and  the 
physical  signs  of  joint-inflammation  are  wanting. 


CHAPTER    XIV. 

THE  DATA  OBTAINED  BY  OBSERVATION— {Continued). 

Chills  ;  fever  ;   subnormal  temperature. 

THE  TEMPERATURE. 

Before  discussing  the  subject  of  fever,  it  is  not  illogical  to  consider 
chills. 

Chills. 

"  Chills  "  vary  from  a  passing  "  creep  "  or  cold  sensation,  extending 
up  and  down  the  spine,  to  the  "  shake  "  or  true  rigor  of  one-half  hour 
or  even  longer.  In  infectious  diseases  the  milder  form  is  of  as  much 
significance  as  the  more  severe.  The  rigor  may  be  so  violent  and  pro- 
longed as  to  terminate  fatally.  It  must  be  distinguished  from  the 
algid  stage  of  cholera  and  the  coldness  of  collapse.  The  chill  is 
attended  by  general  tremor  or  shaking,  chattering  teeth,  cold  extremi- 
ties, pallid  face,  often  parched  blue  lips  and  finger-tips.  Notwithstand- 
ing the  peripheral  coldness  and  the  extreme  sensation  of  cold,  the  in- 
ternal temperature  rises,  and  may  be  104°  to  107°. 

Clinically,  a  chill  or  rigor  marks  the  onset  of  severe  infection,  as 
pneumonia.  "  Chills  "  are  symptoms  of  some  affections,  as  malaria. 
They  are  seen  in  the  course  of  many  diseases,  as  typhoid  fever,  tuber- 
culosis, and  septicemia.  In  typhoid  fever  they  disclose  the  occurrence 
of  a  secondary  infection  or  a  mixed  infection  ;  they  may  be  due  to 
antipyretic  treatment  by  coal-tar  remedies  (Osier)  or  result  from  con- 
stipation. Endocarditis  is  attended  by  daily  chills  or  they  occur  at 
irregular  intervals.  Pysemia  and  septicaemia,  purulent  inflammations 
( infections),  inflammations  of  the  biliary  or  renal  passages,  stone  in  the . 
biliary  canal,  or  the  pelvis  of  the  kidney  (see  Intermitting  Fever)  are 
frequently  attended  by  chills.  The  morphine  habit  gives  rise  to  chills, 
with  some  fever. 

Fever. 

In  conditions  of  health  the  body-temperature  is  maintained  con- 
stantly at  about  98.6°  F.  (37°  C). '  This  stability  of  temperature  is 
due  to  the  central  regulating  apparatus  called  the  thermotaxic  mechan- 
ism, which  controls  the  production  and  the  dissipation  of  heat.  Fever 
is  a  condition  characterized  by  an  increase  of  temperature,  with  usually 
increased  disintegration  of  nitrogenous  tissue.  The  muscles  and  large 
glands,  as  is  well  known,  are  the  chief  seat  of  heat-production.  Both 
heat-production  and  heat-dissipation  are  believed  to  be  under  the 
control  of  the  nervous  system,  either  through  the  motor  nerves  or 


1 92  GENERAL  DIA  GNOSIS. 

special  nerves  which  pass  with  them  to  and  from  definite  centres  in 
the  brain,  called  heat-centres.  In  conditions  of  disease  this  thermo- 
taxic  mechanism  may  be  altered,  so  that  the  normal  temperature  is 
increased  or  lessened.  (1)  There  may  be  elevation  of  temperature 
from  diminished  dissipation  of  heat,  though  not  necessarily  increased 
nitrogenous  disintegration  and  disordered  function.  Or  (2)  there  may 
be  increased  production  of  heat  with  diminished  dissipation,  hence  the 
temperature  will  naturally  be  higher  than  if  increased  heat-production 
were  accompanied  by  normal  heat-dissipation.  (3)  There  may  be  in- 
creased heat-production  and  at  the  same  time  increased  heat-dissipation, 
in  which  case  there  would  be  the  increased  waste  of  fever  with  or 
without  any  elevation  of  temperature.  (4)  It  is  possible  that  heat-dis- 
sipation may  be  greater  than  heat-production,  or  that  the  thermotaxic 
mechanism  may  be  disturbed,  so  as  to  promote  loss,  in  which  case 
there  will  be  subnormal  temperature. 

Mode  of  Determination  of  Fever.  The  temperature  of  the  body 
can  be  roughly  estimated  by  the  hand  of  the  physician,  but  this  method 
is  open  to  many  sources  of  error.  The  skin  is  at  times  hot,  and  gives 
a  deceptive  sensation  of  considerable  elevation  of  temperature,  whereas 
when  tested  by  the  thermometer  the  temperature  is  found  to  be  but 
slightly  or  not  at  all  above  normal.  So,  too,  when  the  skin  feels  cold 
and  clammy  in  phthisis  and  during  a  chill  from  any  cause,  the  actual 
temperature  of  the  body  is  decidedly  above  normal,  and  may  be  as 
high  as  103°  or  104°.  To  insure  accuracy,  therefore,  it  is  now  almost 
the  universal  custom  to  employ  clinical  thermometers.  They  are  of  a 
convenient  size  and  shape  for  insertion  under  the  arm  or  into  the 
mouth,  rectum,  or  vagina.  The  better  ones  are  provided  with  an  inde- 
structible index,  so  that  the  mercury  in  the  capillary  tube  remains 
stationary  at  the  highest  level  to  which  it  rose  when  the  thermometer 
was  in  the  mouth  or  axilla.  When  not  provided  with  such  an  index 
the  reading  must  be  made  when  the  thermometer  is  still  in  position. 

Thermometers  vary  in  the  accuracy  with  which  they  register  tem- 
perature. The  best  ones  are  compared  with  an  acknowledged  standard, 
and  sold  with  a  slip  of  paper  which  gives  their  fractional  variations 
from  the  standard.  When  the  exact  temperature  is  a  matter  of  great 
importance,  it  should  be  taken  in  the  rectum  or  vagina,  as  their  tem- 
perature is  more  nearly  that  of  the  body.  It  is  of  advantage  to  take 
the  temperature  in  the  rectum  of  children  or  in  patients  who  are  coma- 
tose. This  situation  is  also  a  good  one  to  select  when  a  bath  is  being 
administered.  If  possible,  scybalous  masses  should  be  removed  from 
the  rectum.  At  least  an  incorrect  reading  may  be  obtained  if  the  ther- 
mometer should  happen  to  be  plunged  into  the  faeces  ;  this  must  be 
guarded  against.  From  motives  of  delicacy,  however,  the  axilla  is  to 
be  preferred  to  the  rectum  and  vagina  on  all  ordinary  occasions.  The 
temperature  it  records  is  somewhat  less  than  a  degree  below  that  of  the 
rectum.  The  temperature  of  the  mouth  is  above  that  of  the  axilla  and 
below  that  of  the  rectum.  It  has  some  advantages  over  that  of  the 
axilla,  being  more  accessible  and  recording  the  temperature  more 
quickly  and  more  accurately.  Nevertheless,  as  the  physician's  ther- 
mometer  is   carried  from  patient   to   patient,  some   place  should  be 


THE  DATA  OBTAINED  BY  OBSERVATION.  193 

selected  which  is  less  capable  of  absorbing  disease-gemis  than  the 
mouth.  The  axilla  is,  therefore,  by  common  consent  the  usual  place 
for  taking  the  temperature.  Observe  two  precautions  :  (1)  Before 
introducing  the  thermometer  see  that  there  is  no  undue  moisture  ;  if 
there  is,  the  axilla  should  be  wiped  dry,  otherwise  a  lower  than  a  true 
reading  will  be  obtained.  (2)  See  that  the  instrument  is  inserted  into 
the  armpit  and  does  not  project  beyond  the  posterior  fold,  and  that  it 
is  not  caught  in  a  fold  of  the  undershirt  or  night-dress.  After  the 
thermometer  is  in  position  the  arm  should  be  brought  gently  across  the 
chest  and  kept  in  that  position  until  the  instrument  is  withdrawn. 
The  arm  should  not  be  held  rigidly,  as  such  muscular  action  increases 
the  hollow  of  the  armpit  and  may  keep  the  sides  apart,  instead  of  in 
contact,  as  they  should  be  to  make  a  correct  reading.  The  length  of 
time  required  to  take  the  axillary  temperature  will  depend  upon  the 
instrument  used  ;  generally  from  five  to  eight  minutes  are  required. 
Some  very  delicate  thermometers  register  in  one  minute,  but  they  are 
too  fragile  for  ordinary  use.  If  the  index  is  in  such  a  position  that  it 
can  be  seen,  it  is  proper  to  withdraw  the  thermometer  when  the  mer- 
cury has  ceased  to  rise  for  two  minutes. 

The  index,  of  course,  must  be  shaken  down  to  normal,  or  slightly 
below  normal,  before  the  thermometer  is  again  ready  for  use ;  and  the 
instrument  must  be  carefully  cleansed  after  use. 

In  children  who  are  restless  the  temperature  may  be  taken  in  the 
groin,  as  the  folds  of  fat  readily  admit  of  completely  enveloping  the 
bulb  of  the  thermometer.  The  height  to  which  the  mercury  rises 
will  correspond  to  the  temperature  of  the  axilla.  The  temperature  of 
the  urine  corresponds  exactly  with  that  of  the  body,  if  taken  when 
freshly  passed  and  during  the  act,  a  method  only  applicable  in  the 
case  of  males.  Sometimes  this  method  of  securing  the  temperature  is 
resorted  to,  particularly  in  patients  who  may  act  as  malingerers,  when 
it  is  desirable  to  have  the  temperature  taken  in  the  physician's 
presence. 

If  the  mouth  is  selected  as  the  place  in  which  the  temperature  is  to 
be  taken,  care  should  be  exercised  that  the  thermometer  is  placed 
under  the  tongue,  or  along  its  side  between  it  and  the  lower  jaw,  and 
retained  in  position  by  the  lips  of  the  patient.  If  the  teeth  are  set 
firmly  on  the  thermometer,  it  maybe  broken,  or,  what  is  of  still  greater 
importance,  it  will  be  tilted  out  of  position  and  a  correct  reading  will 
not  be  obtained.  The  lips  should  be  closed  and  breathing  be  carried 
on  through  the  nostrils.  Four  to  seven  minutes  is  sufficient  time  to 
allow  it  to  remain  in  position.  The  patient  should  not  have  taken  ice 
or  anything  cold  prior  to  the  observation. 

Observations  of  the  temperature  should  be  made  at  least  twice  a 
day,  in  the  morning  and  evening,  and,  as  far  as  possible,  at  the  same 
hour  on  successive  days.  It  is  frequently  desirable  to  have  the  tem- 
perature taken  every  two  or  three  hours,  and  sometimes  at  more  fre- 
quent intervals.  This  is  particularly  the  case  if  observations  of  the 
indications  for,  and  the  effect  of,  antipyretic  treatment  are  to  be  made. 

In  obscure  cases  the  observations  should  be  repeated  at  night  as  well 
as  during  the  day.      In  this  manner  the  presence  of  unsuspected  tuber- 

13 


194 


GESEEAL  DIAGXOSIS. 


culosis  may  be  revealed,  or  the  occurrence  of  suppuration  in  some  por- 
tion of  the  body  definitely  determined.  It  should  not  be  forgotten, 
however,  that  the  temperature  may  be  taken  too  frequently  for  the 
patient's  good,  the  disturbance  of  his  needed  rest  being  distinctly 
harmful. 

As  the  general  range  of  temperature  and  its  diurnal  variations  are  of 
more  importance  than  the  absolute  temperature  at  any  one  time,  ther- 
mometers not  perfectly  accurate  in  their  reading  are  still  good  enough 
for  clinical  and  therapeutic  purposes. 

Physiological  Variations  of  Temperature.  The  temperature  is 
subject  to  physiological  variations.  1.  It  rises  from  seven  or  eight  in 
the  morning  until  seven  or  eight  in  the  evening,  at  which  time  it 
reaches  its  maximum.  It  then  begins  slowly  to  fall,  reaching  its  lowest 
point  in  the  early  hour-  of  morning,  between  two  and  four.  This 
diurnal  fluctuation  does  not  usually  amount  to  more  than  a  degree.  2. 
Exercise,  etc.  Violent  exertion  rai-es  the  temperature,  and  so  does  a 
heated  atmosphere,  cold  having  a  contrary  effect.  3.  Age.  In  infants 
and  voting  children,  up  to  puberty,  the  temperature  has  a  somewhat 
higher  range,  and  is  subject  to  greater  variations  than  at  a  later  period. 
In  verv  old  persons  the  temperature  may  be  subnormal.  The  normal 
axillary  temperature  of  adults  is  98.6 z  F.  The  period  in  the  twenty- 
four  hour's  in  which  the  temperature  is  at  its  lowest  ebb  is  from  12 
p.m.  to  4  a.m.  It  may  then  be  subnormal.  The  writer  has  known 
an  over-cautious  parent  to  make  this  physiological  fall  the  subject  of 
meddlesome  observation  and  ill-judged  treatment. 

Pathological  Variations  of  Temperature.  An  elevation  of  tem- 
perature above  the  normal,  not  to  be  accounted  for  by  external  heat  or 
severe  exhaustion,  may  be  considered  febrile,  and  is  pathological. 
The  range  of  febrile  temperature  varies  from  above  normal  to  105°  or 
106 c  in  ordinary  cases.  A  range  above  106 c  may  occur,  but  is  not 
usuallv  compatible  with  life.  Certain  terms  have  been  applied  to 
various  degrees  of  temperature,  to  indicate  in  a  general  way  the  degree 
of  fever  : 

Very  low  or  collapse  temperature. 

Subnormal  temperature. 

Xormal  temperature. 

Slightly  aboye  normal  or  sub-febrile  temperatures. 


Below 

(  35°  Cent 
|36      " 

.=  95.0° 
=  96.8 

Fah. 

About 

36^ 

" 

=  97.7 

" 

Normal 

37 

it 

=  9S.6 

it 

(37* 
\  38 
(38  i 

u 

=  99.5 

a 

About 

n 

=100.4 

a 

=101.3 

a 

About 

(39 

I 39} 

a 
it 

=102.2 
=103.1 

« 

About 

f  40 
I  40] 

" 

=104.0 
=104.9 

Aboye 

41 

=105.8 

<< 

Moderately  febrile  temperature. 

Highly  febrile  temperature. 

Hyperpyretie  temperature. 

From  Futlatsoh. 

The  Degree  of  Danger.     In  general  the  degree  of  danger  to  the 

patient  increases  with  the  height  of  the  fever,  but  the  duration  of  the 
high  fever  modifies  this  greatly.  A  temperature  of  106  ~  on  the  second 
or  third  day  of  an  acute  lobar  pneumonia  i-  not  rare,  such  cases  fre- 


THE  DATA  OBTAINED  BY  OBSERVATION. 


195 


quently  ending  in  recovery,  while  a  temperature  of  105°  in  the  second 
or  third  week  of  typhoid  fever  is  of  much  graver  significance.  Da 
Costa  has  reported  a  case  of  cerebral  rheumatism  in  which  the  axillary 
temperature  reached  110°,  yet  the  patient  recovered.  In  the  case  of 
injury  of  the  spine,  reported  by  Teale,  the  extraordinary  temperature 
of  122°  was  recorded,  and  the  temperature-range  for  days  was  between 
112°  and  114°.     The  patient  recovered. 


Fig.  30. 


Malarial  intermittent  fever.    Quotidian  type. 


The  Types  of  Fever.     Fevers  are  divided,  in  accordance  with  the 
character  of  their  range,  into  certain  definite  types.     The  types  may 


Fig.  31. 


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Malarial  intermittent  fever.    Tertian  type. 


be  indicative  of  special  processes.     It  is  certain  that  the  recognition  of 
a  peculiar  type  forms  a  positive  aid  to  diagnosis.     The  fever  that  con- 


196 


GENERAL  DIAGNOSIS. 


tinues  for_  more  than  two  days,  in  which  the  difference  between  the 
daily  maximum  and  minimum  of  temperature  is  less  than  2°,  is  known 
as  continued  fever.  (See  Fig.  36.)  The  fever  existing  more  than  two 
days,  in  which  the  daily  difference  is  greater  than  2°,  is  known  as 
remittent  fever.  Further,  a  fever  in  which  there  is  a  rise  of  temper- 
ature followed  by  a  fall  to  or  below  the  normal,  occurring  periodically, 


Fig.  32. 


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Malarial  intermittent  fever.    Quartan  type. 

is  known  as  intermittent  fever.  The  paroxysms  may  occur  daily,  every 
second  or  third  day,  or  once  a  week.  When  the  paroxysms  occur 
daily,  the  intermittent  fever  is  of  quotidian  type  (see  Figs.  30  and  33)  ; 
every  second  day,  tertian  type,  one  day  intervening  without  fever  (see 
Fig.  37) ;  every  third  day,  quartan  type,  two  apyretic  davs  intervening 
(Fig.  32). 

The  Course  of  the  Fever.  Fevers  frequently  have  a  definite 
course,  known  as  (1)  the  initial  stage  ;  (2)  the  fastigium  ;  (3)  the 
period  of  defervescence.  During  the  initial  stage  the  temperature  rises 
higher  each  hour  (or  if  extended  over  days,  each  day)  than  the  pre- 
ceding hour  or  clay — in  this  latter  instance  interrupted  by  the  daily 
fluctuations.  The  stage  may  last  from  a  few  hours,  as  in  a  paroxysm 
of  _  intermittent  fever,  to  four  or  five  days,  as  in  typhoid  fever.  "  In 
this  stage  we  have  a  chill  such  as  characterizes  the  onset  of  an  inter- 
mittent fever,  or  the  recurrent  chills  or  chilliness  with  headache  and 
backache  that  attend  the  first  four  or  five  days  of  typhoid  fever. 
During  this  stage,  also,  the  heat-dissipation  from  the  cutaneous  surface 
is  diminished  and  the  total  heat-dissipation  is  less.  When  the  hand 
is  placed  upon  the  patient  the  surface  will  be  found  to  be  cool,  whereas 


THE  DA  TA  OB  TA INED  B  Y  OB  SEE  VA  TION.  197 

the  temperature  in  the  mouth  or  rectum  will  be  found  to  be  far  above 
the  normal.  The  patient  complains  of  the  coldness  or  chilliness,  and 
the  low  temperature  of  the  surface  is  indicated  by  the  shrunken  hand, 
the  pallid,  pinched  face.  The  peripheral  arteries  are  contracted,  and 
hence  cause  diminution  in  the  amount  of  blood  to  warm  the  skin  and 
to  compensate  for  the  loss  by  radiation  and  conduction.  This  peripheral 
contraction  is  the  cause  of  the  chilliness  and  the  fall  in  the  tempera- 
ture of  the  skin. 

During  the  second  period  of  the  course  of  pyrexia — the  fastigiwn — 
the  temperature  of  the  body  attains  the  highest  point,  and  remains 
almost  stationary,  or  may  vary  but  a  degree  or  two  between  maximum 
and  minimum.  It  may  last  a  few  hours  or  from  two  days  to  three  or 
more  weeks,  during  which  time  it  may  oscillate  to  the  maximum  point 
of  the  first  day.  The  temperature  of  the  surface  of  the  body  is  about 
the  same  as  that  of  the  deep  parts,  particularly  in  cases  of  pneumonia, 
measles,  and  scarlet  fever.  In  typhoid  fever,  acute  rheumatism,  and 
phthisis,  during  this  period,  there  may  be  a  difference  in  the  external 
temperature  and  the  temperature  taken  in  the  cavities,  as  the  mouth 
or  rectum.  More  or  less  antagonism  between  heat-production  and 
heat-loss  exists  under  these  circumstances.  The  latter  may  be  greater 
than  the  former,  if  the  skin  perspires  freely,  as  in  rheumatism.  The 
temperature  then  remaining  high  indicates  that  the  production  of  heat 
must  be  proportionately  increased,  and  hence  far  greater  than  in  the 
cases  in  which  the  external  and  internal  temperature  are  nearly  the 
same.  (See  Fig.  34  :  the  fastigium  here  occurs  in  the  first  three  days. 
In  Fig.  37  the  fastigium  lasts  until  the  crisis.) 

In  the  period  of  defervescence  the  temperature  falls  to  the  normal. 
In  this  period  an  attempt  is  made  by  the  economy  to  return  to  a  physi- 
ological state,  in  which  heat-production  and  heat-loss  are  evenly 
balanced.  The  state  of  pathological  pyrexia  has  come  to  an  end. 
The  termination  may  be  by  crisis.  (See  Figs.  31  and  37.)  When  this 
takes  place  the  perturbation  of  the  thermotaxic  mechanism  must  be 
very  great,  but  the  normal  state  is  at  once  resumed.  In  other  cases 
the  termination  is  by  lysis — the  temperature  falls  a  degree  or  two  each 
day  until  the  normal  is  reached.  (See  chart  of  Typhoid  Fever.)  It 
seems  that  the  thermotaxic  mechanism  of  health  is  restored  with  diffi- 
culty. In  some  cases,  in  the  period  of  defervescence,  the  aberrations 
are  very  remarkable.  It  seems  as  if  the  thermotaxic  mechanism  which 
controls  heat-loss  was  in  a  convulsive  state.  The  temperature  rises 
and  falls  irregularly,  gradually  resuming  the  normal  only  as  the 
strength  of  the  patient  increases. 

The  Mode  of  Onset ;  Initial  Stage.  The  onset  may  be  sudden  or 
gradual.  1.  The  sudden  onset  occurs  in  acute  diseases,  as  tonsillitis, 
pneumonia,  and  gastro-intestinal  disorders  of  children,  in  erysipelas, 
and  in  intermittent  fever.  Within  a  few  hours  the  maximum  of  tem- 
perature is  reached.  (See  Fig.  37.)  2.  The  mode  of  onset  may  be 
gradual.  The  initial  stage  is  prolonged  under  these  circumstances,  as 
in  cases  of  typhoid  fever.     (See  chart  of  Typhoid  Fever.) 

The  Mode  of  Decline  ;  the  Defervescence.  A  sudden  fall  of 
temperature  at  the  termination  of  a  disease  is  known  as  crisis,  which  is 


198  GENERAL  DIAGNOSIS. 

also  attended  by  copious  perspiration,  a  "  critical  sweat/'  or  by  the 
passage  of  a  large  quantity  of  urine,  and  sometimes  by  several  large 
liquid  stools.  The  pulse-rate  and  respirations  fall  correspondingly 
with  the  temperature.     (See  Fig.  37.) 

The  defervescence  may,  however,  occupy  several  days,  in  which  case 
it  is  called  lysis.  In  this  case  the  sweating  is  less  marked,  but  may 
recur  for  several  days.  The  slowing  of  the  pulse  and  respiration  like- 
wise take  place  gradually.     (See  chart  of  Typhoid  Fever.) 

Diseases  of  sudden  onset  usually  terminate  with  sudden  decline,  and 
conversely  in  diseases  with  a  prolonged  onset  the  decline  is  also  pro- 
longed. Many  cases  which  naturally  terminate  by  crisis  may  end  by 
lysis.  This  irregular  termination  is  usually  due  to  a  complication. 
(See  Fig.  34.)  For  instance,  in  measles,  pneumonia  is  usually  the 
causal  complication,  while  in  pneumonia  it  is  empyema  or  endocarditis. 

The  Daily  Range  of  the  Prolonged  Initial  Stage  and  the  Fas- 
tigium.  The  daily  range  of  the  temperature  in  fever  generally  corre- 
sponds to  the  normal  variations.  That  is,  the  temperature  is  higher 
in  the  evening  than  in  the  morning.  The  difference  in  the  daily  range 
varies  in  the  different  types  of  fever — generally,  as  previously  noted, 
the  continued  fevers  show  a  smaller,  the  intermitting  fevers  a  larger, 
difference  between  morning  and  evening  temperature. 

Sometimes  there  is  inversion  of  the  normal  range.  The  evening 
temperature  is  lower  than  the  morning  ;  although  a  rare  condition, 
this  is  of  serious  import.  It  is  seen  in  the  more  severe  cases  of  typhoid 
fever  and  occasionally  in  tuberculosis. 

Recrudescence.  In  many  cases  the  fever  returns  after  the  temper- 
ature has  fallen  to  the  normal.  This  may  occur  from  a  number  of 
causes.  It  may  be  from  perturbation  of  the  nervous  system,  on  account 
of  excitement,  over-exertion,  loss  of  sleep,  or  from  indigestion.  Slight 
aberrations,  which  in  health  would  not  modify  the  temperature,  cause 
pronounced  oscillations  in  illness.  Recrudescence,  further,  may  be 
produced  by  a  relapse.  After  the  afebrile  period  following  typhoid 
fever,  for  instance,  the  temperature  may  rise  and  a  full  recurrence  of 
the  disease  take  place. 

The  Symptoms  of  Fever.  Pyrexia,  or  increased  temperature,  is 
not  the  only  evidence  of  fever.  The  production  of  heat  within  the 
body  is  not  due  to  increased  tissue-change  alone.  It  may  be  due,  for 
instance,  to  increased  oxidation  of  sugar,  which  is  part  of  the  substance 
of  the  body.  Physiologists  have  found  that  a  high  temperature  may 
take  place,  and  yet  the  quantity  of  urea  and  of  carbonic  acid  discharged 
may  not  be  as  great  as  that  of  a  healthy  person  who  is  taking  active 
exercise  or  who  has  eaten  a  large  meal.  It  must  be  remembered, 
therefore,  that  it  is  not  heat-production  alone  but  alterations  of  heat- 
regulation  which  cause  pyrexia  and  its  phenomena. 

Wasting.  Wasting  of  the  body  is  a  striking  symptom  of  fever. 
There  is  no  doubt  that  even  in  fever  of  moderate  duration  great  wasting 
of  the  solid  structures  takes  place.  At  the  same  time  the  blood  wastes 
(see  observations  of  Thayer)  and  the  various  fluids  of  the  body  are 
also  diminished,  hence  the  disorders  due  to  diminished  secretion  of 
glands  are  prominent  in  the  course  of  fever.     Diminution  of  secretion 


THE  DATA  OBTAINED  BY  OBSERVATION.  199 

in  the  gastrointestinal  tract,  causing  thirst,  loss  of  appetite,  indigestion, 
and  constipation,  indicates  the  wasting  of  the  fluids.  Scanty  urine  of 
high  color  and  specific  gravity  is  due  to  the  same  cause. 

The  Pulse-rate.  Acceleration  of  the  pulse  is  one  of  the  phenom- 
ena that  attend  pyrexia.  While  increased  pulse-frequency  is  the  rule, 
and  is,  in  all  probability,  a  result  of  the  increase  in  temperature,  other 
circumstances  may  cause  a  change  in  the  pulse-rate  in  pyrexia.  Thus, 
in  basilar  meningitis,  although  there  may  be  a  high  fever,  the  pulse  is 
not  more  frequent.  On  the  other  hand,  some  diseases,  usually  accom- 
panied by  fever,  as  diphtheria  and  peritonitis,  may  be  afebrile,  and  yet 
the  pulse  be  very  much  accelerated. 

Arterial  Tension.  The  rapidity  with  which  the  blood  flows  in 
fever  and  the  arterial  tension  do  not  bear  a  due  proportion  to  the  accel- 
eration of  the  pulse.  The  true  febrile  pulse  is  not  dicrotic.  In  the 
early  stages  of  fever  the  pulse  is  large  and  hard,  the  arterial  tension  is 
high,  and  the  vessels  full.  In  the  later  stages  arterial  relaxation  takes 
place,  and  the  pulse  becomes  soft  and  feeble,  and  often  small,  with 
low  pressure.  The  pulse  is  rapid,  and  dicrotism,  or  even  hyperdicro- 
tism,  now  becomes  a  prominent  feature.  The  heart  beating  rapidly 
empties  itself  incompletely  and  discharges  less  rather  than  more  blood 
into  the  arteries.  The  impairment  of  the  cardiac  beat  is  no  doubt  due 
to  the  degenerations  on  account  of  the  high  temperature,  and  is  not 
dependent  upon  any  special  febrile  affection.  Such  changes  also  take 
place  in  the  glands,  particularly  the  liver  and  kidneys,  and  are  known 
as  parenchymatous  degenerations,  or  cloudy  swelling.  These  changes 
in  the  cardiac  muscle  may  induce,  in  the  later  stages  of  fever,  thrombi, 
and  cause  death  from  heart-clot. 

The  Respiration.  The  respirations  are  increased  in  fever,  proba- 
bly because  of  the  close  dependence  of  the  regulating  centre  of  respira- 
tion on  that  of  the  heart.  The  heated  blood  acts  as  a  stimulant  to  the 
respiratory  centre.  As  proof  of  this,  the  hurried  respiration  of  pneu- 
monia ceases  as  soon  as  the  temperature  falls,  notwithstanding  the  fact 
that  the  affected  part  of  the  lung  remains  hepatized. 

Cerebral  Symptoms.  Delirium  and  other  nervous  symptoms  may 
attend  fever.  They  are  not  dependent  upon  the  increased  temperature 
of  the  blood  alone.  No  relation  appears  to  exist  between  the  intensity 
of  the  fever  and  the  severity  of  the  delirium.  In  relapsing  fever  a 
temperature  of  106°  occurs  with  the  mind  clear.  In  certain  cases  of 
typhoid  fever  a  temperature  of  103°  is  attended  with  marked  delirium. 
If  fever  persists  for  a  short  time  a  low  asthenic  state,  so-called  adyna- 
mia, may  develop.  Because  the  symptoms  resemble  those  of  typhus 
fever,  the  term  typhoid  is  also  applied  to  them,  and  the  condition 
about  to  be  described  is  known  as  the  typhoid  state.  The  expression  is 
dull  and  heavy,  the  capillaries  of  the  face  are  congested.  There  are 
stupor  and  sluggishness  of  mental  processes,  so  that  the  patient  is  slow 
in  answering  questions.  The  stupor  is  attended  with  low  muttering 
delirium,  and  may  be  followed  by  complete  unconsciousness.  The 
pupils  are  contracted,  the  eye  heavy  and  dull.  The  patient  is  so  pros- 
trated that  he  slips  down  into  the  bed  from  the  pillow.  There  is 
marked   subsultus   tendinum.     The   tongue,   if   protruded,  conies   out 


200  GENERAL  DIAGNOSIS. 

slowly  and.  is  tremulous.  It  is  dry  and  brown,  and  the  mouth  and 
teeth  are  covered  with  sordes.  The  sensibilities  are  blunted,  so  that 
food  and  drink  are  not  asked  for,  or  particularly  relished  if  given. 
Involuntary  discharges  take  place  from  the  rectum  and  bladder,  and 
the  incontinence  of  retention  of  the  urine  arises.  The  pulse  is  small, 
feeble,  and  dicrotic,  the  heart-sounds  are  weak  and  feeble.  The  first 
sound  becomes  short  and  snappy  like  the  second,  or  may  be  absent 
entirely.  Venous  stases  take  place  in  the  dependent  portions,  particu- 
larly in  the  back  of  the  lungs. 

As  oedema  or  hypostatic  congestion  advances  the  breathing  becomes 
shorter  and  labored.  More  or  less  cyanosis  then  creeps  over  the  gen- 
eral surface.  The  urine  becomes  more  and  more  scanty  and  high- 
colored,  contains  albumin,  and  sometimes  blood. 

The  typhoid  state  may  continue  for  many  days,  or  even  last  two  or 
three  weeks,  although  not  in  so  advanced  a  degree  as  has  been  described. 
It  is  more  likely  to  supervene  when  there  is  excessively  high  temper- 
ature, but  it  also  occurs  in  the  course  of  a  prolonged  illness  with  a 
temperature  of  moderate  degree — that  is,  103°  F.  Although  it  is  in 
all  probability  due  to  the  direct  effects  of  heat  upon  the  nerve-centres 
and  the  organs  of  the  body,  yet  there  are  cases  in  which  the  temper- 
ature is  not  high,  and  yet  all  the  symptoms  of  the  typhoid  state  super- 
vene. While  the  typhoid  state  is  common  to  typhoid  fever,  it  occurs 
also  in  'pneumonia  and  septicaemia,  and  may  even  be  seen  in  its  most 
typical  form  in  other  conditions  in  which  fever  is  not  a  pronounced 
symptom  ;  thus  in  urcemia,  in  the  later  stages  of  softening  of  the 
brain,  in  paresis,  or  in  allied  nervous  diseases  the  symptoms  of  the 
typhoid  state  are  most  striking.  In  this  class  of  cases  it  certainly 
cannot  be  attributed  to  the  fever,  but  is,  in  all  probability,  due  to  the 
depressing  effect  on  the  nervous  system  of  material  which  should  be 
excreted  from  the  body,  a  view  which  has  been  advocated  by  Murchi- 
son,  Flint,  and  others. 

Ataxia,  or  the  ataxic  state,  in  fever  is  a  condition  the  opposite  of 
the  adynamic,  or  typhoid  state.  In  the  latter  there  is  weakness,  while 
in  the  former  there  is  exhibition  of  strength.  In  the  latter  the  nerve- 
centres  and  the  vital  processes  are  depressed  ;  in  the  former  they  are 
stimulated.  Ataxia  as  an  exhibition  of  strength  is  characterized  by  a 
strong  pulse  and  by  active,  violent  delirium,  so  that  it  is  almost  impossi- 
ble to  keep  the  patient  in  bed  ;  by  evidence  of  great  muscular  strength. 
The  face  is  flushed,  bright-red  in  color  ;  the  eyes  injected,  bright,  and 
active.  The  tongue  is  furred,  but  is  not  necessarily  dry  or  brown. 
The  delirium  may  be  constant  or  paroxysmal,  and  is  often  maniacal  in 
character.  The  temperature  of  the  body  is  high,  and  a  sensation  of 
intense  heat  is  imparted  to  the  hand  when  placed  on  the  surface  of  the 
trunk.  The  patient  may  complain  of  a  bursting,  intense  headache.  If 
the  ataxic  state  is  not  controlled  after  a  few  days,  or  at  the  most  a 
week,  the  patient  becomes  exhausted  and  lapses  into  stupor,  which 
may  proceed  to  coma.  In  some  forms,  particularly  in  children,  con- 
vulsions may  accompany  the  excessively  high  temperature  and  be  fol- 
lowed by  coma.  The  so-called  coma  vigil  may  supervene.  The  same 
exhibition  of  strength  is   shown.     Ataxia  is  seen  notably  in  scarlet 


THE  DATA  OBTAINED  BY  OBSERVATION.  201 

fever,  "  cerebral  "  pneumonia,  and  in  forms  of  typhoid  fever.  The 
peculiar  behavior  of  the  temperature  and  nervous  systems  in  this  affec- 
tion and  in  apex  pneumonia,  or  so-called  pneumonia  of  the  cerebral 
type,  have  led  observers  to  mistake  such  cases  for  actual  cerebral 
disease.  Frequently  they  have  been  admitted  into  insane  asylums  for 
supposed  mania.  The  true  nature  of  such  cases  is  often  mistaken, 
and,  because  of  lack  of  attendants,  the  patients  have  jumped  from  the 
window  or  done  violence  to  themselves  in  other  ways. 

It  is  as  difficult  to  determine  the  exact  cause  of  the  extreme  pertur- 
bation of  the  nervous  system  in  febrile  ataxia  as  in  adynamia.  It  may. 
be  due  to  a  high  temperature,  acting  on  nerve-centres  ;  or  to  a  poison, 
as  the  special  toxin  of  the  infection  which  has  caused  the  fever. 

The  presence  of  fever  may  be  suggested  by  flushing  of  the  face. 
This  may  be  general  or  local.  The  local  flush  of  phthisis  and  of  pneu- 
monia has  previously  been  referred  to.  Dryness  and  pungency  of  the 
skin  occur  in  fever.  In  former  times  the  sense  of  heat  was  given 
different  attributes,  said  to  be  distinctive  of  various  affections.  Hence 
the  terms  calor  mordex,  etc.  Thus  the  sensation  to  the  hand  of  the 
heat  in  typhus  fever  was  said  to  be  peculiar  and  characteristic.  The 
degree  of  fever  was  determined  by  the  sense  of  touch.  The  thermom- 
eter has  displaced  this  method  of  reckoning  temperature.  Sweating  is 
a  condition  habitual  in  some  fevers.  It  may  occur  throughout  the 
course  of  the  disease,  or  at  certain  stages  only  as  instanced  by  the  early 
morning  or  night-sweats  of  tuberculosis.  In  such  cases  it  is  cold  and 
clammy.  The  same  sweatings  are  common  in  the  fever  of  deep-seated 
suppuration  and  in  disease  of  the  bones.  Sweating  in  defervescence 
marks  the  occurrence  of  crisis. 

Headache  axd  paix  ix  the  back  occur  in  the  acute  specific 
fevers  in  the  initial  stage.  One  or  both  are  nearly  always  present,  but 
in  different  affections  they  have  diagnostic  significance.  Thus  severe 
pain  in  the  back  is  more  pronounced  in  tonsillitis  and  smallpox,  severe 
headache  in  cerebro-spinal  meningitis,  and  protracted 'throbbing  head- 
ache in  typhoid  fever. 

Subnormal  Temperature.  A  temperature  below  the  normal  may 
occur  independently  of  fever.  It  may  follow  as  a  sequela?  of  the  dis- 
eases with  more  or  less  prolonged  pyrexia.  It  occurs  in  the  course  of 
wasting  diseases,  as  in  cancer,  in  starvation,  at  times  in  ana?mia.  It  is 
seen  habitually  in  myxcedema,  and  occasionally  in  diabetes.  In  cer- 
tain forms  of  tuberculosis  it  may  extend  over  a  long  period  of  time, 
as  in  tuberculous  peritonitis.  (See  chart  under  Tuberculous  Peritonitis.) 
In  cases  of  cerebral  abscess  the  temperature  is  often  subnormal. 

Sometimes  the  drop  to  subnormal  temperature  may  occur  suddenly, 
to  be  followed  by  a  return  to  normal  or  even  a  rise  above  normal. 
The  sudden  fall  may  occur  in  shock,  or  in  hemorrhage  from  any  cause. 
It  may  take  place  from  disturbance  of  the  nerve-centres,  as  from 
apoplexy,  thrombosis,  or  embolism  of  the  brain,  causing  shock  or  other 
disturbance  of  the  thermotaxic  mechanism.  It  is  characteristic  of 
cholera.  In  the  course  of  organic  heart  disease  pulmonary  embolism 
is  also  attended  by  subnormal   temperature.      In  many   of  these  in- 


202 


GENERAL  DIAGNOSIS. 


stances  the  temperature  will  rise  (reaction)  after  the  shock  if  the  latter 
is  not  too  profound.  This  is  notably  the  case  in  apoplexy  and  in 
embolus  or  thrombus,  because  of  local  irritation  or  a  secondary  soften- 
ing. In  apoplexy  the  rise  in  temperature  will  occur  either  from  cen- 
tral disturbance  of  the  thermic  mechanism  or  from  secondary  inflam- 
mation about  the  clot.     A  subnormal  temperature  in  the  course  of 

Fig.  33. 


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Subnormal  temperature.    Oscillations  in  hepatic  intermittent  fever  with  jaundice.    Catarrh  of 
ducts,  with  diffused  hepatitis.    G.  W.,  aged  60.    Philadelphia  Hospital,  1877. 


fever  may  be  due  to  an  accident  or  complication,  as  hemorrhage  in 
disease  of  the  lungs,  or  in  typhoid  fever,  or  perforation  of  the  intestine 
in  the  latter  condition.  It  may  attend  the  crisis  of  acute  disease.  More 
or  less  collapse  usually  attends  the  pathological  fall  of  temperature 
below  the  normal.  While  such  fall  is  the  result  of  accident  in  many 
of  the  diseases  mentioned,  in  others  it  is  a  part  of  the  process. 

The  chart  (Fig.  33)  represents  the  effect  of  a  local  process  in  the 
largest  gland  of  the  body  upon  the  general  temperature.  It  is  possi- 
bly a  septic  temperature,  although  the  observation  was  made  before 
the  days  of  bacteriological  research.  The  extreme  low  temperature  is 
remarkable. 


THE  DATA  OBTAINED  BY  OBSERVATION.  203 

The  Diagnostic  Significance  of  Fever.    Its  Clinical  Causes. 

The  presence  of  fever  is  itself  of  diagnostic  importance. 

A.  It  usually  excludes  hysteria  and  malingering  disease. 

B.  It  indicates  that  one  of  several  morbid  processes  is  present.  The 
morbid  processes  which  give  rise  to  fever  are  : 

First,  an  infection,  general  or  local,  as  seen  in  any  one  of  the  infec- 
tious diseases  and  in  the  local  inflammations  induced  by  micro-organ- 
isms, especially  those  known  as  pus-producing.  When  local,  the 
inflammation  is  known  as  purulent,  suppurative,  or  septic.  The  micro- 
organism, a  product  of  its  growth,  or  the  poisons  or  ferments  resulting 
from  the  tissue  change,  disturbs  the  thermotaxic  mechanism  and  causes 
fever.  Any  tissue,  membrane,  or  organ  of  the  body  may  be  the  seat 
of  an  infectious  process. 

Second,  an  intoxication,  or  toxaemia,  as  caused  by  albumoses,  ferments, 
toxins,  or  ptomaines,  generated  within  the  system,  the  result  of  im- 
paired functional  activity  of  organs  or  structures,  or  of  cell  metabolism, 
as  seen  in  tissue  waste ;  and  by  food  products,  medicines,  or  toxic 
substances  introduced  from  without.  Catarrhal  inflammations  cause 
a  toxic  fever.     The  fever  of  gout,  of  anaemia,  of  starvation  is  toxic. 

Third,  fever  may  be  of  central  origin,  from  disease  of  the  brain  in- 
volving the  centres  controlling  heat,  or  from  disease  in  proximity  to  the 
heat-centres.  It  may  arise  in  cases  of  brain-tumor,  in  cases  of  apoplexy, 
and  of  thrombosis.  The  centres  may  also  be  irritated  by  direct  ex- 
posure to  external  heat  alone,  or  possibly  by  poisons  generated  within 
the  system  on  account  of  the  heat  (an  intoxication),  as  in  sunstroke. 

Fourth,  a  pronounced  -peripheral  irritation  or  sensation  of  pain,  reflexly 
altering  the  thermotaxic  mechanism,  will  produce  fever.  Hence,  in  iritis 
or  orchitis  a  fever  arises  out  of  all  proportion  to  the  local  inflammation. 

Finally,  cases  of  continued  fever  exist  that  have  not  thus  far  been 
classified.  One  of  the  nurses  of  the  Presbyterian  Hospital  with  a 
continued  temperature  from  100°  to  103°  was  under  my  care  for  two 
months.  No  general  or  local  condition  could  account  for  it.  The 
patient  was  emaciated.  She  had  had  two  years  of  very  hard  work. 
Although  fever  kept  up,  the  appetite  was  good.  Careful  and  abundant 
feeding,  with  rest  for  many  weeks,  caused  the  temperature  to  fall  to 
normal,  with  complete  recovery.  I  looked  upon  it  as  a  nervous  fever ; 
an  expression  of  exhaustion.      Fagge  refers  to  such  cases. 

Practically,  we  must  in  all  cases  of  fever  decide  between  one  of  infec- 
tious and  one  of  toxic  origin.  Discussion  of  the  mode  of  determining 
the  occurrence  of  an  infection  will  be  considered  shortly.  In  the  mean- 
time we  may  observe  that  the  poisons  which  are  generated  in  the 
gastro-intestinal  tract  are  likely  to  disturb  the  cardiac  and  respiratory 
as  well  as  the  thermotaxic  mechanism.  Hence  we  often  see  irregu- 
larity and  intermittency  of  the  heart — so  often  as  to  look  upon  it  as  of 
diagnostic  value  in  favor  of  toxic  fever. 

Certain  clinical  features  of  a  febrile  course  belong,  in  the  main,  to 
special  affections,  and  thus  far  are  diagnostic  of  them.  Hence  the 
mode  of  onset  or  initial  stage,  the  course  or  fastigium,  the  decline  and 
the  type  should  be  carefully  studied.  They  are  a  most  important  in- 
dication of  the  nature  of  the  disease. 


204  GENERAL  DIAGNOSIS. 

The  Initial  Stage.  1.  In  the  initial  stage  of  fever  sudden,  ex- 
cessive rise  of  temperature  from  a  condition  of  apparent  health  argnes 
against  any  of  the  acute  specific  fevers  except  scarlet  fever.  It  is  of 
more  frequent  occurrence  in  acute  gastric  or  gastro-intestinal  catarrh 
in  children  than  in  any  other  ailment.  It  may  be  due  to  pneu- 
monia, and  is  significant  of  this  infection  in  adults  if  attended  by  a 
rigor.  In  children  convulsions  may  replace  the  chill.  The  sudden 
rise  may  be  due  to  certain  types  of  malaria,  when  it  is  also  preceded 
by  a  chill  and  followed  by  free  sweating.  It  may  also  be  due  to  affec- 
tions of  the  throat,  to  follicular  or  phlegmonous  inflammation  of  the 
tonsils.  The  throat  must  always  be  examined  in  cases  of  sudden  high 
temperature. 

In  children,  if  pain  attends  any  inflammatory  affection,  the  tempera- 
ture will  rise  to  a  greater  height  than  the  local  process  alone  would 
warrant.  This  is  the  case  with  suppurative  inflammation  of  the 
middle  ear.  This  must  always  be  borne  in  mind  in  sudden  rise  of 
temperature.  The  same  active  febrile  reaction  will  take  place  in  osteo- 
myelitis and  in  mastoid  abscess.  The  associate  signs  point  to  the  true 
nature  of  the  affection,  although  it  must  be  confessed  that  in  both  the 
symptoms  are  often  obscure  in  the  beginning. 

2.  In  typhoid  fever  the  temperature  rises  in  a  characteristic  Avay. 
It  ascends  by  successive  evening  rises,  followed  by  morning  remis- 
sions, until  it  reaches  the  maximum  at  about  the  end  of  the  first  week. 

The  Fastigium.  In  typhoid  fever  the  course  of  the  fastigium  is 
of  characteristic  significance.  From  the  end  of  the  first,  throughout 
the  second  week,  and  sometimes  longer,  the  fever  is  of  the  continued 
type.  Subsequently  during  the  third  week,  or  later,  morning  remis- 
sions set  in,  the  temperature  for  a  time  still  rising  to  the  former  height 
in  the  evening.  Then  the  morning  remissions  become  more  decided, 
the  temperature  not  rising  as  high  in  the  evening,  and  so  gradually 
the  temperature  sinks  to  and  below  normal.  This  course  of  the  tem- 
perature in  typhoid  fever  is  very  far  from  being  invariable  ;  it  is  modi- 
fied by  indiscretions  on  the  part  of  the  patient  or  his  attendants,  and 
by  the  necessities  of  antipyretic  or  other  treatment ;  nevertheless,  the 
gradual  onset  of  the  fever  and  its  long  duration  are  sufficiently  com- 
mon to  make  them  of  great  value  in  diagnosis,  as,  with  the  exception 
of  tuberculosis,  there  is  hardly  any  other  disease  in  which  a  continued 
fever  exists  for  two  or  three  weeks  apart  from  local  inflammation  or 
suppuration. 

The  Declixe.  Defervescence.  In  the  self -limited  diseases  there 
is  a  period  when  defervescence  should  take  place.  A  continuance  of 
the  fever,  the  persistence  of  the  fastigium  beyond  the  usual  period, 
indicates  that  the  case  is  one  of  a  greater  degree  of  gravity  than  usual, 
or  that  there  is  a  complication.  It  is  usually  significant  of  a  compli- 
cation. In  measles  the  complication  is  usually  pneumonia.  This 
may  take  place  after  the  disease  has  developed,  and  may  be  the  cause 
of  the  unusual  rise  in  temperature.  In  scarlatina  it  may  indicate 
acute  nephritis,  or  inflammation  of  any  of  the  serous  membranes, 
particularly  the  pericardium  or  endocardium.  Persistence  of  the 
fastigium  of  typhoid  fever  after  the  period  at  which  it  should  decline, 


THE  DATA   OBTAINED  BY  OBSERVATION. 


205 


if  the  patient  is  well  nursed  and  properly  fed,  usually  indicates  the 
occurrence  of  a  reinfection,  a  secondary  infection,  or  the  development 
of  tuberculosis.  If  the  latter,  the  fever  is  more  likely  to  develop  dur- 
ing convalescence.  Of  the  inflammatory  complications,  phlebitis  and 
glandular  and  bone  infections  are  likely  to  cause  persistence  of  fever. 


Fig.  34. 


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vl  Sudden  Fall ;  Subnormal  Temperature.  A  sudden  fall  of  tempera- 
ture in  a  person  who  has  previously  had  high  fever  signifies  the  crisis 
if  the  time  for  that  event  has  arrived,  as  in  pneumonia ;  or  of  a  grave 
complication,  which  induces  shock.  In  typhoid  fever  this  unusual 
drop  in  the  temperature  will  take  place  if  there  has  been  hemorrhage 
from  the  bowels,  or  perforation,  or  if  peritonitis  has  developed.  It 
must  not  be  confounded  with  the  sudden  falls  of  temperature  that 
occur  in  the  typhoid  fever  of  children,  corresponding  to  the  onset  of 
cimvalescence.  They  occur  earlier  in  the  period  of  the  disease  than 
with  adults. 

The  Type  of  the  Fever.  Intermittent  Fever.  The  representative 
of  the  type  is  seen  in  malaria,  but  it  is  simulated  by  a  number  of 
conditions  :  (1)  In  certain  cases  of  typhoid  fever  and  of  relcqising  fever 
the  type  is  intermitting  or  paroxysmal.  The  same  type  of  fever  is 
seen  (2)  in  suppuration,  particularly  if  the  pus  is  confined,  although  in 
brain  abscess  the  temperature  may  be  normal  or  subnormal ;  (3)  in 
infectious  endocarditis;  (4)  in  tuberculosis.  a.  It  may  occur  in  the 
earlier  stages  of  tuberculosis.  The  primary  seat  of  the  lesion  may  be 
in  the  lungs,  in  the  bones,  or  in  the,  glands,  b.  In  pulmonary  tuber- 
culosis, after  the  formation  of  a  cavity,  intermitting  fever  is  of  common 
occurrence.  It  is  then  of  septic  origin  due  to  the  septic  influence  of  the 
necrosed  tissue  and  products  of  putrefaction  in  the  cavity.  (See  Fig.  35.) 
(5)  In  lymphadenoma  and  ancemia  the  fever  is  at  times  paroxysmal. 


206 


GENERAL  DIAGNOSIS. 


(6)  In  syphilis  the  same  type  is  often  seen.  It  may  be  noted  (a)  in  the 
initial  fever  ;  (6)  in  the  tertiary  periods  of  the  disease  where  giunmata 
have  formed,  or  other  forms  of  visceral  syphilis  have  developed.     (7) 


Fig.  35. 


Intermitting  fever  of  tuberculosis. 


Urinary  intermitting  fever  is  the  form  which  usually  occurs  after  the 
passage  of  a  catheter  or  sound,  but  it  may  also  occur  when  there  is 
suppuration  in  the  genito-urinary  tract.  (8)  Hepatic  intermitting  fever 
is  a  form  of  frequent  occurrence  and  of  great  diagnostic  importance. 


Fig.  36. 


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It  may  be  due  to  (a)  gallstones  somewhere  in  the  biliary  ducts,  usually 
with  obstruction  ;  (6)  suppuration  in  the  canal,  with  or  without  ob- 
struction ;  (c)  obstruction  of  the  biliary  passages  by  external  pressure 
without  suppuration  ;  (d)  inflammatory  affections  of  the  liver,  as  ab- 
scess, and  forms  of  cirrhosis.  It  occurs  rarely  in  rapidly  growing  cancer. 
(See  Fig.  33.)  (9)  Intermittent  fever  may  also  attend  the  prolonged 
use  of  morphine. 


THE  DATA   OBTAINED  BY  OBSERVATION. 


207 


Of  the  above-mentioned  varieties  of  paroxysmal  or  intermitting 
fever,  those  of  the  most  common  occurrence  are  due  to  suppuration, 
pyaemia,  to  infectious  endocarditis,  to  tuberculosis,  and  to  hepatic  dis- 
order. In  addition  to  the  paroxysmal  temperature,  rigors  precede  and 
sweating  follows  the  paroxysm,  as  in  cases  of  malarial  intermittent  fever. 


Fig.  37. 


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The  diagnosis  from  malarial  intermittent  fever  can  be  established  at 
once  by  an  examination  of  the  blood,  which  reveals  in  the  latter  the 
plasmodia  of  Laveran. 

Remittent  Fever.  Fever  of  a  remittent  type  occurs  in  many  of  the 
conditions  in  which  intermittent  fever  is  present.  It  is  characteristic 
of  one  of  the  forms  of  malaria.  It  is  most  frequently  encountered  in 
tuberculosis  of  the  lungs.  The  remissions  usually  occur  in  the  morn- 
ings, but  the  order  may  be  reversed.  The  same  type  of  fever  is  met 
with  in  puerperal  fever,  pyaemia,  and  septicaemia,  and  in  local  suppu- 
rations, such  as  abscess  of  the  liver  and  empyema.  A  continued  fever 
may  be  made  to  resemble  a  remittent  by  antipyretic  treatment,  which 
may  cause  abnormal  remissions.  Remissions  characterize  the  decline 
of  the  continued  fevers,  particularly  typhoid,  during  the  period  of  lysis. 

Continued  Fever.  Continued  fever  is  met  with  in  lobar  pneumonia, 
typhoid  fever,  typhus  fever,  erysipelas,  and  tuberculosis.  In  acute 
lobar  pneumonia  the  temperature  rises  rapidly,  and  in  a  few  hours 
from  the  initial  chill  reaches  103°  or  105°.  The  morning  and  even- 
ing temperatures  vary  but  little,  usually  not  more  than  one  or  two 
degrees,  until  a  crisis  occurs  in  from  four  to  eight  days.  The  temper- 
ature then  falls  to  or  slightly  below  normal,  and  does  not  rise  again. 
(See  Fig.  37.) 


208  GENERAL  DIAGNOSIS. 

A  marked  remission  in  the  fever  sometimes  occurs  on  the  fourth 
day,  before  the  actual  crisis ;  the  temperature  falls  to  100°,  and  rises 
again  to  103°  or  104°,  remaining  at  that  level  for  twenty-four  or  forty- 
eight  hours,  when  the  true  crisis  occurs.  The  first  fall  is  known  as  the 
pseudocrisis.  The  fall  of  temperature  of  defervescence  (crisis)  may  be 
completed  within  a  few  hours. 

The  Ixfluence  of  Age  and  Sex.  The  significance  of  a  high 
febrile  change  is  not  so  great  in  children  as  in  adults.  That  is,  the 
high  temperature  is  not  so  important,  inasmuch  as  children  are  liable 
to  have  sudden,  excessive  increase  of  temperature ;  and  a  higher  tem- 
perature may  persist  in  children  without  deleterious  effects  upon  the 
tissues  which  are  noticed  in  adults.  In  women  of  nervous  tempera- 
ment the  temperature  is  also  likely  to  rise  to  a  great  height  without 
adequate  cause  or  serious  result. 


CHAPTER    XV. 

THE  DATA  OBTAINED  BY  OBSERVATION— {Continued). 


FEVER.     THE  INTOXICATIONS. 

Practically,  it  may  be  said  that  the  symptom  fever  may  be  due  to 
an  intoxication,  an  infection,  or  a  central  cerebral  lesion.  In  this 
chapter  a  word  may  be  said  of  the  fever  of  an  intoxication.  The  sub- 
stance which  produces  fever  of  this  type  may  be  a  toxic  material,  the 
product  of  local  or  general  disturbance  of  tissue  metabolism.  Thus  in 
a  local  catarrhal  inflammation,  as  of  the  bronchi,  the  result  of  the 
direct  action  of  an  irritant  vapor,  toxic  substances  are  generated  which 

Fig.  39. 


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Aseptic  or  fermentation  fever. 

disturb  the  heat  mechanism  and 
produce  fever.  Now,  an  intoxica- 
tion or  simple  inflammation,  there- 
fore, is  attended  by  fever,  which 
may  be  styled  catarrhal  fever. 
(See  Fig.  41.)  In  anaemia,  on  the 
other  hand,  if  all  infections  can  be 
excluded,  it  may  be  said  the  gen- 
eral disturbance  of  tissue  metab- 

Temperature  curve  after  amputation  of  the  forearm,  olisill      possibly  gives    rise    to    the 

formation  of  a  toxin  which  causes 
the  fever  well  known  to  attend  this  process — anaemic  fever. 

A  better  example  of  fever  due  to  a  poison  is  that  which  Collins 
Warren  terms  aseptic  fever.     It  is  also  known  as  absorption  or  fermen- 

14 


210 


GENERAL  DIAGNOSIS. 


Fig.  40. 


tation  fever.  The  fever  follows  a  perfectly  aseptic  operation,  and  no 
causal  factor  is  present.  It  is  due  to  the  absorption  of  ferments,  from 
blood  clot,  or  coagulated  serum,  or  tissue  debris.  The  temperature 
rises  to  102°,  and  may  remain  above  normal  from  three  days  to  two 
weeks.  (See  Figs.  38  and  39.)  There  is  a  striking  absence  of  consti- 
tutional symptoms,  however.  Another  peculiarity  is  that  the  fever 
begins  immediately  after  the  operation.  The  urine  is  not  lessened,  the 
body-weight  remains  normal,  and  the  pulse-rate  corresponds  to  the 
temperature  rise.  In  some  instances  an  eruption  like  that  of  scarlet 
fever — surgical  scarlet  fever — breaks  out. 

Should  it  happen  that  the  retained  fluids  undergo  decomposition  and 
are  absorbed,  a  more  intense  type  of  fever  is  seen,  attended  by  marked 
constitutional  symptoms.  "We  then  have  traumatic  fever — a  fever  which 
subsides  as  soon  as  the  poison  is  liberated  from  the  wound.  In  the 
meantime  the  temperature  has  been  as  high  as  102°  to  103° — the  pulse 
very  rapid,  delirium  has  been  marked,  and  there  has  been  furred 
tongue,  thirst,  anorexia,  restlessness,  and  malaise. 

It  may  happen  that  septic  infection  of  a  wound  takes  place.  Thus, 
one  of  my  patients,  while  dressing  a  suppurating  vaccine  wound,  inoc- 
ulated or  infected  her  finger.  The  ten- 
der spot  was  followed  by  redness  along 
the  lymphatics,  and  enlargement  of  the 
glands — a  lymphangitis.  She  had  fever. 
A  deep  cut  in  the  infected  spot  released 
a  serous  discharge,  the  fever  disap- 
peared, and  the  lymphatic  inflammation 
subsided  at  once.  Such  accidents  hap- 
pen frequently  to  surgeons.  Another 
patient  was  infected  by  a  surgeon  who 
had  just  operated  on  an  osteomyelitis. 
The  temperature  rose  to  106.5°  in  twen- 
ty-four hours,  and  the  constitutional 
symptoms  were  extreme.  The  wound 
in  the  abdominal  walls  was  opened  and 
cleansed,  and  the  peritoneum  was  not 
reopened  ;  no  peritonitis  resulted.  The 
temperature  fell  four  degrees  at  once. 
The  muscles  and  other  tissues  of  the 
woimd  became  grayish  and  almost  pu- 
trid. Recovery  was  slow.  Such  cases  are  known  as  septic  cases,  the 
ailment  septicaemia,  and  the  intoxication  saprazmia.  (See  Fig.  40.) 
No  bacterial  invasion  of  the  body  takes  place,  and  there  is  no  local 
suppuration.  Xo  doubt,  in  each  instance  micro-organisms  infected  the 
wound,  but  the  symptoms  arose  from  the  chemical  product  resulting 
from  their  growth. 

In  obstetric  practice  the  retained  putrefying  placental  fragment  will 
cause  such  symptoms.  In  medicine  we  see  such  intoxication  tat  e  place 
in  infections.  Thus  in  diphtheria,  systemic  intoxication  with  fever 
results  from  the  absorption  of  a  toxin  from  the  local  point  of  bacterial 
growth.      In  tetanus  the  same  toxic  fever  and  symptoms  occur.     It  is 


M  E 

M  E 

M  E 

M   E 

M  E 

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Septic  intoxication. 


THE  DA  TA   OB  TAIN  ED  B  Y  OB  SEE  VA  TIOX.  21 1 

impossible  to  draw  hard-and-fast  lines  between  the  toxic  fever  and  the 
infective,  pyogenic  or  suppurative  fever,  and,  indeed,  such  cases  prop- 
erly belong  and  will  be  considered  under  the  next  prominent  causes 
of  fever  to  be  considered — the  infections. 

But  "  fever  "  may  be  due  to  other  intoxications.  It  is  well  known 
that  pepsin  and  other  digestive  ferments  injected  into  the  body  cause 
fever.  It  is  supposed  products  of  imperfect  assimilation  or  digestion 
absorbed  into  the  system  from  the  gastro-intestinal  tract  give  rise  to 
fever.  Ptomaines  or  leucomaines,  albumoses  or  peptones,  absorbed 
from  the  intestinal  tract  may  thus  cause  fever.  The  retention  of  ex- 
cretory products,  as  those  of  the  renal  organs,  cause  a  systemic  intoxi- 
cation, with  the  frequent  occurrence  of  fever.  Gout,  too,  may  be  con- 
sidered as  an  intoxication  giving  rise  to  fever. 

The  fever  of  auto-intoxication  (gastro-intestinal  or  glandular),  so 
called,  therefore,  is  an  entity.  The  clinician,  at  least,  without  proof 
by  the  bacteriologist,  sweeps  the  intestinal  tract  with  his  mercurials  and 
salines,  and  thereby  administers  the  causal  antipyretic. 

Poisoning  by  food  products,  as  of  cheese,  meats,  sausages,  milk,  etc., 
appear  to  cause  fever,  although  it  is  possible  intestinal  bacteria  may 
play  some  part  in  the  process. 

Varieties  of  Febrile  Intoxications.  It  is  assumed  that  the  student  is 
investigating  a  case  of  fever.  In  keeping  in  mind  an  intoxication  as 
a  cause  of  fever,  he  must  first  consider  all  causes  of  intoxication  from 
within  ;  second,  all  causes  from  without  the  organism. 

To  the  first  belong  gout,  uraemia,  cholesteraemia,  and  the  auto-in- 
toxications from  the  intestinal  tract,  as  well  as  those  from  modification 
or  suppression  of  internal  secretions,  as  of  the  thyroid  and  other  glands. 

To  the  second  belong  the  following  :  Sunstroke,  morphinism,  and 
food-poisoning.  The  fever  due  to  an  intoxication,  as  in  the  so-called/e6W- 
cula  and  in  the  simple  continued  or  catarrhal  fever,  is  of  doubtful  origin. 

Diagnosis.  The  Action  of  the  Heart.  Increased  frequency  of  car- 
diac action  is  a  symptom  common  to  all  forms  of  fever.  It  is  more 
common  to  see  irregularity  and  intermittency  in  the  fever  of  intoxica- 
tion, and  especially  of  auto-intoxication,  than  in  that  of  infections. 
Indeed,  I  should  call  a  fever  which  is  attended  by  a  cardiac  neurosis, 
cardiac  mural  disease  and  cerebral  disease  excluded,  one  of  intoxication. 

Increased  Respiration.  The  same  may  be  said  of  the  breathing. 
When  a  respiratory  neurosis  prevails  in  the  course  of  fever,  it  and  the 
fever  attending  are  due  to  a  common  cause,  an  intoxication.  Of 
course,  pulmonary  and  central  brain  and  medulla  disease  are  excluded. 
It  seems  both  the  above  observations  aid  in  the  diagnosis  of  an  in- 
toxication  from  an  infection. 

Febrile  Intoxications. 

Sunstroke  (siriasis,  thermic  fever,  insolation,  heatstroke).  Whether 
the  cause  is  the  direct  action  of  heat  upon  the  brain  centres,  or  whether 
a  toxic  substance  is  generated  and  becomes  operative,  in  this  affection 
we  have  the  most  pronounced  expression  of  fever  outside  of  the  in- 
fectious disorders.     The  Hushed  face,  the  pungent  skin,  the  dyspnoea, 


212  GENERAL  DIAGNOSIS. 

and  the  rapid  pulse  forebode  the  high  body  temperature  which  in 
the  axilla  may  reach  108°  to  112°.  This  is  reached  very  rapidly, 
and  death  takes  place  in  coma  hyperpyrexia.  If  recovery  takes  place, 
the  temperature  may  be  moderately  continuous  a  few  days.  The  pic- 
ture is  added  to  by  the  nervous  and  cardio-respiratory  phenomena. 
In  some  instances  dyspnoea,  heart-failure,  and  coma  may  follow  on 
rapidly,  and  death  ensue  in  one  or  two  hours.  In  other  cases  pain 
in  the  head,  dizziness,  and  languor  precede  the  stupor.  Nausea  and 
vomiting,  perhaps  diarrhoea,  chest  oppression,  frequent  micturition, 
and  convulsions  may  precede  the  insensibility.  Unconsciousness  is 
lost  quickly  or  gradually,  and  it  may  be  transient  or  pass  into  deep 
coma.  Relaxation  of  the  muscles  with  twitching  is  seen,  and  the  pupils, 
at  first  dilated,  become  contracted.  As  the  coma  deepens,  the  heart's 
action  becomes  more  rapid  and  feeble,  the  respirations  hurried,  shallow, 
and  irregular,  and  death  ensues,  preceded  or  not  by  convulsions. 

The  diagnosis  is  based  on  the  history,  the  mode  of  onset,  and  the 
hyperpyrexia.     It  must  be  distinguished  from  uraemia  and  apoplexy. 

Heat  exhaustion  is  readily  recognized.  The  moist,  pale,  and 
cool  skin,  the  soft,  feeble  pulse,  the  quiet  but  hurried  breathing,  are 
unattended  by  fever.  The  collapse,  for  such  it  is,  is  not  attended  by 
coma,  and  it  usually  responds  to  treatment. 

Morphinism.  Lewin  showed  that  morphinism  is  attended  by  fever. 
The  fever  may  be  continued  or  intermittent.  When  the  latter,  chills 
are  of  frequent  occurrence.  The  diagnosis  is  based  on  the  history,  on 
the  evidence  of  poor  nutrition  without  cause,  on  the  general  depression 
and  lassitude,  and  upon  the  temperament  of  the  patient,  to  which  is 
added  poor  sleep,  restlessness,  and  itching  of  the  skin.  The  peculiar 
sallowness  of  the  complexion  and  the  prematurely  aged  appearance  are 
well  known.  Pseudo-neuralgic  pains  are  common,  tabetic  symptoms 
may  be  present,  and  notably  gastro-intestinal  symptoms,  as  gastralgia, 
vomiting,  diarrhoea,  especially  if  the  drug  is  withheld.  Fever,  it 
must  be  remembered,  may  be  absent. 

Simple  Continued  Fever.  A  non-contagious  fever,  lasting  from 
one  to  twelve  days,  not  dependent  upon  any  known  specific  cause,  and 
not  attended  with  any  definite  local  lesions.  Its  chief  characteristic  is 
the  continued  elevation  of  temperature. 

It  occurs  especially  in  children  and  in  those  prone  to  ready  disturb- 
ance of  the  heat-regulating  apparatus.  Great  mental  and  physical 
exhaustion,  prolonged  bathing  in  the  hot  sun,  and  disturbances  in 
digestion  may  cause  it.  Perhaps,  as  suggested  by  Guiteras,  some  of 
the  cases  occurring  in  the  tropics  and  in  very  hot  weather  should  be 
regarded  as  very  mild  forms  of  thermic  fever. 

The  onset  of  the  disease  is  abrupt.  There  may  be  a  chill,  or  in  ner- 
vous children  a  convulsion  ;  but  these  are  rare.  The  temperature  rises 
rapidly  from  102°  to  104°,  accompanied  by  headache,  thirst,  restlessness 
or  drowsiness,  loss  of  appetite,  a  coated  tongue,  constipation,  and  occa- 
sionally nausea.  The  urine  is  scanty,  and  sometimes  there  is  a  heavy 
deposit  of  urates.  There  may  also  be  more  or  less  muscular  soreness. 
Sometimes  within  twenty-four  or  forty-eight  hours  free  perspiration 
takes  place,  with  rapid  subsidence  of  the  fever.     This  is  ephemeral  fere  r. 


THE  DATA  OBTAINED  BY  OBSERVATION. 


213 


In  other  cases  the  fever  continues  for  a  week  or  ten  days  longer. 
During  this  time  the  symptoms  already  noted  continue.  Sleep  is  dis- 
turbed and  mild  delirium  is  at  times  present.  Respiration  and  pulse 
are  not  much  accelerated.  Sudamina  upon  the  abdomen  and  herpes 
on  the  lips  are  common.      Pale-bluish  macula?  are  sometimes    seen. 


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IS 

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Simple  continued  fever. 


The  spleen  is  not  enlarged  except  in  very  rare  cases,  and  there  are  no 
local  evidences  of  disease.  The  fever  subsides  more  gradually  than  in 
ephemeral  fever,  the  defervescence  being  marked  at  times  by  perspira- 
tion, a  few  loose  stools,  a  copious  deposit  of  urates  in  the  urine,  or  by 
hemorrhages  from  the  nose,  rectum,  uterus,  or  urethra. 

The  diagnosis  from  other  fevers  and  febrile  affections  is  made  by  the 
absence  of  any  characteristic  eruption,  of  enlargement  of  the  spleen  and 
liver,  and  of  any  lesion,  such  as  endocarditis,  bronchitis,  or  pneumonia. 

Food  Intoxications.  Among  the  intoxications  which  give  rise  to 
fever  are  those  due  to  food-poisoning.  Meat,  milk  products,  and  shell- 
fish cause  an  intoxication  of  the  system  which  in  the  instance  of  the 
first  three  forms  often  threatens  life,  and,  from  the  suddenness  of  the 
attack  and  the  severity  of  the  symptoms,  points  to  an  infection  rather 
than  an  intoxication. 

The  history  of  the  case  is  often  the  first  clue  to  its  nature.  The 
symptoms  are  those  of  acute  gastro-intestinal  irritation,  to  which  are 
added,  with  or  without  afebrile  periods,  the  symptoms  of  collapse. 

Meat-poisoning".  In  the  intoxication  arising  from  poisoning  by 
meat,  the  temperature  rises  from  101°  to  104°,  preceded  usually  by  a 
brief  period  of  chilliness.  The  occurrence  of  fever  may  be  preceded 
by  a  period  of  incubation  lasting  from  twelve  to  forty-eight  hours. 
During  the  period  of  incubation  there  is  malaise,  loss  of  appetite, 
nausea,  and  colicky  pains.  As  they  increase  chilliness  ensues,  and  in 
some  instances  there  is  a  marked  rio-or.     Prostration   occurs  almost 


214  GENERAL  DIAGNOSIS. 

immediately,  with  giddiness  and  faintness,  and  the  occurrence  of  cold 
perspiration.  Headache  and  backache  are  liable  to  occnr.  Following 
the  chilliness  the  symptoms  of  gastro-  intestinal  irritation  arise,  diar- 
rhoea being  more  frequent  than  vomiting.  The  abdominal  pain  in- 
creases and  the  perspiration  and  clammy  sweats  become  more  pro- 
nounced. As  further  evidence  of  the  intoxication,  there  is  an  extreme 
degree  of  muscular  weakness.  The  pulse  becomes  rapid,  and  later, 
thready.  In  addition  to  muscular  weakness,  cramps  in  the  legs  and 
arms,  followed  by  convulsive  movements,  occur,  and  the  patient  com- 
plains of  paresthesia  of  various  forms.  In  milder  cases  the  symptoms 
of  gastro-intestinal  irritation  and  of  muscular  weakness  attend  the 
fever.     In  the  more  severe  cases  fever  is  replaced  by  collapse. 

Poisoning  by  Milk  Products.  Symptoms  of  gastro-intestinal  irri- 
tation and  choleraic  symptoms  ensue.  The  diarrhoea  of  infants  and 
cholera  infantum  are  types  of  this  intoxication.  The  high  degree  of 
fever  that  occurs  is  well  known.  In  cheese-poisoning  the  fever  is  not 
continuous  as  in  the  other  forms,  the  temperature  becoming  subnormal 
with  the  onset  of  collapse. 

Poisoning  by  Shell-fish.  In  mussel-poisoning  the  symptoms  are 
those  of  an  acute  mineral  poisoning  with  profound  nervous  symptoms. 
Fever  does  not  attend  this  condition,  but  collapse  follows  quickly. 
There  are  no  gastro-intestinal  symptoms. 

Fish-poisoning  is  also  unattended  by  fever,  collapse  occurring  early. 

Afebrile  Intoxications. 

For  convenience,  and  by  contrast,  the  afebrile  intoxications  will  be 
considered.  Herein  will  not  be  considered  those  important  afebrile 
intoxications  due  to  disease  of  the  ductless  glands.  They  include  some 
diseases  of  the  suprarenal  bodies  (Addison's  disease),  the  thyroid  gland 
(exophthalmic  goitre  and  myxcedema),  the  lymphatic  glands  (status 
lymphaticus),  and  the  spleen. 

Alcoholism.  In  acute  alcoholism  the  reeling  gait,  the  incoherent 
speech,  followed  by  narcosis,  are  well  known.  The  temperature  is 
afebrile.  Often,  indeed,  it  is  subnormal,  and  when  equal  on  both  sides 
of  the  body  is  very  suggestive.  The  flushed  face,  possibly  slightly 
dusky,  and  the  injected  eye,  would  lead  us  to  suspect  the  presence  of 
fever.  The  odor  of  the  breath  furnishes  a  clue.  The  heavy  breath- 
ing, the  full  pulse,  the  dilated  pupils,  the  stuporous  rather  than  coma- 
tose state,  are  accompaniments  of  this  intoxication.  The  flaccid  limb 
of  one  side  would  point  to  hemiplegia  from  hemorrhage,  especially  if 
the  coma  is  deeper  than  usual  and  the  stupor  more  marked.  But 
uraemia  and  apoplexy,  and  either  of  the  two  in  a  drunken  subject,  must 
be  borne  in  mind. 

Chronic  Alcoholism.  When  the  poison  is  taken  for  a  long  time  it 
acts  as  a  tissue  poison  and  a  check  upon  waste.  Epithelial  and  nerve 
degeneration  and  fibrous  overgrowth  follow  the  first  or  poisonous  irri- 
tative action  ;  and  fatty  change  the  second.  In  the  alcoholic,  tremor 
of  the  hands  and  tongue  is  seen.  The  action  of  the  muscles  is  un- 
steady.    The  mind  is  dull,  the  temper  irritable,  forgetf illness  is  most 


THE  DATA   OBTAINED  BY  OBSERVATION.  215 

common,  and  later  a  dementia  and  epilepsy  may  ensue.  Alcoholic 
neuritis,  to  be  described  later,  is  of  frequent  occurrence. 

Gastro-intestinal  catarrh  with  poor  appetite  and  constipation  is  most 
liable  to  ensue,  and  later  cirrhosis  of  the  liver  and  kidneys.  Endar- 
teritis and  cardiac  dilatation  develop  in  some  independently  ;  in  others 
with  the  nervous  affections,  delirium  tremens. 

Grain-poisoning'.  Three  forms  are  seen.  When  the  grain  is  con- 
taminated by  ergot,  symptoms  known  as  ergotism  occur.  Chronic 
ergotism  may  cause  gangrene  or  a  train  of  nervous  symptoms  in  which 
convulsive  movements  are  most  prominent.  In  the  gangrenous  form 
the  toes  and  fingers  are  the  seat  of  mortification.  The  process  is  pre- 
ceded by  anaesthesia,  paresthesia,  and  pain.  In  the  convulsive  form 
there  is  slight  fever  with  some  weakness  and  tingling  sensations  in  the 
body.  Cramps  and  contractures  occur  in  the  extremities,  continuing 
for  hours  or  days,  and  relapsing  frequently.  A  mild  delirium  or  the 
development  of  melancholia  or  dementia  attends  the  convulsive  form. 

In  other  intoxications  fever  is  not  so  pronounced.  In  lathyrism  the 
symptoms  are  those  of  spastic  paralysis,  which  may  proceed  to  para- 
plegia. In  pellagra,  a  disturbance  due  to  maize,  there  are  disorders 
of  digestion,  loss  of  sleep,  general  pain,  and  debility.  The  digestive 
symptoms  are  those  of  salivation,  dyspepsia,  and  diarrhoea.  A  pecu- 
liar erythema  arises.  Subsequently,  desiccation  and  desquamation  of 
the  epidermis  occur,  and  often  small  boils  develop.  Headache,  back- 
ache, spasms,  and  paralysis  of  the  legs  occur  in  the  severe  and  chronic 
forms.     The  nervous  symptoms  may  give  way  to  melancholia. 

Lead-poisoning.  Intoxication  due  to  lead  or  plumbism  may  be 
acute  or  chronic.  In  the  acute  form  we  have  symptoms  of  gastro-in- 
testinal irritation  with  constipation  and  extreme  colicky  pains.  Anae- 
mia may  develop  rapidly,  and  pronounced  nervous  symptoms  arise. 
Among  the  latter  we  have  neuritis,  convulsions,  epilepsy,  and  delirium. 
Hemorrhages  from  mucous  membranes  may  be  seen,  and  a  form  of 
nephritis  develops  rapidly.  The  urine  contains  albumin  and  tube-casts. 
Fever  is  not  a  pronounced  symptom. 

The  characteristic  symptoms  of  chronic  poisoning  are  (a)  saturnine 
cachexia,  in  which  anaemia  is  most  pronounced ;  (6)  colic;  (c)  paralysis, 
which  may  be  acute,  subacute,  or  chronic,  and  which  usually  develops 
without  fever.  The  paralysis  may  be  anti-brachial,  causing  character- 
istic wrist-drop  ;  brachial,  in  which  the  scapulo-humoral  form  of  paraly- 
sis is  seen,  and  an  Aran-Duchenne  class,  resembling  chronic  anterior 
poliomyelitis.  Another  is  the  peroneal  type,  in  which  the  lateral 
peroneal  muscles,  the  extensor  communis  of  the  toes  and  the  extensor 
proprius  of  the  big  toe  are  paralyzed,  causing  the  steppage  gait.  Fi- 
nally, paralysis  of  the  adductor  muscles  of  the  larynx  occurs  in  lead- 
poisoning.  The  paralysis  often  extends  from  a  local  group  of  muscles 
throughout  the  body,  presenting  symptoms  like  those  of  an  ascending 
paralysis  with  rapid  wasting.  In  other  instances  the  general  paralysis 
occurs  primarily,  the  wasting  and  loss  of  power  going  hand  in  hand. 
Fever  sometimes  attends  a  general  paralysis  in  lead-poisoning.  (d)  The 
cerebral  symptoms  of  the  acute  form  have  been  mentioned.  In  the 
chronic  cases  they  may  also  occur.      Optic  neuritis,  or  neuro-retinitis,  is 


216  GENERAL  DIAGNOSIS. 

common.  Delirium,  with  hallucination,  may  occur.  Tremor  is  a  common 
symptom.  It  must  not  be  forgotten  that  headache,  convulsions,  epi- 
lepsy, and  delirium  may  be  manifestations  of  lead  encephalopathy, 
even  in  cases  in  which  the  history  of  exposure  to  lead  is  not  direct ;  (e) 
chronic  lead-poison  leads  to  arterial  sclerosis  and  contracted  kidneys  with 
hypertrophy  of  the  heart ;  (/)  gout  is  very  common,  and  may  be  seen  in 
both  acute  and  chronic  forms,  particularly  in  the  big  toe  ;  (g)  as  described 
in  the  section  in  which  the  mouth  and  gums  are  discussed,  the  blue  line 
is  the  specific  symptom  of  lead-poisoning.  The  reader  is  referred  to 
that  chapter  for  a  description  of  the  line.  It  must  be  remembered  that 
in  all  forms  of  obscure  nervous  disease,  in  gastro-intestinal  irritation, 
in  arterio-sclerosis,  and  gouty  arthritis,  this  line  must  be  looked  for. 

Arsenic-poisoning.  Acute  arsenical  poisoning  is  attended  by 
severe  symptoms  of  gastro-intestinal  irritation  followed  by  the  rapid 
development  of  collapse.  Fever  is  not  a  prominent  symptom  unless 
recovery  is  about  to  take  place.  The  temperature  is  subnormal,  but 
as  the  collapse  symptoms  disappear  fever  due  to  gastro-intestinal  ulcer- 
ation develops. 

In  chronic  arsenical  poisoning  the  fever  occurs  only  if  there  is  great 
irritation  of  the  mucous  membranes,  as  of  the  conjunctiva,  mouth,  or 
pharnyx.  In  this  form,  in  addition  to  the  irritation  of  these  mucous 
membranes,  there  may  be  subacute  gastro-intestinal  catarrh,  with  diar- 
rhoea. In  other  instances  there  is  profound  anaemia  and  debility,  with 
parsesthesia  and  neuralgia.  In  others,  again,  paralysis  like  that  of  lead 
palsy  may  occur.  It  must  not  be  forgotten  that  puffiness  under  the 
eyelids  may  be  due  to  this  cause. 


CHAPTER    XVI. 

THE  DATA  OBTAINED  BY  OBSERVATION  -(Continued). 

Causal  relation  of  bacteria  to  disease,  Koch's  laws,  value  in  diagnosis.  Bacteria  : 
Saprophytes,  parasites,  pathogenic,  non-pathogenic,  aerobic,  anaerobic,  facul- 
tative anaerobic.  Morphology :  Micrococci,  bacilli,  spirilla — Micrococci.  Mor- 
phology :  Form  and  size.  Reproduction,  fission  ;  grouping.  Biological  char- 
acters :  Non-motile.  Pigment  production.  Liquefaction  of  gelatin.  Production 
of  acids  Toxic  ptomaines  and  toxalbumins — Bacilli.  Morphology :  Form  and 
size.  Reproduction,  fission,  spores  ;  grouping.  Biological  characters:  Motility. 
Pigment  production.  Liquefaction  of  gelatin.  Production  of  acids.  Putrefaction, 
fermentation.  Spirilla.  Morphology  :  Form  and  size.  Reproduction,  fission  ; 
grouping.  Biological  characters.  Motility.  Pigment- production.  Liquefaction 
of  gelatin.     Production  of  acids  and  fermentation  wanting. 

FEVER.     THE   INFECTIONS. 

A\te  have  already  indicated  the  diagnostic  significance  of  the  type  of 
the  fever  (Chapter  XIV.).  Following  the  lead  in  part  of  the  subjective 
symptoms,  we  next  examine  every  organ  and  structure  of  the  body 
when  the  symptom — -fever — is  present.  By  this  examination  we  will 
find  either  (1 )  a  functional  disturbance  of  some  organ  of  the  body  ;  (2) 
an  inflammation  ;  (3)  or  we  will  find  a  general  process,  or  infection,  any 
local  inflammation  being  secondary,  brain  disease  and  intoxications 
having  been  excluded. 

1.  Any  functional  disturbance  of  one  or  more  organs — glandular — 
attended  by  fever  must  be  looked  upon  as  an  intoxication.  Fevers  due 
to  such  causes  have  been  discussed  in  the  preceding  chapter,  so  we 
pass  on  to  inflammations,  toxic  and  infectious,  which  cause  fever. 

2.  Suppose  we  find  local  inflammation  of  some  part,  as  an  inflamma- 
tion of  the  nares,  a  bronchitis,  or  an  apparent  gastritis  or  enteritis. 
The  inflammation  may  be  toxic  or  it  may  be  infectious.  As  another 
example,  let  us  take  the  kidneys.  Blood,  albumin,  and  renal  casts 
would  show  that  they  are  the  seat  of  inflammation.  This  inflammation 
may  be  toxic,  as  from  cantnarid.es,  or  the  toxin  of  an  infection,  or  it 
may  be  infectious.  In  either  instance  the  fever  is  caused  by  the  local 
process.  To  determine  whether  the  inflammation  is  toxic  (generally 
catarrhal)  or  infectious,  we  must  rely  upon  the  data  obtained  by  in- 
quiry, the  clinical  course,  and  the  result  of  the  examination  described 
in  Chapter  XVII. ,  which  discloses  the  method  of  determining  the 
presence  of  an  infection. 

3.  If  the  above  are  excluded  we  proceed  with  the  bacteriological 
diagnosis.  By  this  means  we  find  if  a  general  infection  prevails.  Such 
diagnosis  may  be  necessary  also  to  recognize  pyaemia  and  septicaemia. 


218  GENERAL  DIAGNOSIS. 

The  Infections. 

It  had  long  been  surmised  that  micro-organisms  had  much  to  do 
with  morbid  processes,  and  that  the  relationship  was  that  of  cause  and 
effect.  It  was  known,  for  instance,  that  suppuration,  surgical  fever, 
erysipelas,  hospital  gangrene,  and  puerperal  fever  were  associated  with 
conditions  which  favored  the  multiplication  of  the  lower  forms  of  life. 
What  relationship  the  micro-organisms  bore  to  the  various  affections 
was  not  known.  Least  of  all  were  the  specific  micro-organisms  which 
were  the  causes  of  particular  specific  morbid  processes  known.  I  have 
said  that  it  was  surmised  ;  but  there  was  groping  about,  a  difference  of 
opinion,  and  a  maximum  of  theory,  a  minimum  of  fact.  It  is  true 
that  in  relapsing  fever  the  spirillum  had  been  found,  and  that  none 
had  been  found  in  any  other  disease.  Moreover,  it  is  true  that  mon- 
keys had  been  inoculated  and  the  disease  reproduced  in  them.  It  is 
true  that  the  bacillus  of  anthrax  had  been  seen  in  the  blood  in  the 
early  sixties.  It  is  true  that  the  great  genius  Pasteur  had  prosecuted 
studies  of  bacteria  in  animal  and  vegetable  pathology  to  most  brilliant 
and  practical  conclusions.  Nevertheless,  there  were  confusion  and 
doubt ;  scientists  were  not  satisfied  with  the  demonstrations  which 
undertook  to  prove  the  causal  relationship  of  micro-organisms  to 
disease. 

Laws  to  Establish  Causal  Relationship.  By  the  genius  of  Robert 
Koch  theories  and  objections  were  set  at  naught.  The  scientific  world 
was  fully  prepared  by  the  labors  of  early  investigators  to  accept  Koch's 
conclusions.  They  were  based  upon  an  array  of  well-authenticated 
facts,  which  anyone  could  prove  for  himself.  The  postulates  formu- 
lated by  Koch,  the  fulfilment  of  which  he  considered  as  necessary  in 
order  to  identify  an  organism  as  the  etiological  factor  in  a  given  disease, 
are  as  follows  :  The  constant  presence  of  the  organism  in  the  affected 
tissue  of  the  diseased  animal ;  its  isolation  from  the  pathological  lesions, 
and  its  continuous  cultivation  in  pure  cultures  under  artificial  condi- 
tions through  many  generations  ;  the  power  of  such  pure  cultures  to 
reproduce  the  disease  when  inoculated  into  susceptible  animals  ;  and 
the  detection  of  the  organism  in  pure  culture  in  the  lesion  found  in  the 
animal  thus  inoculated.  The  experimental  circle  was  then  repeated. 
In  this  manner  the  causal  relationship  of  micro-organisms  to  special 
diseases  had  been  proved  by  the  distinguished  investigator  in  the  case 
of  anthrax,  tuberculosis,  and  other  affections.  In  a  certain  number  of 
cases  particular  species  of  bacteria  and  other  micro-organisms  have 
been  isolated  from  definite  diseases  and  reasonably  believed  to  stand  in 
causal  relation  to  them,  but  which  have,  nevertheless,  not  fulfilled  all 
the  requirements  of  the  above-cited  postulates.  The  difficulties  often 
encountered  are  :  The  impossibility  of  reproduction  in  animals  of  the 
clinical  and  pathological  features  that  the  diseases  present  in  human 
beings,  as  is  the  case  with  typhoid  fever,  influenza,  gonorrhoea,  and 
fibrinous  or  lobar  pneumonia  ;  and  the  impossibility  of  satisfactorily 
cultivating  certain  other  organisms  that  are  the  constant  accompani- 
ment of  particular  diseases  of  man,  as,  for  instance,  the  plasmodium 
malarias,  the  bacillus  of  syphilis,  and  the  amoeba  coli. 


THE  DATA  OBTAINED  BY  OBSERVATION.  219 

The  infectious  diseases,  then,  are  those  that  are  produced  by  a  living 
contagion  or  micro-organism.  The  organism  is  introduced  into  the 
body  through  the  skin,  if  the  latter  is  the  seat  of  some  lesion,  as  in 
syphilis,  tuberculosis,  and  anthrax  ;  through  the  air-passages,  as  in 
diphtheria,  scarlet  fever,  and  other  specific  fevers  ;  or  through  the 
digestive  tract,  as  in  typhoid  fever,  dysentery,  and  cholera.  The 
virus,  as  the  living  cause  is  named,  m  many  instances  produces  certain 
changes  at  the  point  of  entrance — the  initial  phenomena.  It  is  then 
conveyed  by  the  lymphatics  or  bloodvessels  to  near-by  organs  in  the 
related  lymph-stream  or  blood-stream,  or  transmitted  to  the  whole 
body.  When  the  whole  body  is  affected  an  eruption  is  sometimes  pro- 
duced (eruptive  fever),  or  the  blood  is  changed  in  quality  (diphtheria), 
or  many  tissues  are  affected  simultaneously,  or  the  nervous  system  is 
notably  disturbed.  The  above  are  the  phenomena  of  general  distribu- 
tion of  the  virus,  or  of  infectiveness.  The  virus  or  poison  thus  distributed 
may  be  the  living  organism,  as  in  tuberculosis  or  anthrax,  or  it  may  be 
a  poison  generated  by  the  organism,  a  toxin  or  ptomaine,  as  in  diphtheria. 

Phenomena  of  secondary  local  distribution  are  due  to  local  changes 
in  organs  affected  secondarily.  The  poison  has  a  special  affinity  for 
certain  organs,  as  in  whooping-cough,  parotitis,  pneumonia,  or  leprosy. 

In  some  instances  the  local  phenomena  are  so  marked  as  to  give  to 
the  disease  a  corresponding  distinctive  feature.  They  are  the  granulo- 
mata.  Bearing  in  mind  the  above  distinctions,  specific  infectious  dis- 
eases are  divided  into  six  classes. 

First  Class.  Acute  Specific  Fevers.  The  initial  phenomena  are 
slight.  The  phenomena  of  infectiveness  are  marked  ;  an  eruption  is 
one  of  the  most  characteristic.  The  secondary  local  phenomena  are 
variable.  The  following  are  included  in  this  class  :  Typhoid  fever, 
typhus  fever,  variola,  varicella,  scarlet  fever,  measles,  relapsing  fever, 
rubella,  influenza,  dengue,  the  plague,  and  cholera. 

Second  Class.  Specific  Inflammation.  Initial  phenomena  indefi- 
nite. General  phenomena  (infectiveness)  variable,  but  no  eruption. 
Specific  affinity  of  poison  for  one  particular  structure.  Whooping- 
cough,  mumps,  diphtheria,  dysentery,  erysipelas,  tetanus,  hydrophobia, 
cerebro-spinal  meningitis,  rheumatic  fever,  and  pneumonia  belong  to 
this  class. 

Third  Class.  Contagious  or  Infectious  Suppuration.  Initial  phe- 
nomena marked  (suppuration)  ;  generalization  not  marked  unless  the 
virus  enters  the  blood  ;  secondary  local  phenomena  decisive.  Gonor- 
rhoea is  one  type,  pyaemia,  or  any  infection  from  pus-producing  micro- 
organisms, as  abscess,  carbuncle,  etc.,  a  second,  in  which  the  blood  is 
infected. 

Fourth  Class.  Infective  Granulomata.  Distinct  initial  phenom- 
ena. Phenomena  of  generalization  not  marked,  or  like  specific  fevers. 
Secondary  local  phenomena  prominent.  Examples  :  Tuberculosis, 
.syphilis,  leprosy,  and  glanders. 

Fifth  Class.     Miasmatic  Diseases.     No  initial  phenomena. 

Sixth  Class.      Vegetable  Parasitic  Disease*. 

It  is  readily  seen  that  when  the  definite  cause  of  an  infectious  disease 
is   isolated,   and  the   morphological   and   biological   properties   of    the 


220  GENERAL  DIAGNOSIS. 

causal  micro-organism  determined,  the  clinician  has  acquired  a  valu- 
able aid  to  diagnosis.  Indeed,  in  such  affections  the  bacteriological 
diagnosis  has  become  an  absolute  certainty. 

Bacteria. 

To  determine  the  micro-organism  which  causes  the  mfection  the 
student  must  be  familiar  with  the  morphology  and  biological  properties 
of  the  various  forms  of  bacteria.  (By  means  of  this  knowledge  a  bac- 
teriological diagnosis  is  made.)  The  morphology :  The  shape,  the  size, 
the  mode  of  reproduction  and  grouping  are  to  be  studied.  Bacteria  or 
fungi  are  divided  morphologically  into  micrococci  or  spherical  bacteria, 
bacilli  or  rod-shaped  bacteria,  and  spirilla  or  twisted  forms.  Bacteria 
procreate  by  simple  fission,  and  are  therefore  known  as  fission-fungi  or 
schizomycetes.  Some  forms  also  produce  spores.  The  biological  proper- 
ties include  motility,  color,  the  growth  on  various  culture-media  and 
under  various  temperatures,  and  the  product  of  vital  activity. 

Micrococci. 

Morphology.  To  this  group  belong  the  spherical  bacteria.  Each 
coccus  is  of  nearly  equal  diameter  in  all  directions.  They  vary  in  size 
from  0.1  /j.  to  1  or  2ju.  A  micromillimetre  (//)  is  one  twenty-five  thou- 
sandths of  an  inch.  The  various  micrococci  resemble  each  other  so 
much  in  form  and  size  that  they  cannot  be  distinguished  by  their  micro- 
scopic appearances.  To  distinguish  them  we  depend  on  the  color  and 
character  of  their  growth  in  various  culture-media,  on  their  pathogenic 
power,  and  on  other  biological  differences.  The  mode  of  grouping, 
after  fission  or  reproduction,  is  an  important  characteristic  by  which 
varieties  are  differentiated.  Just  before  dividing  they  are  not  perfectly 
spherical,  but  short  or  long,  oval.  After  division  (for  they  divide  in- 
definitely when  growing)  the  staphylococci  are  solitary  or  in  pairs,  or, 
occasionally,  in  groups  of  four  or  in  clusters,  roughly  likened  to  a 
bunch  of  grapes,  from  which  latter  grouping  they  derive  their  name. 
The  organism  is  called  a  diplococcus  when  associated  in  pairs.  Some- 
times two  or  four  are  included  in  a  capsule.  Zqogloea  are  groups  of 
cocci  held  together  by  a  transparent  glutinous  substance.  Streptococci 
are  characterized  by  a  grouping  in  chains,  known  as  chaplets  or  torula 
chains,  because  division  takes  place  in  one  direction  onlv.  When 
division  takes  place  in  two  directions,  groups  of  fours,  or  tetrads,  are 
formed ;  and  when  in  three  directions,  groups  or  packets  of  eight  are 
formed,  of  which  the  sardnce  are  the  most  familiar  examples.  These 
names,  significant  of  the  grouping,  refer  to  the  predominating  groups 
as  seen  in  microscopic  preparations.  In  some  of  such  groups,  for  in- 
stance, are  seen  only  diplococci  or  streptococci ;  but  in  all,  transitional, 
irregular,  and  accidental  groupings  may  be  observed. 

Biological  Characteristics.  Micrococci  are  not  motile  and  do  not 
form  spores.  Products  of  vital  activity :  The  various  forms  of  bacteria 
are  also  distinguished  by  noting  the  difference  in  the  products  of  vital 
activity.  Of  these,  pigment-production  is  one  of  the  most  apparent. 
The  staphylococcus  pyogenes  aureus  and  citreus  are  chromogenic  or  pig- 


TE    111 


Fig     2. 


A ^   V     ^  i\ 


*$$M 


A.  Tubercle-bacilli.  B.  Pueumococcus. 

Fig.  S. 


A.  Anthrax.  B.  Streptococcus  and  Staphylococcus. 

Fig .   4. 


A.  Comma-bacillus.      B.  (ionococcus. 
Fite 


A .   Recurrent  Spirilla.       B.  Leprosy. 

Fig     S 


.•T  Normal  Blood.       B.  Normal  Blood. 


A.  Leukaemia.       B.  Ebertli's  Bacillus. 


THE  DATA  OBTAINED  BY  OBSERVATION.  221 

merit-producing  bacteria.  The  liquefaction  of  gelatin,  when  cultures 
are  made,  is  a  biological  characteristic  which  assists  in  the  diagnosis  of 
the  various  species.  Some  pathogenic  as  well  as  non-pathogenic  germs 
have  this  effect  on  the  nutrient  medium  ;  others  of  both  classes  do  not 
affect  it.  A  peptonizing  ferment  is  formed  during  the  growth  of  cells 
which  acts  upon  and  dissolves  the  gelatin.  The  amount,  degree,  and 
character  of  the  liquefaction  serve  to  distinguish  various  species.  The 
staphylococcus  pyogenes  aureus  and  albus  (as  well  as  some  others)  are 
liquefying  micrococci.  Production  of  acids:  Many  bacteria  produce 
an  acid — lactic  acid,  acetic  acid,  butyric  acid — which  gives  an  acid 
reaction  to  the  culture-media.  This  may  be  seen  if  a  neutral  litmus 
solution  has  been  added  to  the  gelatin.  The  pink  color  produced  indi- 
cates the  presence  of  an  acid.  Culture-media,  it  must  be  remembered, 
are  alkaline  or  neutral.  The  pathogenic  micrococci  which  produce  an 
acid  are  the  staphylococci  of  pus — lactic  acid. 

Putrefactive  fermentation  is  set  up  by  bacilli  and  not  by  micrococci. 
Other  products  of  vital  activity  need  not  concern  us,  as  they  are  pro- 
duced by  non-pathogenic  forms. 

Toxic  ptomaines  and  toxalbumins  are  products  of  many  forms  of  patho- 
genic bacteria,  and  cause  the  symptoms  of  infective  diseases  in  many 
instances  ;  thus  in  diphtheria  the  local  infective  inflammation  represents 
the  seat  of  activity  of  the  bacillus,  the  point  at  which  its  poisons  are 
being  manufactured  at  the  expense  of  the  tissues  in  and  on  which  it  is 
growing ;  the  general  symptoms  are  due  to  the  toxalbumin  that  has 
been  absorbed  by  the  circulating  fluids  from  this  local  seat  of  action. 
The  isolation  and  detection  of  the  toxalbumins  are  not  sufficiently  easy 
to  warrant  such  a  mode  of  investigation  for  diagnostic  purposes.  Often 
the  results  of  inoculation,  by  which  the  lethal  effect  is  produced,  aid  in 
the  diagnosis  of  the  suspected  ailment.     (See  Plate  III.,  Fig.  2,  b.) 

The  Bacilli. 

Morphology.  The  bacilli,  or  rod-shaped  bacteria,  differ  widely  in 
form,  in  size,  and  in  modes  of  grouping  after  fission.  Form  and  size : 
The  longitudinal  diameter  is  greater  than  the  transverse,  and  the 
forms  vary  from  short  oval  or  slender  rods  to  long  filaments  ;  some- 
times short  rods  and  long  filaments  are  seen  in  pure  cultures  of  the 
same  bacillus,  as  in  the  typhoid  bacillus.  The  transverse  diameter  of 
a  given  species  does  not  vary,  as  a  rule.  The  form  of  the  extremities 
of  the  rods  must  be  observed.  They  may  be  square,  slightly  rounded, 
round,  oval,  or  lance-shaped  or  spindle-shaped.  Reproduction  and 
grouping:  Fission  or  reproduction  takes  place  by  binary  division, 
transverse  to  the  longitudinal  axis.  They  group  in  long  chains,  or  are 
solitary  or  united  in  pairs.  They  may  be  surrounded  by  a  capsule  or 
collect  in  zooglcea  masses. 

Spores.  When  conditions  unfavorable  to  continuous  multiplication 
by  transverse  division  arise  certain  bacilli  possess  the  property  of 
entering  into  a  permanent  or  resting  stage.  In  this  case  there  de- 
velops within  the  body  of  the  bacillus  an  oval,  egg-shaped  structure — 
an  endogenous  spore.     The  spore  represents  the  inactive  stage,  and  lies 


222  GENERAL  DIAGNOSIS. 

dormant  until  circumstances  favorable  to  growth  reappear,  when  it 
develops  into  a  bacillus  identical  with  that  from  which  it  was  formed. 
Spores  do  not  develop  into  spores  but  into  bacilli.  The  spores  retain 
their  vitality  for  months  or  years,  and  resist  desiccation.  They  are 
spherical  or  oval,  and  highly  reproductive.  They  are  formed  by  con- 
densation of  protoplasm  at  the  centre  or  at  one  end  of  the  bacillus, 
where  they  are  retained  in  a  linear  position  until  set  free.  Some 
bacilli  grow  into  long  filaments  during  spore-formation  ;  others  change 
their  shape,  swelling  at  the  centre,  becoming  spindle-shaped  or  club- 
shaped,  according  to  the  location  of  the  spore  within  it.  Many  bacilli 
do  not  change  their  shape  at  this  stage.  The  spores  are  free  or  col- 
lected in  masses  with  the  bacilli  as  well  as  located  in  the  parent  bacillus. 

Motility.  The  bacilli  are  often  actively  motile,  because  of  the 
presence  of  flagella.  The  movement  is  one  of  progression  in  different 
directions.  It  may  be  slow  and  deliberate,  in  a  to-and-fro  motion,  or 
serpentine,  or  a  quick,  darting  forward  motion. 

Biological  Characters.  Products  of  vital  activity.  They  may  be 
ascertained  in  the  same  manner  as  in  the  study  of  micrococci.  Pig- 
merit-production  is  seen  in  cultures  of  the  bacillus  pyocyaneus  or  bacil- 
lus of  green  pus,  of  which  there  are  several  varieties  producing  various 
shades  of  blue  or  fluorescent  green.  Liquefaction  of  gelatin :  This  is 
produced  by  the  bacillus  anthracis  and  the  bacillus  pyocyaneus,  the 
"  comma  "  bacillus  of  cholera  and  many  other  species.  Production  of 
acids :  The  bacillus  coli  communis  produces  lactic  acid.  Fermentation : 
The  latter  bacillus  sets  up  fermentation  of  carbohydrates,  as  of  glucose, 
lactose,  and  saccharose.     (See  Plate  III.) 

The  Spirilla. 

Morphology.  They  are  seen  in  the  form  of  curved  rods  or  spiral 
filaments.  The  shorter  ones  are  curved,  the  longer  are  spiral,  like  a 
corkscrew.  The  curved  filaments  may  be  short  and  rigid,  or  long  and 
flexible. 

Reproduction.     They  reproduce  by  binary  division  (fission). 

Biological  Characters.  Motility.  They  are  motile  ;  the  move- 
ment is  rotary,  as  well  as  progressive  in  the  direction  of  the  long  axis 
of  the  filament.  The  presence  of  flagella  is  determined  by  Loffler's 
method  of  staining.  They  are  single  at  the  ends  of  rods,  or  several 
are  seen  at  one  extremity,  or  one  or  more  may  occur  at  both  ends. 
Pigment-production:  Pathogenic  spirilla  do  not  produce  pigment. 
Liquefaction  of  gelatin:  The  spirillum  of  cholera  Asiatica  (comma 
bacillus)  and  the  spirillum  of  cholera  nostras  (Finkler  and  Prior)  both 
liquefy  gelatin  in  a  peculiar  manner.     (See  Plate  III.,  Fig.  4,  a.) 


CHAPTER    XVII. 

THE  DATA  OBTAINED  BY  OBSEEVATION— {Continued). 

Data  obtained  by  inquiry — By  observation.  Local  infection— General  infection. 
Pyaemia ;  septicaemia.  Terminal  infections.  Fever  in  carcinoma.  Afebrile 
infections.  Infections  of  certain  bacteriology;  of  uncertain  bacteriology.  Bac- 
teriological diagnosis.  Method  of  research  :  Microscopical  examination,  culti- 
vation, inoculation.  Essentials  in  technique. — Method  of  research :  Blood,  dis- 
charges, exudations;  mode  of  collection.  Apparatus.  Preparation  of  apparatus. 
Sterilization.  Microscopical  examination  :  Technique,  cover-glass  preparations. 
Methods  of  staining;  spores.  "Hanging  drop" — Cultivation  of  micro-organ- 
isms. Culture-media.  Tube-  and  plate  cultures.  Smear-  and  stab-cultures — 
Inoculation  of  animals — Special  bacteriological  diagnosis. 

FEVER.     THE  INFECTIONS. 

Unfortunately,  the  cause  of  many  of  the  infectious  diseases  has 
not  been  definitely  isolated.  This  group  is  largely  the  infectious 
disorders  which  are  epidemic  and  contagious.  In  order  to  diagnosti- 
cate them  it  is  necessary  to  associate  with  the  mode  of  onset  and  clini- 
cal course  of  the  disease  the  facts  and  laws  pertaining  to  epidemics  and 
to  contagion.  Data,  therefore,  obtained  by  inquiry  are  quite  necessary 
to  establish  the  diagnosis.  Such  data  are  useful  in  confirming  the 
results  of  an  objective  or  bacteriological  examination  of  the  patient, 
even  though  the  diagnosis  be  at  once  established  by  the  latter  method. 

Data  Obtained  by  Inquiry.  In  the  first  place,  we  note  the  social 
history,  learning  this  while  preparing  for  the  objective  examination. 
It  should  be  personal  and  general.  The  age,  the  sex,  the  habits,  the 
occupation,  are  looked  into.  The  nature  of  the  prevailing  diseases  in 
the  community  are  known  or  sought  for,  and  all  possible  unusual  cir- 
cumstances in  food,  drink,  clothing,  are  inquired  for.  In  short,  a  his- 
tory of  exposure  to  influences  which  attend  an  intoxication  or  those 
which  permit  infection  are  to  be  zealously  sought  for. 

An  inquiry  for  previous  diseases  does  not  imply  a  history  alone  of  a 
previous  infectious  disease,  but  a  history  of  such  diseases  as  are  often 
followed  by  infection.  Thus,  a  history  of  a  previous  attack  of  gall- 
stones or  of  renal  calculus  may  be  a  clue  to  the  localization  of  an  infec- 
tious process.  Too  much  stress  cannot  be  laid  upon  the  diagnostic 
value  of  the  data  obtained  in  this  manner. 

The  next  data  obtained  by  inquiry  is  the  history  of  the  present,  dis- 
ease. The  mode  of  onset  is  of  itself  suggestive.  Sudden  onset  points 
more  closely  to  an  intoxication,  though  not  necessarily,  although  more 
likely  in  children.  Otherwise  sudden  onset  usually  indicates  one  of 
the  short  infections,  of  which  scarlatina  and  pneumonia  are  representa- 


224  GENERAL  DIAGNOSIS. 

tive  types  ;  while  gradual  onset,  a  long  infection,  of  which  typhoid 
fever  is  a  type. 

The  subjective  symptoms  are  then  inquired  for  and  their  site  affords 
a  clue  as  to  the  steps  to  be  taken  in  the  objective  examination.  Thus, 
pain  in  the  throat  with  difficulty  in  swallowing  calls  for  an  examination 
of  the  fauces  ;  pain  in  the  chest,  of  the  lungs  ;  in  the  prsecordia,  of  the 
heart,  etc.  Any  functional  disturbance  of  an  organ  should  also  lead  us 
to  a  study  of  it. 

Data  Obtained  by  Observation.  The  appearance  of  the  inflam- 
matory process  may  be  sufficient  to  decide  its  nature,  however — a  boil, 
an  abscess,  a  carbuncle,  which  gives  rise  to  more  or  less  fever,  because 
they  are  local  infections,  are  readily  recognized. 

Local  Infection.  When  not  preceded  or  accompanied  by  any  pro- 
cess elsewhere  the  infection  is  said  to  be  local.  An  appendicitis,  a 
cholangitis,  an  inflammation  of  a  serous  membrane,  as  well  as  a  boil  or 
carbuncle,  may  be  a  local  infection.  In  like  manner  the  accidental 
wound  of  a  surgeon  by  which  he  is  inoculated  or  infected  by  the  micro- 
organism of  the  pus  may  be  an  infection.  The  natural  or  acquired 
wounds  of  the  puerperium  may  also  be  infections.  A  local  infection 
here  arises.  It  must  be  borne  in  mind  that  any  local  inflammation  may 
be  infectious.  It  is  not  our  purpose  to  consider  here  local  infections. 
Some,  indeed  nearly  all,  of  the  streptococcus  and  staphylococcus  infec- 
tions are  local.  The  general  symptoms  are  produced  by  a  toxaemia, 
the  toxin  alone  passing  into  the  blood. 

General  or  Systemic  Infections.  General  infections  alone,  and 
those  winch  may  have  more  pronounced  local  expression,  as  pneu- 
monia or  the  pneumococcus  infection,  are  discussed.  It  is  of  importance, 
however,  to  remember  that  in  determining  whether  a  local  inflamma- 
tion is  infectious  or  not,  we  use  the  same  methods  that  are  employed  to 
determine  the  nature  of  a  general  infection. 

It  is  also  important  to  remember  that  a  local  infection  may  be  circum- 
scribed and  cause  a  toxic  fever.  On  the  other  hand,  a  small  portion  of 
the  purulent  exudate  from  the  infection  may  get  into  the  circulation 
and  be  carried  to  distant  parts,  as  the  brain,  the  lungs,  the  kidney,  the 
joints,  the  spleen.  Distant  foci  of  inflammation  are  set  up,  giving  rise 
to  multiple  small  abscesses  in  the  organs  affected.  Pycemia  is  the  name 
of  this  form  of  systemic  infection.  Finally,  such  local  infection  may 
become  general  and  the  case  terminate  in  septicmnia. 

Pyaemia  is  characterized  by  rigors,  fever,  usually  intermittent,  and 
sweats.  There  is  exhaustion  ;  the  skin,  is  slightly  icterode.  The  odor 
of  the  breath  is  sweet.  There  is  anorexia,  nausea,  perhaps  vomiting, 
frequently  diarrhoea.  Erythematous  eruptions  are  seen.  With  these 
general  symptoms  there  are  present  the  physical  signs  of  abscess  in  the 
lungs  or  the  spleen  or  other  organs  of  the  body,  or  we  may  have  an 
endocarditis.  When  the  affection  is  limited  to  the  portal  area,  and 
multiple  abscesses  of  the  liver  succeed  a  purulent  process  in  the  area 
of  the  portal  vein,  the  general  symptoms  are  combined  with  enlarge- 
ment of  the  liver,  which  is  tender  and  painful,  and  perhaps  with  deeper 
jaundice.  The  micro-organisms  which  invade  the  system  and  cause 
areas  of    suppuration  are  the   streptococcus  and  staphylococcus  pyo- 


THE  DATA  OBTAINED  BY  OBSERVATION.  225 

genes,  the  micrococcus  lanceolatus,  the  gonococcus,  the  bacillus  coli 
communis,  the  bacillus  typhi  abdominalis,  the  bacillus  proteus,  the 
bacillus  pyocyaneus,  the  bacillus  influenzae,  and  the  bacillus  aerogenes 
capsulatus. 

Diagnosis.  Pyaemia  resembles  in  many  respects  tuberculosis  of  the 
kidneys  and  calculous  pyelitis,  in  both  of  which  recurring  rigors  and 
sweats  are  common.  In  gross  aspects  it  resembles  malaria.  (See  Inter- 
mittent Fever.)  In  prolonged  cases  of  pyaemia  the  symptoms  may 
resemble  typhoid  fever,  but  leucocytosis  is  present  in  the  former  con- 
dition. Ulcerative  endocarditis  and  acute  miliary  tuberculosis  usually 
resemble  septicaemia,  but  may  be  confounded  with  pysemia.  Any  febrile 
process  associated  with  chills  may  be  taken  for  pyaemia.  These  phe- 
nomena are  seen  in  grave  anaemias,  in  Hodgkin's  disease,  in  hepatic 
intermittent  fever,  and  in  the  intermittent  fever  of  carcinomatosis. 
(See  Chills,  Chapter  XIV. )  Post-febrile  arthritis,  after  scarlet  fever 
and  gonorrhoea,  is  in  all  probability  pyaemic.  Of  course,  we  rely  in  the 
diagnosis  of  pysemia  upon  the  data  obtained  by  bacteriological  methods 
when  their  employment  is  practical. 

Septicaemia.  Again,  we  may  find  with  the  above-described  wound,  or 
without  any  apparent  local  inflammation,  fever,  which  is  more  or  less 
continuous.  In  addition  there  may  be  an  occasional  rigor.  The  pulse 
is  rapid,  exhaustion,  anaemia,  and  some  emaciation  are  present.  Sec- 
ondary infection  of  other  structures  may  or  may  not  be  present. 
Microbic  infection  of  the  blood  usually  takes  place.  The  process  is  a 
septiecemia.  If  it  originates  from  a  local  infection  it  is  known  as  pro- 
gressive septicemia.  If  independently  of  any  apparent  local  infection 
it  is  a  cryptogenetic  septicaemia.  The  former  is  easily  recognized,  par- 
ticularly if  there  is  a  history  of  a  primary  local  infectious  process. 
The  micro-organisms  which  may  give  rise  to  the  latter  are  the  staphy- 
lococcus pyogenes,  the  streptococcus  pyogenes,  the  bacillus  proteus,  the 
bacillus  pyocyaneus,  and  the  micrococcus  lanceolatus.  It  is  recognized 
by  a  bacteriological  diagnosis. 

The  accompanying  chart  (Fig.  42)  represents  the  course  of  an  infec 
tion  and  various  areas  of  secondary  infection  in  a  general  septicaemia. 
The  illness  extended  over  a  period  of  thirty-five  days.  The  first  five 
days,  as  indicated  by  the  chart,  there  was  pneumonia  at  the  base  of  the 
left  lung.  The  crisis  only  is  represented.  From  the  tenth  to  the 
twenty-first  day,  to  save  space,  the  chart  does  not  give  the  tempera- 
ture range.  During  this  time  the  fever  was  continuous.  On  the 
twelfth  the  right  pleura  was  infected  ;  on  the  nineteenth  the  fem- 
oral vein  of  the  right  leg,  the  temperature  not  rising  above  101°.  On 
the  twenty-first,  as  the  chart  indicates,  a  patch  of  pneumonia  was  found 
in  the  right  lung  posteriorly.  On  the  twenty-fourth  pseudocrisis,  and 
on  the  twenty-fifth  and  twenty-sixth  the  true  crisis  took  place.  On 
the  twenty-ninth  and  thirtieth  there  was  reinfection  of  the  pleura  of 
the  left  side.  On  April  3d  phlebitis  of  the  femoral  vein  of  the  left  leg 
developed.  During  the  course  of  the  disease  there  was  a  low-pitched 
endocardia]  murmur,  which  in  all  probability  was  anaemic.  Sweats, 
attacks  of  collapse,  and  irregular  rigors  took  place.  Life  was  imperiled 
at  the  time  of  the  collapse.     The  spleen  was  enlarged  ;  the  sputa  con- 

15 


226 


GENERAL  DIAGNOSIS. 


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THE  DATA  OBTAINED  BY  OBSERVATION. 


227 


tained  pneumococci.  The  blood  examination  was  negative.  The 
patient  recovered. 

Fever,  varying  in  type,  sweats,  emaciation,  anaemia,  and  exhaustion 
are  the  common  general  symptoms.  The  pulse  is  increased  in  fre- 
quency, and  is  dicrotic  and  compressible.  The  heart  sounds  grow 
weak,  the  breathing  hurried.  There  is  slight  delirium  at  times.  The 
urine  contains  albumin  and  casts.  It  is  scanty,  high  colored,  and  of 
high  specific  gravity.  In  some  forms  there  is  leucocytosis.  There  is 
anorexia,  nausea,  and  vomiting,  often  diarrhoea.  As  the  case  advances 
the  symptoms  of  the  typhoid  state  develop.    (See  Chapter  XIV.) 

Objective  Signs  of  Septicaemia.  In  other  instances  there  is 
marked  evidence  of  a  septic  process  in  the  structures  which  carried  the 
poisoned  or  infected  blood  from  the  primary  point  of  entrance  of  the 
infecting  material — the  infection  atrium.     Hence  in  this  infectious  pro- 

FiG.  43. 


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cesS — in  septicaemia — we  may  see  lymphangitis  and  adenitis.  The 
spleen  is  enlarged.  There  may  be  phlebitis,  especially  of  the  femoral, 
inflammation  of  which  is  always  infectious  in  character.  Other  veins 
may  be  affected.  The  endocardium  is  infected,  and  indeed  endocarditis 
may  be  the  chief  symptom-complex  of  the  septic  process.  The  serous 
membranes  may  be  involved,  so  that  septic  pleurisy  or  meningitis  or 
pericarditis  or  peritonitis  or  arthritis,  singly  or  combined,  may  be  local 
expressions  of  the  sepsis.  Hemorrhages  from  the  mucous  membranes, 
or  subcutaneously,  either  because  the  blood  is  destroyed  (toxic)  or  be- 
cause of  multiple  small  infarcts,  frequently  attend  septicaemia,  Hemor- 
rhages may  be  the  most  pronounced  symptom  of  certain  forms  of  in- 
fection, as  that  due  to  capsulated  bacilli.  A  slight  jaundice  of  toxic 
origin  may  prevail. 

Toxic  Symptoms.     In  some  instances  there  is  a  profound  to.ixcmia  in- 
dicated by  delirium,   stupor,   and  later   coma  and  convulsions.     The 


228  GENERAL  DIAGNOSIS. 

typhoid  state  may  predominate.  The  intoxication  may  overwhelm 
the  cardio-vascular  centres.  The  pulse  grows  rapid  and  feeble,  the 
respirations  hurried  and  shallow.  The  urine  is  diminished  in  amount 
and  contains  albumin. 

The  clinical  course  varies  with  the  infective  agent.  Streptococcus 
infections  are  characterized  by  chills,  high  fever,  and  an  extreme  septic 
state.  Infection  by  the  capsulated  bacilli  (Howard)  gives  rise  to  a 
hemorrhagic  septicaemia.  In  other  infections  the  greater  part  of  the 
clinical  course  may  be  afebrile.  Toxic  symptoms,  and  especially  in- 
creased frequency  of  jmlse-rate  with  collapse  phenomena,  are  present, 
as  in  forms  of  infectious  peritonitis. 

A  general  infection,  or  this  general  expression  of  septicaemia,  occurs 
in  the  course  of  diseases  in  which  the  clinical  course  of  the  infectious 
process  is  usually  a  definite  one.  Hence  we  speak  of  typhoid  septi- 
caemia or  a  pneumococcus  septicaemia  when  the  intoxication  or  general 
infection  is  paramount  to  the  local  process.  Then  in  tuberculosis  and 
other  prolonged  infections  septicaemic  symptoms  arise,  so  that  the  ter- 
minal phenomena  of  the  disease  are  usually  due  to  a  mixed  infection. 
It  must  then  be  understood  that  pycemia  or  septicemia  or  septico- 
pyemia are  not  due  to  special  micro-organisms  in  the  sense  that 
typhoid  fever  is  due  to  the  bacillus  typhosus,  malaria  to  the  plasmo- 
dium,  or  pneumonia  to  the  pneumococcus. 

Terminal  Infections.  At  the  termination  of  many  chronic  diseases, 
as  the  various  fibroid  affections — cirrhosis  of  the  liver,  the  kidneys, 
endarteritis,  or  spinal  cord  disease,  and  in  carcinoma — there  is  fever. 
This  is  generally  due  to  an  infection  which  the  weakly  resisting  organ- 
ism invited. 

Flexner  has  studied  the  terminal  infections.  In  255  cases  of  renal 
and  cardiac  disease  he  found  213  infections,  excluding  tuberculosis. 
They  were  local  and  general.  Infections  of  the  serous  membranes  are 
the  most  common.  The  old  clinical  fact  that  serous  inflammations 
were  complications  of  Bright' s  disease  has  been  proven  by  bacteriologi- 
cal methods  to  be  due  to  an  infection,  and  not  as  formerly  thought  to  a 
chemical  change  in  the  blood.  The  following  micro-organisms  are  met 
with  :  the  streptococcus  pyogenes,  the  pneumococcus,  the  staphylococ- 
cus aureus,  the  bacillus  proteus,  the  gonococcus,  the  bacillus  pyocy- 
aneus,  and  the  gas  bacillus. 

Tuberculous  infection  is  also  a  terminal  process  in  many  diseases. 
Frequently  an  acute  tuberculosis  of  serous  membranes  is  found  in  the 
course  of  chronic  heart  or  kidney  disease. 

Fever  in  Carcinoma  Fever  occurs  in  the  course  of  carcinoma 
under  two  circumstances.  If  it  is  proven  that  carcinoma  is  an  infec- 
tion this  process  is  one  cause  of  the  fever.  It  is  well  known,  however, 
that  in  rapidly  growing  cancer  of  the  liver,  fever,  often  intermitting  in 
type,  is  present.  It  may  also  be  present  in  general  carcinoma,  and  in 
all  probability  in  carcinoma  of  the  lungs  and  of  the  bones.  But  fever 
in  the  course  of  cancer  may  be  due  to  a  secondary  infection.  It  can  be 
readily  understood  that  the  process  is  likely  to  take  place  if  the  malig- 
nant disease  occurs  in  the  course  of  any  of  the  tubes  or  channels.  The 
infection  atrium,  is  the  inflammation  or  ulceration  found  so  often  in 


THE  DATA  OB  TA  IN  ED  B  Y  OBSER  VA  TION.  229 

carcinoma,  and  in  consequence  local  suppuration  occurs.  From  this 
local  infection  a  general  septicaemia  may  arise. 

Afebrile  Infection.  Although  most  infections  cause  such  reaction 
of  the  system  as  to  produce  fever,  some  few  are  afebrile.  Such  is  the 
case  with  tuberculosis — when  it  is  local — and  of  syphilis  in  certain 
stages.  The  writer  is  of  the  belief  that  when  the  syphilitic  poison  is 
active — i.  e.,  productive  of  lesions — fever  is  present  some  time  during  the 
twenty-four  hours.  He  is  fully  persuaded  that  mistakes  are  made 
because  fever  is  not  considered  a  part  of  the  syphilitic  infection.  He 
has  seen  it  in  all  of  the  arbitrarily  called  stages  of  infection,  and  pre- 
senting all  types  of  fever — intermittent,  remittent,  and  continuous. 
The  rise  may  be  moderate  or  very  pronounced.  For  its  detection  the 
thermometer  should  be  employed  every  two  hours. 

Typhoid  fever  is  an  example  of  an  infection  which  sometimes  runs 
its  course  without  rise  in  temperature.  This  is  very  rare,  but  never- 
theless does  at  times  occur. 

Infections  of  Certain  Bacteriology.  In  our  investigation  of  the 
cause  of  the  fever  in  a  suspected  case  we  have  found  evidence  of  an 
infection  as  shown  by  (1)  the  phenomena  of  a  local  inflammation,  (2) 
by  the  presence  of  pyaemia  or  (3)  of  septicaemia.  The  clinical  course 
alone  enables  one  to  make  a  diagnosis  generally.  At  times  we  may 
have  to  resort  to  more  positive  methods.  The  nature  of  the  process, 
however,  is  usually  proven  ;  the  nature  of  the  infection  must  be  decided 
by  bacteriological  examination.  We  must,  therefore,  follow  this  mode 
of  recognition  of  an  infection. 

Infections  of  Uncertain  Bacteriology.  The  presence  of  those 
infections,  the  bacterial  cause  of  which  is  not  known,  must  be  deter- 
mined somewhat  differently.  In  one  group  we  must  be  content  with 
the  data  obtained  by  inquiry  and  by  observation,  comparing  the  symp- 
toms with  the  known  course  of  a  similar  disease.  Scarlet  fever  can 
only  be  recognized  in  this  way.  In  subsequent  chapters,  therefore,  the 
infections  are  divided  into  those  recognized  by  inquiry  and  observation, 
and  those  recognized  by  supplementary  observation  with  bacteriological 
methods. 

The  classification  of  the  infectious  diseases  is  based  upon  the  fact 
that  a  specific  micro-organism  is  known  which  gives  rise  to  phenomena 
similar  in  the  respective  infections.  In  other  words,  the  infection  of 
malaria  or  of  tuberculosis  or  of  diphtheria  follows  a  recognized  clinical 
course.  The  period  of  invasion,  the  mode  of  onset,  the  symptoms 
throughout  the  course  of  the  disease,  are  with  notable  exceptions  prac- 
tically the  same. 

Bacteriological  Diagnosis. 

Bacteriological  examination  includes  (1)  the  finding  of  the  specific 
micro-organism  in  the  blood  or  tissues  (of  the  subject)  or  in  the  patho- 
logical secretions  or  excretions  ;  (2)  the  isolation  and  cultivation  of  the 
micro-organism  ;  (3)  the  inoculation  and  the  reproduction  thereby  of 
the  disease  in  animals.  In  many  infections  the  morphological  pecu- 
liarities of  the  micro-organism  are  so  characteristic  that  a  diagnosis  may 
be  established  by  finding  it  in  the  blood  or  the  secretions.     Thus  an 


230  GENERAL  DIAGNOSIS. 

examination  of  the  blood,  with  or  without  staining,  will  disclose  the 
presence  of  the  micro-organism  of  relapsing  fever  and  of  anthrax  and 
the  protozoa  of  malaria.  The  examination  of  inflammatory  products 
of  an  inf  ection,  as  the  sputa  in  pneumonia  or  tuberculosis,  are  sufficient 
to  determine  the  nature  of  the  infectious  inflammation  of  the  lungs. 
On  the  other  hand,  in  some  infections,  the  absence,  or  rather  failure  of 
detection,  of  the  micro-organism  in  the  fluids  or  discharges  is  not  proof 
that  the  disease  is  not  present  in  the  suspected  individual.  The  infec- 
tion tuberculosis  well  illustrates  the  propositions  in  the  last  two  sen- 
tences. If  the  bacillus  is  found  in  the  sputum  of  a  suspected  case  the 
diagnosis  is  established  definitely,  and  no  further  procedures  for  diag- 
nostic purposes  are  necessary.  In  other  clinical  forms,  as  tuberculous 
pleurisy,  or  empyema,  or  glandular  or  joint  tuberculosis,  the  micro- 
organisms are  few  and  difficult  to  find.  Cultures,  or,  more  conclusive 
still,  inoculations,  must  frequently  be  resorted  to  before  a  final  conclu- 
sion can  be  arrived  at.  It  is  possible  that  spores  alone  exist — morpho- 
logical elements  difficult  to  detect  by  staining  and  microscopical 
methods,  but  which  may  rapidly  multiply  under  favorable  culture 
conditions  or  inoculation  conditions.  Again,  micro-organisms  have 
been  found  in  certain  infections,  and  although  thus  far  their  causal 
relationship  to  them  has  not  been  fully  proved,  nevertheless  their  con- 
stant occurrence  in  the  special  affection,  and  in  it  alone,  renders  their 
presence  of  high  diagnostic  value.  Thus  the  amoeba  of  dysentery  and 
the  plasmodium  malarise  of  Laveran  are  diagnostic  of  their  respective 
affections. 

For  diagnostic  purposes  bacteriological  investigations  must  be  con- 
ducted in  accordance  with  the  methods  of  bacteriology.  Such  researches 
are  possible  at  this  time,  because  of  (1)  the  high  degree  of  development 
and  mode  of  use  of  optical  apparatus,  including  oil-immersion  lenses, 
Abbe's  condenser  and  diaphragms  ;  (2)  the  discoveries  by  AVeigert  of 
the  effects  of  aniline  dyes  on  protoplasm,  and  the  property  of  micro- 
organisms of  taking  different  stainings  ;  (3)  of  the  principles  of  steril- 
ization by  heat,  by  which  foreign  micro-organisms  are  excluded  ;  (4) 
of  the  use  of  solid  culture-inedia,  and  the  plate-method  of  obtaining 
pure  cultures  suggested  by  Koch. 

Method  of  Procedure. 

To  determine  the  presence  of  moist  infections  it  is  necessary  to  pro- 
ceed as  follows  : 

A.  Examination  of  the  blood. 

B.  Examination  of  the  pathological  secretions  and  excretions. 

C.  Examination  of  products  of  infectious  inflammation  secured  by 
exploratory  puncture  or  evacuation  of  abscesses.    (See  Chapter  XXI.) 

D.  Inoculations  of  animals  with  pure  cultures  of  the  organism  or  with 
the  products  of  inflammation,  as  cheesy  matter  from  a  tuberculous  abscess. 

E.  The  use  of  products  of  bacterial  growth  to  secure  reaction,  as 
tuberculin  in  tuberculosis,  and  mallein  in  glanders.    (See  Tuberculosis.) 

When  there  is  no  distinctive  pathological  fluid  all  the  fluids  of  the 
body  must  be  examined.     In  other  cases  the  pathological  discharge 


THE  DATA   OBTAINED  BY  OBSERVATION.  231 

(pus),  or  perhaps  the  diseased  tissue,  must  be  studied.  We  get  a 
clue  to  the  direction  which  the  examination  is  to  take  from  the  nature 
of  the  symptoms.  In  cases  of  pulmonary  disease,  the  sputum  ;  of 
faucial  disease,  the  membrane,  pus,  or  other  secretions  from  the  fauces  ; 
in  intestinal  disease,  the  discharge  from  the  bowels  ;  and  in  genito- 
urinary disease,  the  urine.  It  must  not  be  forgotten  that  in  many, 
even  highly  fatal  diseases,  the  blood  is  not  invaded  by  micro-organ- 
isms. Death  is  due  to  the  development  of  toxic  substances.  Hence, 
as  in  cholera  and  diphtheria,  the  presence  of  the  micro-organism  is  not 
sought  for  in  the  blood,  but  in  the  specific  excretion  or  exudation. 
(See  Tuberculosis.) 

The  Apparatus.  The  apparatus  necessary  for  the  simplest  bacte- 
riological research  comprises  the  following :  Sterilizers,  incubators, 
glass  flasks,  covered  dishes,  test-tubes  and  plates,  platinum  needles 
fixed  in  glass  handles,  raw  cotton,  materials  for  culture-media,  micro- 
scope, with  slides  and  cover-glasses,  and,  in  addition  to  lenses  of  lower 
powers,  a  one-twelfth  oil-immersion  lens,  and  finally  the  various  stains 
used. 

Prepaeatiox  of  Apparatus.  Boil  all  glassware  for  half  an  hour 
in  a  solution  of  common  soda  (2  to  3  per  cent.),  then  scrub  thoroughly  ; 
rinse  in  warm  solution  of  HC1  (1  per  cent.)  and  then  in  pure  water ; 
drain  with  tops  down  ;  plug  tubes  and  flasks  with  raw  cotton,  fitting 
firmly  and  evenly,  so  that  the  cotton  can  hold  the  weight  of  the  test- 
tube  ;  sterilize  in  dry  oven.  The  test-tubes  (plugged)  are  placed  in  a 
rack  for  further  use. 

The  tubes  and  flasks  are  best  filled  with  the  culture-media  through 
a  spherical  funnel  that  can  be  plugged  with  cotton.  Then  they  are 
to  be  sterilized  in  the  steam  sterilizer,  as  heretofore  described. 

The  cover-glasses  must  be  thorouffhlv  cleansed  bv  immersion  in 
strong  nitric  acid  for  a  few  hours,  then  rinsed  in  water,  then  in  alcohol 
and  ether.     They  are  then  kept  in  alcohol. 

Sterilization.  It  should  be  understood  that  the  first  requisite  for 
the  prosecution  of  these  studies  is  to  secure  absolute  cleanliness  and  to 
prevent  the  invasion  of  extraneous  micro-organisms.  The  first  step  is 
thorough  sterilization  of  all  appliances  required  for  work  and  of  all  the 
media,  to  destroy  previously  existing  bacteria. 

The  sterilization  is  best  accomplished  with  steam,  where  the  objects 
to  be  sterilized  admit  of  it.  With  dry  heat  a  temperature  of  at  least 
150°  C.  must  be  applied  for  at  least  an  hour,  and,  of  course,  can  only 
be  used  for  glassware  and  metal  instruments.  All  media  (see  page 
159),  whether  solid  or  fluid,  are  sterilized  by  steam.  Media  which 
cannot  withstand  long  exposure  to  the  necessary  heat  are  sterilized  by 
the  intermittent  application  of  steam.  The  reason  that  this  is  effective 
is  that  fully  developed  bacteria  are  destroyed  at  a  much  lower  temper- 
ature and  with  shorter  exposure  than  are  the  spores.  One  application 
kills  the  developed  bacteria,  then  the  material  is  kept  for  a  time  in  an 
incubator  ;  spores  develop  into  bacteria  and  are  easily  killed  by  a 
second  application.  By  repeating  this  process  from  three  to  five  times 
the  substance  is  effectually  sterilized.  If  the  exposure  is  made  longer 
a  much  lower  degree  of  heat  may  be  used,  so  that  in  the  case  of  blood 


232  GENERAL  DIAGNOSIS. 

serum  it  may  be  sterilized  without  coagulating  the  albumin.  Usually 
an  exposure  of  fifteen  minutes  to  steam  on  each  of  three  successive 
days  is  used  for  stable  media,  and  an  exposure  of  an  hour  on  six  suc- 
cessive days  to  a  temperature  of  70°  C.  for  more  delicate  media,  as 
blood  serum.  In  the  intervals  the  material  must  be  kept  at  a  temper- 
ature of  25°  to  30°  C.  A  single  application  of  steam  under  one  to 
one  and  one-half  atmosphere  pressure  is  now  often  used. 

The  ordinary  "Arnold  steam  sterilizer"  is  as  good  as  any.  The 
dry  sterilizer  is  merely  a  metal  box  with  copper  bottom  and  ventilating 
holes.     It  is  well  to  have  an  asbestos  casing. 

Metallic  articles,  as  forceps,  platinum  probes,  etc.,  are  best  sterilized 
in  the  flame  of  a  Bunsen  burner. 

Collection  of  Material.  A  definite,  careful  method  must  be  ob- 
served when  the  pathological  product  is  removed  from  the  patient  or 
collected  for  investigation.  (See  Chapter  V.,  Exploratory  Puncture.) 
Pus  and  fluids  should  be  placed  in  sterilized  glass  bottles  or  tubes,  care 
having  been  taken  that  instruments  for  the  removal  of  the  fluid  were 
previously  sterilized.  Exposure  to  air  should  be  as  brief  as  possible. 
The  fluid  should  not  be  contaminated  with  blood  or  antiseptic  fluids 
used  for  flushing  or  other  surgical  procedure.  If  an  abscess  is  opened 
or  purulent  peritonitis  cut  down  upon,  for  instance,  tube-inoculations 
can  be  made  at  the  bedside.  The  previously  sterilized  platinum  point 
should  be  kept  before  use  in  a  test-tube  closed  with  sterilized  cotton. 
It  is  dipped  into  the  pus  before  it  flows  over  the  skin,  and  the  pus 
should  be  free  from  the  blood  of  the  incision.  It  is  at  once  transferred 
to  the  medium  in  the  test-tube.  Sputum  should  be  collected  in  a  pre- 
viously sterilized  bottle,  or  one  thoroughly  cleansed  by  boiling.  The 
bottle  should  have  a  wide  mouth.  Care  must  be  taken  to  secure 
sputum  from  the  lungs,  and  not  the  secretion  from  the  mouth  and 
fauces.  Purulent  portions,  rather  than  mucoid,  are  to  be  sent  for  ex- 
amination. Intestinal  discharges  may  be  collected  in  sterilized  glass 
jars  and  examined  as  soon  as  practicable.  It  may  be  necessary  to  keep 
the  discharge  at  the  temperature  of  the  body.  (See  Faeces — amceba 
dysenterica.) 

Examination  of  Blood. 

To  secure  blood  for  microscopical  study  the  finger  must  be  thor- 
oughly cleansed  with  alcohol  and  puncture  made  with  a  sterilized 
lancet  or  needle.  After  the  blood  flows  a  few  seconds  it  is  removed 
and  the  cover-slip,  previously  cleansed  in  nitric  acid  solution,  is  gently 
pressed  upon  the  second  overflow.  Another  cover  is  placed  over  the 
blood-stained  surface  of  the  first  slip,  the  two  rubbed  together  and 
separated  by  sliding  them  apart.  (See  Fig.  45.)  Sternberg  prefers  to 
spread  the  blood,  which  was  collected  at  the  edge  of  the  cover- 
slip,  by  drawing  a  polished  glass  slide,  held  at  an  acute  angle,  over  the 
cover-slip.  In  either  case  this  thin  film  of  blood  is  allowed  to  dry, 
and  can  be  examined  later.  Sternberg  mounts  the  blood  on  a  glass 
slide  at  once. 

1.  Microscopical  examination  is  made  of  the  fresh  blood.  2.  Smear 
preparations  on  cover-glass  or  slide  are  made  for  staining.     3.  A  drop 


THE  DATA  OBTAINED  BY  OBSERVATION. 


233 


of  the  blood  is  examined  to  observe  the  biological  properties  known 
as  agglutination,  or  the  Widal  reaction — the  serum  diagnosis.  4.  The 
number  of  white  corpuscles  is  counted,  to  show  the  presence  or  ab- 


FlG.  44 


Fg.  45. 


Proper  method  of  holding  a  cover-glass.    (Cabot.) 


Illustrating  the  position  of  cover- 
glass  during  the  spreading  of  blood 
films.    (Cabot.) 


sence  of  leucocytosis  (see  Blood),  and  a  differential  count  of  these  cor- 
puscles is  also  made.  5.  The  fresh  blood  is  inoculated  on  media  for 
cultures. 

I.  Fresh  blood  is  examined  with  the  oil-immersion  objective  and 
the  diaphragm  of  the  sub-stage  condensing  apparatus  (Abbe's)  nearly 
closed.  The  protozoa?  of  malaria,  the  bacillus  of  anthrax,  and  the 
spirillum  of  relapsing  fever  may  be  detected. 

II.  Cover-glass  preparations  are  examined  with  the  diaphragm  open. 
The  micro-organisms  above  mentioned  and  those  of  yellow  fever  and 
typhoid  fever  may  be  found  in  this  manner.  The  method  of  staining 
the  blood  is  described  below.  The  following  solutions  are  used  :  1. 
Basic  aniline  dyes.     2.  Loffler's  alkaline  methyl-blue.     3.  Gram's. 

III.  Serum  Diagnosis.  The  phenomena  of  agglutination  consists 
in  the  gradual  approximation,  clumping,  and  loss  of  motility  in  the 
micro-organisms  of  some  infectious  disease  when  the  blood  of  a  patient 
suffering  from  that  disease  is  brought  in  contact  with  it.  This  is  known 
as  the  serum,  or  AVidal  reaction,  and  by  means  of  it  a  number  of  infec- 
tious diseases  can  now  be  recognized.  If  a  drop  of  bouillon  culture  is 
examined  with  a  high-power  lens  the  organisms  are  seen  darting  about 
and  across  the  field  with  great  rapidity  in  various  directions.  If  to 
ten  drops  of  a  pure  culture  of  certain  varieties  of  infectious  micro- 
organisms one  drop  of  the  blood  of  a  patient  suffering  from  that  infec- 
tion be  added  the  motility  of  the  organisms  is  checked  and  clumps 
appear  in  the  field.  The  clumps  enlarge  rapidly,  so  as  to  be  easily 
visible  under  a  magnifying  power  of  500  diameters. 

Serum  from  patients  suffering  from  other  diseases  or  from  healthy 
patients  does  not  produce  agglutination  if  the  proportion  of  serum  to 
culture  in  the  mixture  is  1  to  10  or  less.  The  reaction  is  specific. 
Tims  typhoid  bacilli  are  not  clumped  by  any  serum  other  than  that  of 
a  typhoid  patient  or  a  patient  immunized  against  typhoid  fever  by  a 
more  or  less  recent  attack  of  the  disease.     Typhoid  serum  clumps  no 


234 


GENERAL  DIAGNOSIS. 


organism  except  the  typhoid  bacillus  when  used  with  a  certain  degree 
of  dilution  and  examined  within  a  certain  period  of  time. 


Fig.  46. 


Bouillon  culture  of  typhoid  bacilli  before  the  addition  of  diluted  typhoid  serum. 
(Magnified  500  diameters.)    After  Cabot— serum  diagnosis. 

Serum  diagnosis  has  become  a  valuable  mode  of  recognition  of 
tvphoid  fever,  Malta  fever,  yellow  fever,  and  glanders.  It  may  be  of 
use  in  other  infections,  as  cholera  and  the  pneumococcus  infections. 
Thev  are  more  accurately  diagnosticated  by  other  bacteriological  meth- 
ods, however,  and  need  not  be  considered  here. 

Method.  Three  methods  of  securing  the  serum  reaction  are  em- 
ployed :  microscopic,  or  quick  test  of  the  fluid  serum  or  blood  ;  the 
microscopic,  or  quick  test  of  the  dried  blood ;  and  the  macroscopic,  or 
slow  test.  Each  of  these  methods  is  of  value.  The  observer  should 
select  one  and  make  it  his  object  to  become  thoroughly  familiar  with 
that  selected. 

First,  the  quick  test  with  fluid  serum.  The  steps  are  :  first,  to  collect 
the  blood  ;  second,  to  add  it  in  certain  proportion  to  the  fluid  culture ; 
third,  to  examine  the  slide  and  cover-slip. 

1.  Collecting  the  Blood.  The  blood  is  secured  by  puncture  as 
in  the  method  described  in  diseases  of  the  blood.  If  the  ear  is  selected 
it  can  be  bled  freely  or  blood  squeezed  out  by  the  milking  process  until 
about  fifteen  drops  are  collected  in  a  small  test-tube.  It  is  not  neces- 
sary to  observe  strict  antiseptic  precautions  as  in  other  instances.     The 


THE  DATA   OBTAINED  BY  OBSERVATION.  235 

instruments  and  test-tube  should  be  thoroughly  cleansed.  The  blood 
thus  collected  is  allowed  to  coagulate  in  the  tube,  which  may  occupy 
several  hours.     It  is  to  be  remembered  that  the  clot  collects  on  the 

Fig.  47. 


The  same,  five  minutes  after  the  addition  of  typhoid  serum  (dilution  1 :  10),  showing 
typical  clump  reaction.    (Magnified  400  diameters.)    (Cabot.) 

sides  of  the  tube  and  over  the  surface  of  the  blood.     To  secure  the 
serum  this  clot  must  be  removed  with  a  bit  of  wire. 

2.  Dilution.  One  drop  of  the  serum  is  added  to  forty  drops  of  a 
bouillon  culture.  The  same  dropper  must  be  used  for  each  fluid,  in 
order  that  the  size  of  the  drops  will  be  equal.  The  fluids  are  to  be 
mixed  intimately  in  a  small  test-tube.  A  drop  of  this  mixture  of  cul- 
ture and  serum  is  placed  upon  a  cover-glass,  which  is  then  inverted 
over  a  hollow  ground  slide  and  examined  under  the  microscope  with 
the  immersion  lens.  Within  twenty  minutes  clumping  should  take 
place.  If  the  reaction  does  not  take  place  a  new  mixture  should  be 
made,  in  the  proportion  of  1  to  20  or  1  to  10.  If  there  is  no  reaction 
with  this  dilation  the  test  is  negative.  Instead  of  making  successive 
mixtures  three  tubes  can  be  prepared  at  once,  containing  ten,  twenty, 
and  forty  drops  each  of  the  culture.  A  drop  of  serum  can  be  added 
and  the  test  conducted  as  above. 

3.  Examination  of  Slide.  A  Xo.  7  Leitz  dry  lens  or  oil-immer- 
sion lens  can  lie  used  with  a  Xo.  3  or  Xo.  4  eye-piece.  Artificial  light  is 
preferable  to  daylight  ;  if  the  latter  is  used  a  small  aperture  diaphragm 
is  the  best,  It  is  very  necessary  that  the  slide  and  cover-slip  should 
be  thoroiiffhlv  cleansed. 


236  GENERAL  DIAGNOSIS. 

The  Reaction.  In  a  complete  or  typical  reaction  the  field  shows 
the  presence  of  large  clumps  of  bacilli  isolated  and  motionless.  (See 
Fig.  47.)  No  motile  bacilli  can  be  seen.  The  clumping  may  occur 
instantaneously  or  gradually.  If  the  reaction  is  very  marked,  Greene 
states  a  mottling  can  be  seen  with  the  naked  eye.  Clumping  and 
cessation  of  motion  are  the  essentials  of  the  reaction,  providing  they 
take  place  within  a  certain  time,  and  notwithstanding  a  certain  degree 
of  dilution  of  the  serum.  When  the  reaction  is  feeble  small  clumps 
appear,  or,  as  Widal  calls  them,  agglutination  centres.  As  the  field  is 
studied  bacilli  are  seen  moving  toward  the  centres  and  gradually  rang- 
ing themselves  in  loose  masses,  sometimes  like  the  spokes  of  a  wheel. 
Durham  has  called  attention  to  a  peculiar  spinning  motion  of  the 
bacilli  around  one  of  its  own  ends,  which  is  seen  in  some  of  the  fields 
in  which  a  few  isolated  bacilli  remain.  Such  movements  occur  at  the 
margin  of  the  clump. 

It  is  very  necessary  to  examine  a  drop  of  the  pure  culture  before 
the  addition  of  any  serum,  to  make  sure  that  clumping  has  not  already 
taken  place,  particularly  if  the  culture  is  old  or  has  undergone  sedi- 
mentation. It  is  desirable  that  the  bacilli  should  be  isolated  and 
actively  motile. 

Time  Limit  and  Dilution.  As  Cabot  forcibly  states,  only  when 
clumping  occurs  within  a  certain  time  and  in  a  certain  degree  of  dilu- 
tion is  it  of  diagnostic  importance.  The  test  is  quantitative  and  not 
qualitative.  The  degree  of  dilution  of  1  to  10  is  quite  sufficient  if  the 
time-limit  for  the  reaction  is  at  least  fifteen  minutes.  Any  clumping 
of  typhoid  bacilli  which  takes  place  fifteen  minutes  after  one  part  of 
serum  has  been  added  to  ten  of  the  culture  gives  a  probable  typhoid 
reaction.  Various  observers  select  different  dilutions.  Thus,  Wilson 
and  Westbrooke  make  a  dilution  of  1  to  50  with  a  two-hour  time- 
limit.     Durham  uses  a  dilution  of  1  to  17  or  1  to  20. 

Instead  of  the  serum  from  the  blood  the  serum  of  a  blister  may  be 
used,  or  the  serum  from  blood  which  has  been  drawn  directly  from  a 
vein  with  antiseptic  precautions. 

The  whole  blood  can  also  be  used  in  a  fluid  state.  A  drop  of  the  blood 
can  be  drawn  directly  into  ten  drops  of  the  culture  previously  meas- 
ured. This  method  is  of  great  advantage  for  rapid  work.  The  same 
dropper  should  be  used  for  measuring  the  culture  and  subsequently 
the  blood.  With  the  microscope  at  the  bedside  the  test  can  be  made 
rapidly  with  but  little  risk  of  failure. 

A  still  more  convenient  method  consists  in  the  employment  of  the 
pipette,  used  for  diluting  the  blood  in  counting  leucocytes.  The  blood 
from  the  finger  is  drawn  up  to  the  0.5  or  1.0  mark  on  the  stem,  and 
the  bulb  then  filled  with  distilled  water.  The  mixture  is  then  blown 
into  a  small  test-tube.  As  the  dilution  has  already  been  made,  a  drop 
of  bouillon  culture  or  a  small  portion  of  an  agar  culture  may  be  added 
to  it  directly  and  examined  as  above. 

The  Reaction  with  Dried  Blood.  We  owe  to  Wyatt  Johnston,  of 
Montreal,  the  great  credit  of  working  out  this  simple  but  accurate 
method  of  performing  the  reaction.  It  is  of  special  value  for  sanitary 
work  where  blood  has  to  be  sent  bv  mail  for  examination.    The  method 


THE  DATA  OBTAINED  BY  OBSERVATION.  237 

is  simple.  The  blood  is  collected  on  glass  or  glazed  paper.  In  this 
manner  it  can  be  preserved  for  an  indefinite  time  and  transported 
easily.  If  the  drop  of  blood  is  dried  on  a  glass  slide  it  can  be  dissolved 
by  the  addition  of  a  little  water  and  then  the  culture  added  in  the  way 
previously  described.  If  the  drop  is  dried  on  paper  it  can  be  cut  out 
with  a  pair  of  scissors  and  rubbed  up  in  a  watch-glass  with  one  drop  of 
water.  When  the  blood  is  dissolved  ten  drops  of  culture  are  added, 
and  the  examination  is  carried  on  as  in  the  previous  method. 

Some  operators  collect  the  blood  in  the  eye  of  a  wire  loop  of  a  given 
size,  and  after  placing  it  on  a  glass,  dilute  with  water  in  the  proportions 
desired,  ten  loopfuls  of  water  being  the  amount  usually  selected  to  mix 
with  the  drop  in  the  wire  loop.  Wilson  and  Westbrooke  have  modi- 
fied Johnston's  technique  as  follows  :  They  use  a  bit  of  platinum 
wire,  number  19  gauge,  one  end  of  which  is  bent  into  a  loop,  the 
inside  diameter  of  which  is  2  mm.  The  loop  is  used  to  collect  the 
blood,  several  drops  of  which  are  deposited  on  a  bit  of  aluminium  foil, 
number  40  gauge,  5  cm.  square.  After  the  blood  is  dried  the  foil  is 
rolled  up.  At  the  laboratory  the  bit  of  foil  is  then  cleared  of  blood, 
which  flakes  off  easily.  One  mgm.  of  dried  blood  and  200  mgm.  of 
distilled  water  are  weighed  out  and  mixed.  This  gives  an  exact  dilu- 
tion of  1  to  200  by  weight ;  1  to  50  dilution  by  volume.  A  hanging 
drop  of  the  dilution  is  inoculated  with  the  bouillon  culture  and  exam- 
ined.    The  time  limit  is  two  hours. 

It  is  essential  for  the  success  of  the  reaction  that  a  pure  culture  of 
the  typhoid  bacillus  should  be  employed.  The  most  suitable  culture 
for  diagnostic  work  is  that  which  is  the  most  actively  motile.  It  is 
true,  however,  that  many  observers  recommend  the  attenuated  cultures. 
The}'  hold  that  an  actively  motile  culture  is  too  sensitive,  and  may  cause 
clumping  even  with  normal  serum.  If  a  fresh  culture  is  kept  at  room 
temperature  and  transplanted  every  two  or  three  days  the  culture  main- 
tains its  motility  and  sensitiveness  for  a  long  period.  The  incubator 
bouillon  cultures  of  twelve  hours'  growth  are  probably  the  most  avail- 
able. Johnston,  whose  experience  is  worth  following,  thinks  the  mo- 
tility must  not  be  excessive.  He  reduces  the  motility  of  the  bacilli  by 
transplanting  his  agar  cultures  once  a  month,  growing  them  at  room 
temperature.  The  bacilli  from  this  culture,  grown  for  twenty-four 
hours  on  bouillon,  show  a  slight  gliding  motion,  which  differs  from 
the  darting  motion  seen  in  an  active  culture.  The  bouillon,  Johnston 
holds,  should  be  slightly  acid,  contrary  to  the  general  rule,  which  states 
that  it  should  be  neutral.  It  is  quite  necessary  that  the  bouillon  cul- 
ture should  be  young — that  is,  twelve  to  twenty-four  hours'  duration 
in  the  incubator  or  two  days  at  room  temperature.  When  a  culture 
is  made  under  these  circumstances,  before  it  is  used  it  should  be  free 
from  sediment  and  only  slightly  turbid.  It  should  also  be  free  from 
any  spontaneous  clumping  and  from  non-motile  or  sluggish  forms. 

Vali'e.  The  question  may  well  be  asked,  What  is  the  value  of 
the  serum  reaction?  Let  us  answer  by  referring  to  typhoid- fever 
chiefly.  When  it  is  recalled  that  this  reaction  takes  place  in  about  Its 
per  cent,  of  all  cases  of  typhoid  fever,  it  can  readily  be  seen  what  a  con- 
stant phenomenon  it  is  in  the  course  of  continued  fever.     As  a  symp- 


238  GENERAL  DIAGNOSIS. 

torn,  therefore,  it  is  one  of  the  most  constant.  Its  presence,  however, 
cannot  be  determined  in  a  large  number  of  cases  before  the  eighth  or 
tenth  day.  It  has  been  found  as  early  as  the  third  day,  and,  on  the  other 
hand,  may  be  absent  until  after  convalescence  has  set  in.  In  a  large 
majority  of  cases  the  reaction  appears,  however,  before  the  fourteenth 
day.  In  a  few  instances,  as  Widal  pointed  out,  the  reaction  disappears 
as  soon  as  the  temperature  remains  normal.  In  other  instances  it  mav 
continue  several  months,  and  in  rare  cases  has  been  found  as  long  as 
ten  years  after  the  disease. 

It  is  thus  seen  that  the  presence  of  the  serum  reaction  is  a  valuable 
diagnostic  symptom  of  some  diseases,  and  notably  of  typhoid  fever. 
Its  absence,  however,  does  not  disprove  the  presence  of  the  disease. 
Sometimes  the  blood  of  a  patient  ill  with  some  other  disease,  who  has 
previously  had  typhoid  fever,  may  give  a  positive  reaction,  and  thus 
lead  to  a  false  diagnosis.  Absence  of  reaction  in  a  supposed  case  of 
typhoid  fever  implies,  in  98  per  cent,  of  all  cases,  that  this  infection  is 
not  present,  providing,  of  course,  that  the  technique  is  correct  and 
that  repeated  examinations  have  been  made.  In  the  following  diseases 
the  serum  diagnosis  is  employed  :  (1)  Glanders  ;  (2)  Malta  fever ;  (3) 
yellow  fever  ;  (4)  cholera  ;  (5)  relapsing  fever  ;  (6)  typhoid  fever. 

4.  Leucocytosis.  The  presence  of  leucocytosis  is  characteristic  of 
many  infections,  and,  on  the  other  hand,  is  against  not  a  few  of  the 
most  common  of  the  infectious  disorders.  Accurate  study  of  the  num- 
ber of  white  cells  has  led  to  fairly  definite  conclusions  as  to  the  diag- 
nostic value  of  their  increase  or  their  diminution.  The  method  of 
determining  the  number  is  described  in  the  chapter  on  Diseases  of 
the  Blood,  which  may  be  referred  to  in  order  that  the  student  mav 
also  learn  the  circumstances  under  which  leucocytosis  occurs  physio- 
logically. Pathologically  we  find  inflammatory  leucocytosis  or  the 
leucocytosis  of  infectious  disease  occurring  with  such  frequency  as  to 
be  diagnostic.  A  classification  of  the  degree  can  be  roughly  made  only. 
1.  In  Asiatic  cholera,  relapsing  fever,  scarlet  fever,  diphtheria,  syphilis, 
and  erysipelas,  leucocytosis  occurs  to  a  moderate  degree.  2.  In  pneumonia, 
smallpox  in  the  stage  of  suppuration,  septicaemia,  actinomycosis,  trich- 
inosis, glanders,  beri-beri,  acute  rheumatism,  cerebro-spinal  meningitis, 
and  gonorrhoea  it  is  also  found,  but  more  constant  and  more  marked. 
3.  In  all  pyogenic  infections,  especially  abscesses,  in  inflammations  of 
serous  membranes  and  in  gangrenous  inflammation  usually  due  to  strep- 
tococci or  staphylococci  infection,  leucocytosis  is  great. 

The  significance  of  leucocytosis  depends  not  alone  upon  the  number 
of  the  white  cells,  but  also  upon  their  rise  and  fall  in  the  course  of  the 
disease.  The  amount  of  local  inflammation  attending  the  infection  is 
not  a  measure  of  the  amount  of  leucocytosis.  Moreover,  the  degree  of 
fever  does  not  affect  the  leucocytosis.  Fever  may  occur  without  in- 
crease in  the  white  cells,  and  the  opposite  condition  may  also  obtain. 
When  leucocytosis  and  fever  are  due  to  the  same  infection  they  may 
rise  and  fall  together,  as  we  often  see  in  cases  of  pneumonia. 

Absence  of  Leucocytosis.  While  the  presence  of  leucocytosis  is  sig- 
nificant of  various  infections,  its  absence  is  likewise  of  great  significance. 
Hence  if  there  is  no  leucocytosis  it  is  possible  either  typhoid  fever, 


THE  DATA  OBTAINED  BY  OBSERVATION.  239 

malaria,  influenza,  measles,  rotheln,  or  tuberculosis  are  present.  The 
blood-count  can  in  this  manner  be  employed  to  distinguish  typhoid 
fever,  in  which  there  is  an  absence  of  leucocytosis  from  a  pyogenic 
infection,  as  appendicitis  in  which  the  other  signs  and  symptoms 
may  be  quite  similar.  Pneumonia,  on  the  other  hand — an  infection 
characterized  by  great  leucocytosis — may  in  this  manner  be  distin- 
guished from  tuberculosis,  in  which  there  is  an  absence  of  leucocytosis. 

When  leucocytosis  occurs  in  the  course  of  any  disease  in  which  it  is 
normally  absent  it  is  an  indication  of  a  complication.  In  typhoid 
fever  it  is  an  indication  of  intestinal  perforation  and  peritonitis,  because 
of  a  mixed  infection.  On  the  other  hand,  a  fall  of  leucocytes  in  a 
disease  in  which  they  are  increased  is  suggestive  of  localization  of  the 
infection,  as  the  "  walling  off  "  of  the  abscess  in  appendicitis.  Such 
fall  in  pneumonia  is  of  grave  prognostic  omen. 

5.  For  direct  bacteriological  examination  of  the  blood  culture 
methods  are  resorted  to.  After  the  skin  has  been  cleansed  and  made 
aseptic  either  a  considerable  portion  of  blood  is  withdrawn  from  a  vein 
with  a  sterilized  hypodermatic  needle  or  blood  is  directly  drawn  with 
the  instrument  described  by  Ewing.  After  the  blood  is  thus  removed 
it  is  transferred  to  the  various  media,  and  its  further  treatment  is  carried 
on  in  accordance  with  bacteriological  methods.  (See  Cultivation  of 
Micro-organisms.) 

Examination  of  Pathological  Secretions  and  Excretions. 

Microscopical  examination,  with  and  without  staining,  and  culture 
methods  are  employed,  as  detailed  in  the  sections  to  follow : 

In  nasal  discharges  the  bacillus  of  diphtheria,  of  glanders,  of  tuber- 
culosis, and  of  the  pneumococci,  as  well  as  pyogenic  micro-organisms, 
are  found. 

In  the  mouth  the  micro-organisms  peculiar  to  that  cavity  and  the 
micro-organisms  of  actinomycosis  may  be  found. 

In  the  fa  uces  and  pharynx  the  bacillus  of  diphtheria  and  pyogenic 
micro-organisms  are  discovered. 

The  sputa  (see  Disease  of  Langs)  yield  the  tubercle  bacilli,  the  pneu- 
mococcus,  the  bacillus  of  influenza,  and  actinomycosis. 

The  forces  (see  Disease  of  Intestines)  are  examined  for  the  bacillus 
coli  communis,  the  spirillum  of  cholera  Asiatica,  bacillus  typhosus,  and 
tubercle  bacillus. 

The  urine.  Pyogenic  micro-organisms,  tubercle  bacillus,  typhoid 
bacillus,  the  pneumococcus,  and  gonococcus  are  found  in  the  urine. 
They  are  secured  by  cover-slip  preparations  of  the  pus,  or  by  culture 
methods,  as  described  in  the  section  devoted  to  Diseases  of  the  Kidneys. 

Examination  of  the  Products  of  Infectious  Inflammation  - 
Material  Secured  by  Exploratory  Puncture. 

Material  removed  by  exploratory  operation  or  puncture  may  be 
serous,  bloody,  or  purulent  (See  Chapter  XXI.)  It  must  be  examined 
bacteriologically,  microscopically,  by  culture  methods,  and  by  inocula- 
tion.    Serous  fluids  are  not  usually  productive  of  bacteria  when  exam- 


240  GENERAL  DIAGNOSIS. 

inecl  unless  treated  by  sedimentation,  and  even  then  it  is  often  neces- 
sary to  inoculate. 

The  most  important  pathological  product  is  pus.  Fresh  and  stained 
preparations  are  examined,  and  cultures  are  taken.  AVe  may  find  only 
one,  sometimes  two  at  the  same  time,  of  the  following  micro-organisms  : 
1.  Staphylococcus  pyogenes  aureus.  2.  Staphylococcus  pyogenes  albus. 
3.  Staphylococcus  epidermidis  albus  (Welch).  4.  Streptococcus  pyo- 
genes. 5.  The  tubercle  bacillus.  6.  The  bacillus  of  syphilis.  7.  Ac- 
tinomycosis. 8.  The  bacillus  of  glanders.  9.  The  bacillus  of  anthrax. 
10.  The  bacillus  of  leprosy.  11.  The  bacillus  of  tetanus.  12.  The 
bacillus  of  influenza.  (See  Sputum.)  13.  The  micrococcus  lanceolatus. 
14.  The  bacillus  coli  conrmunis.     15.  The  gonococcus. 

Fresh  pus  may  be  examined,  but  the  stained  is  more  satisfactory. 
Staining  by  the  method  of  Gram  is  the  best,  and  is  as  follows  :  After 
a  cover-glass  has  been  prepared  and  placed  in  Koch-Ehrlich's  solution 
of  gentian-violet  and  aniline  water,  it  is  put  into  a  solution  of  iodine 
and  iodide  of  potassium  for  two  or  three  minutes.  A  dull  red-brown 
color  is  produced.  It  is  then  rinsed  in  absolute  alcohol  for  some  time. 
The  micro-organisms  are  stained  dark  blue..  The  iodide  of  potassium 
solution  is  :  Iodine,  1  part ;  iodide  of  potassium,  2  parts  ;  distilled 
water,  300  parts.  By  this  method  the  various  forms  of  micro-organ- 
isms just  indicated  are  readily  brought  out. 

Methods  of  Staining  Blood,  Pus  and  Discharges.  It  is  well  to 
consider  these  collectively.  Many  have  been  devised,  but  those  of 
clinical  value  are  the  following  : 

1.  Aqueous  solutions  of  basic  anilines. 

2.  Loffler's  alkaline  methyl-blue. 

3.  Koch-Ehrlich's  aniline  water  solutions. 

4.  Ziehl's  carbol-fuchsin. 

5.  Loffler's  method  of  staining  flagella. 

6.  Gram's  method. 

7.  Friedlander's  method. 

8.  Giinther's  method. 

1.  Basic  anilines.  Aqueous  solutions  of  the  basic  aniline  colors  — 
fuchsin,  gentian-violet,  and  methyl-blue — are  used  of  such  strength 
that  they  can  be  seen  clearly  through  an  ordinary  test-tube.  They 
may  be  kept  on  hand  in  bottles  with  pipettes,  or  made  from  concen- 
trated alcoholic  solutions  as  needed.  They  are  used  by  simply  drop- 
ping a  few  drops  on  the  cover-glass  preparation,  which  is  held  with 
the  forceps,  allowing  it  to  remain  about  thirty  seconds,  and  carefully 
washing  off  in  water.  It  is  placed  on  a  slide,  bacteria  down,  and  the 
excess  of  water  removed  with  blotting-paper. 

2.  Loffler's  alkaline  methyl-bine  solution.  Certain  bacteria  take  a 
stain  more  readily  when  an  alkali  has  been  added.  The  formula  is  as 
follows  : 

Concentrated  alcoholic  solution  methvl-blue     ...       30  c.c. 
Caustic  potash,  1  :  10,000  .  .         .  .  .      100    " 

It  is  used  in  the  same  way  as  the  simple  solutions. 

3.  Koch-Ehrlich's  aniline  water  solutions.  Add  to  100  c.c.  of  dis- 
tilled water,  aniline  oil,  drop  by  drop,  thoroughly  shaking  after  each 


THE  DATA  OBTAINED  BY  OBSERVATION.  241 

drop  until  it  becomes  opaque.  Then  filter.  Add  10  c.c.  absolute 
alcohol  and  11  c.c.  of  a  concentrated  alcoholic  solution  of  either  fuchsin, 
methyl-blue,  or  gentian-violet. 

4.  Ziehl's  carbol-fuchsin  solution. 

Distilled  water 100  c.c. 

Carbolic  acid      .........  5  gm. 

Alcohol 10  c.c. 

Fuchsin 1  gm. 

The  use  of  these  various  stains  will  be  described  in  the  description 
of  the  different  bacteria. 

5.  Loffler's  solution  for  flagella. 

Tannic  acid,  20  per  cent.    .......       10  c.c. 

Cold  saturated  solution  ferric  phosphate    .         .         .         .         5    " 

Saturated  solution  fuchsin  .         .         .         .         .         .         1    " 

A  few  drops  of  this  solution  are  placed  on  the  cover-glass  contain- 
ing the  bacteria  and  very  gently  heated  until  they  begin  to  steam,  and 
then  the  cover-glass  is  washed  off  in  water.  The  preparation  is  then 
stained  with  aniline  water  fuchsin.  Different  bacteria  require  differ- 
ent reactions,  and  so  a  few  drops  of  an  acid  or  alkaline  solution  are 
recommended  to  be  added  as  the  case  requires.  As  a  rule,  however, 
the  results  obtained  when  neither  acids  nor  alkalies  are  added  are  just 
as  satisfactory  as  those  following  such  additions. 

6.  Gram's  method  consists  in  staining  with  a  Koch-Ehrlich  solution 
of  gentian-violet  for  twenty  to  thirty  minutes,  and  then  decolorizing  in 

Iodine 1  gm. 

Potassium  iodide        .         .         .         .         .         .         .         -         2    " 

Distilled  water 300  c.c. 

After  remaining  in  this  for  five  minutes  the  preparations  are  rinsed  in 
alcohol,  and  the  process  repeated  until  the  violet  color  has  disappeared. 

For  Friedlander's  and  Giinther's  methods,  see  Sputum. 

To  detect  spores  of  bacilli  double  staining  may  be  employed.  The 
preparation  is  first  stained  in  a  hot  Ziehl-Xeelsen  fuchsin  solution, 
then  decolorized  with  alcohol  containing  from  0.2  to  0.3  per  cent, 
hydrochloric  acid.  When  stained  again  with  methylene-blne  the 
spores  appear  red  and  the  bacilli  blue. 

The  "hanging  drop."  By  the  examination  of  colonies  in  the  hang- 
ing drop  we  learn  of  the  movement  of  the  micro-organism.  Place  a 
drop  of  physiological  salt  solution  on  a  cover-slip,  and  add  a  tiny  por- 
tion of  colony  on  platinum  wire  ;  place  the  slip,  drop  down,  on  a  glass 
slide,  in  the  centre  of  which  is  a  depression  or  hollow.  Fix  the  slip 
by  applying  a  thin  layer  of  vaseline  around  the  margin  of  the  depres- 
sion. Care  must  be  taken  in  focusing  that  the  lens  does  not  break  the 
glass,  which  may  be  readily  done  because  of  its  transparency.  The 
bacteria  are  seen  in  motion  ;  on  account  of  the  motion  their  position  is 
constantly  altered.  This  motion  must  not  be  mistaken  for  the  Brown- 
ian  movement  of  suspended  articles,  which  is  vibratory  from  molecular 
t I*  mor. 

Cultivation  of  Micro-organisms.  The  object  is  to  isolate  the 
pathogenic  organism  from  all  other  organisms  and  to  exclude  organ- 
ic 


242  GENERAL  DIAGNOSIS. 

isms  that  may  be  introduced  from  without  by  unclean  instruments  or 
other  means.     Pure  cultures  are  thus  obtained. 

Culture-media.  Experience  has  taught  us  that  various  forms  of 
bacteria  require  different  pabulum,  and  that  various  nutrient  media  are 
required  for  the  isolation  of  different  micro-organisms.  As  to  the  bac- 
teria hereafter  noted,  we  are  familiar  with  the  proper  soil  for  their 
growth.  The  media  used  for  bacteria  of  clinical  importance  are  : 
a  freshly  steamed  potato,  gelatin,  bouillon,  agar-agar,  milk,  and  blood- 
serum.  They  are  prepared  or  mixed  in  various  ways,  and  other  things 
may  be  added,  as  a  solution  of  litmus,  to  determine  the  reaction  of  the 
bacterial  products. 

Bouillon.  Lean  beef,  500  gm.,  soaked  in  one  litre  of  water  for 
twenty-four  hours  in  an  ice-chest ;  strain  through  a  coarse  towel  and 
press  until  a  litre  of  fluid  is  obtained.  Add  10  gm.  of  dried  peptone 
and  5  gm.  of  salt.  Then  neutralize  with  a  normal  solution  (4  per  cent.) 
of  caustic  soda.     Boil  till  albumin  is  coagulated.     Filter  and  sterilize. 

Nutrient  Gelatin.  Make  bouillon  as  above  (except  neutral- 
izing) and  add  10  to  12  per  cent,  of  gelatin,  and  neutralize  after  dis- 
solving it  by  heat.     Filter. 

If  not  perfectly  transparent,  clarify  by  heating  to  60°  or  70°  C,  add 
the  whites  of  two  eggs  beaten  up  with  50  c.c.  of  water  ;  mix  thoroughly 
and  boil  until  albumin  coagulates  ;  then  filter.  Sterilize  and  keep  in 
flasks  or  tubes. 

Nutrient  Agar.  Prepare  bouillon  complete  ;  add  finely  chopped 
agar,  1  to  1.5  per  cent.  Place  in  a  porcelain-lined  iron  vessel,  mark 
level  of  fluid,  add  250  c.c.  of  water  and  boil  slowly,  with  occasional 
stirring,  for  three  or  four  hours.  Keep  the  fluid  up  to  the  mark  by 
adding  water.  Take  the  vessel  from  the  fire  and  set  in  cold  water. 
Stir  until  cooled  at  68°  to  70°  C.  ;  add  the  whites  of  two  eggs  beaten 
up  in  50  c.c.  of  water.  Mix  carefully  and  boil  for  half  an  hour,  keep- 
ing the  fluid  up  to  the  level.     Filter. 

Sometimes  5  to  7  per  cent,  of  glycerin  is  added. 

Potatoes.  Select  old  potatoes ;  scrub  under  water-faucet  with 
stiff  brush  ;  cut  out  eyes  and  defects.  Then  place  in  1  :  1000  HgCl2 
for  twenty  minutes.  Then  place  in  steam  sterilizer  and  steam  forty- 
five  minutes.  Leave  them  in  and  steam  fifteen  or  twenty  minutes  each 
day  for  three  days.  Cut  with  knife  sterilized  in  flame  and  lay  with 
cut  surface  upward  in  a  sterilized  covered  dish. 

Another  way  of  preparing  potatoes  is  to  cut  cylinders  with  a  cork 
borer  of  such  size  as  to  fit  loosely  in  a  test-tube.  A  slanting  surface 
is  then  cut  from  the  junction  of  the  first  and  second  thirds  of  the  cyl- 
inders diagonally  to  the  opposite  edge.  These  are  left  in  running 
water  over  night,  then  placed  in  test-tubes  with  a  cotton  plug  and 
steamed  for  forty-five  minutes.  On  the  second  and  third  days  they 
are  steamed  fifteen  to  twenty  minutes. 

Milk.  It  should  be  sterilized  in  a  steam  sterilizer  by  the  fractional 
method.     It  is  a  good  soil  for  the  tubercle  bacillus  (Abbott). 

Blood-serum.  The  original  method  of  preparing  blood-serum,  as 
recommended  by  Koch  (given  in  the  text-books  on  Bacteriology),  has, 
in  this  country  at  least,  almost  entirely  given  place  to  the  method  of 


THE  DATA  OBTAINED  BY  OBSERVATION.  243 

Councilman  and  Mallory,  the  popularity  of  which  is  due  to  the  follow- 
ing advantages  :  By  it  the  serum  is  more  quickly  and  easily  prepared  : 
rigid  precautions  against  contamination  during  collection  of  serum  are 
not  necessary,  and  the  resulting  medium,  while  not  transparent  or  even 
translucent  (points  aimed  at  in  the  original  method),  fully  meets  all 
the  requirements. 

The  special  points  in  the  method  are  :  the  serum  is  decanted  into 
test-tubes  as  soon  as  obtained  ;  it  is  then  firmly  coagulated  in  a  slant- 
ing position  in  the  dry-air  sterilizer  at  from  80°  to  90°  C.  ;  it  is  then 
sterilized  in  the  steam  sterilizer  at  100°  C.  on  three  successive  days, 
as  in  the  case  of  other  culture-media.  It  may  then  be  protected 
against  evaporation  by  sterilized  rubber  caps  or  sterilized  corks,  and 
set  aside  until  needed. 

Unless  the  coagulation  in  the  dry  sterilizer  be  complete,  the  surface 
of  the  serum  will  be  found  to  be  lacerated  by  bubbles  and  cavities  after 
it  has  been  subjected  to  the  steam  sterilization.  A  similar  formation 
of  cavities  over  the  surface  of  the  serum  will  occur  if  the  temperature 
of  the  hot-air  sterilizer,  in  which  it  is  solidified,  is  allowed  to  get  above 
90°  C,  or  if  it  be  elevated  to  this  point  too  quickly. 

It  is  of  no  special  advantage  to  have  the  serum  clear,  as  the  admix- 
ture of  blood-coloring  matter  does  not  affect  its  nutritive  properties. 

Lofner's  blood-serum  mixture  : 

Neutral  meat  infusion  bouillon  (see  Bouillon)  .         .         .     1  part 
Grape-sugar       .........     1  per  cent. 

Blood-serum      .........     3  parts. 

Tube-cultures  and  Plate-cultures.  The  plate  method  was  intro- 
duced by  Koch  for  the  purpose  of  isolating  individual  species  of  bac- 
teria from  mixtures.  It  may  be  practised  either  with  gelatin  or  agar- 
agar.  Three  tubes  previously  filled  with  the  culture-media  are  liquefied 
by  warming  in  a  water-bath,  then  cooled  to  the  lowest  point  at  which 
the  medium  remains  fluid.  One  of  the  tubes  is  then  held  in  the  left 
hand.  A  sterilized  looped  platinum  wire  inserted  in  a  glass  handle  is 
taken  in  the  other  hand,  passed  through  a  flame,  and  cooled  for  a  few 
seconds.  With  this  a  bit  of  the  material  to  be  examined  is  taken  up, 
the  cotton  plug  is  removed  from  the  tube  with  the  free  fingers,  and 
the  wire  inserted  into  the  medium.  By  rolling  the  tube  it  is  thor- 
oughly mixed.  Then  a  second  tube  is  inoculated  with  three  loopfuls 
from  the  first,  and  a  third  with  three  loopfuls  from  the  second.  Plates 
have  been  previously  sterilized  and  placed  in  covered  dishes  also  care- 
fully sterilized.  The  plates  are  levelled  and  the  contents  of  the  tubes 
poured  upon  their  surface.  Then  they  are  cooled  over  ice-water  until 
the  medium  becomes  solid,  when  they  are  placed  in  a  proper  tempera- 
ture for  development.  In  this  way  the  bacteria  are  sufficiently  diluted 
to  form  distinct  colonics  from  which  pure  cultures  may  be  obtained. 

A  convenient  modification  of  the  method  is  the  use  of  Petri's  plate*, 
which  are  flat,  round  dishes  with  covers,  the  bottom  of  the  dish  serving 
as  the  plate. 

Another  modification  {Emiarchh  tubes)  is  the  use  of  tubes  with  a 
small  quantity  (5  c.c.)  of  the  medium.     By   rolling  the  tube  in  the 


244  GENERAL  DIAGNOSIS. 

fingers  the  sides  are  coated  with  the  media.  They  are  then  rolled  on 
ice,  so  that  the  medium  solidifies  in  a  thin  layer  about  its  walls. 

Smear  cultures  and  Stab-cultures.  When  the  bacteria  has  been 
isolated  by  one  of  these  methods  pure  smear-cultures  or  stab-cultures 
must  be  made  from  them.  A  tube  of  the  proper  culture-medium  is 
taken  in  the  left  hand,  a  bit  of  pure  colony  taken  up  on  a  sterilized 
straight  platinum  needle,  the  cotton  plug  removed  as  above,  and  the 
needle  thrust  straight  into  the  medium  for  a  stab-culture,  or  rubbed 
over  a  slanting  surface  of  media  for  a  smear-culture.  The  plug  is 
immediately  inserted  and  the  tubes  transferred  to  the  incubator. 

When  pure  cultures  have  been  obtained  the  species  are  recognized 
by  their  mode  of  growth  and  behavior  in  different  culture-media,  the 
reaction  produced  by  their  growth,  and  their  appearance  under  the 
microscope  when  stained  and  unstained. 

When  nutrient  media  are  inoculated  they  must  be  kept  at  a  favora- 
ble temperature.  This  will  be  detailed  when  each  micro-organism  is 
discussed,  as  a  number  of  pathogenic  bacteria  require  a  definite  and 
continuous  temperature. 

The  primary  inoculation  will  often  yield  numerous  colonies,  the 
nature  of  the  bacteria  comprising  which  must  be  determined  by  their 
morphology  and  biological  characteristics.  It  is  frequently  necessary 
to  repeat  the  process  of  platiug  with  several  of  the  colonies  obtained 
on  the  original  plates,  otherwise  one  cannot  always  be  certain  that  the 
organism  for  which  he  is  seeking  has  been  isolated  in  pure  culture. 

Microscopical  Examination  of  Colonies.  Just  here  may  be 
stated  the  methods  employed  for  the  study  of  the  morphology  of  the 
colonies  secured  by  plate  and  other  means  of  cultivation. 

Cover-glass  preparations  are  made  as  follows  :  Place  on  the  cover- 
glass  a  small  drop  of  distilled  water.  With  a  platinum  needle  take 
up  the  smallest  possible  quantity  of  the  colony  to  be  examined,  mix 
it  with  the  drop  and  spread  over  the  surface  of  glass.  Dry  under 
cover  or  by  holding  with  fingers  over  a  flame,  the  layer  of  bacteria 
being  away  from  the  flame.  When  dry  pass  it  with  forceps  three 
times  through  the  gas  or  alcohol  flame  to  "  fix  "  the  albumin.  It  is 
then  ready  for  staining. 

Inoculation  of  Animals. 

Another  method  of  determining  the  pathogenic  character  of  morbid 
material,  as  sputum,  pus,  or  exudation,  is  by  inoculating  animals  with 
a  pure  culture.  This  is  done  either  by  feeding  or  injection,  as  subcu- 
taneous or  intravenous,  into  the  peritoneal  or  pleural  cavity,  and,  in 
rare  instances,  into  the  anterior  chamber  of  the  eye  or  into  the  cranial 
cavity. 

As  animals  are  subject  to  only  a  few  of  the  microbic  diseases  of 
man,  many  experiments  must  often  be  made  before  a  susceptible 
animal  is  found,  and  no  conclusions  can  be  reached  as  to  the  patho- 
logical power  of  a  micro-organism  until  this  point  has  been  determined. 
The  clinical  course  of  the  artificial  disease  must  be  observed  to  fulfil 
the  diagnosis,  and  the  difficulty  of  reproducing  faithfully  in  animals 


THE  DATA  OBTAINED  BY  OBSERVATION.  245 

the  clinical  manifestations  seen  in  man  is  often  one  of  the  gravest 
obstacles  to  this  method  of  diagnosis. 

Examination  of  the  animal  is  made  as  soon  as  possible  after  death. 
The  autopsy  is  made  with  antiseptic  precautions.  After  the  skin  is 
removed  only  sterilized  instruments  are  to  be  used.  The  macroscopi- 
cal  appearances  and  the  mode  and  progress  of  infection  are  noted  for 
the  purpose  of  aiding  in  the  diagnosis.  When  the  organs  are  exposed, 
material  for  culture  is  first  obtained  by  inserting  a  platinum  needle 
through  a  small  puncture  in  the  capsule.  Afterward  cover-glasses 
may  be  prepared  for  immediate  examination.  Blood  is  taken  from 
one  of  the  cavities  of  the  heart.  After  the  autopsy  all  remains  are  to 
be  burned  and  all  instruments  carefully  sterilized. 

Special  Bacteriological  Diagnosis.  The  following  points  must  be 
investigated  in  order  to  determine  the  specific  nature  of  the  micro- 
organism which  is  supposed  to  be  the  productive  agency  of  the  disease 
in  question,  viz.  :  The  form — micrococci,  bacilli,  spirilla,  polymorphous  ; 
relation  to  oxygen — aerobic,  facultative  anaerobic,  strict  anaerobic  ; 
growth  in  nutrient  gelatine — liquefy,  do  not  liquefy,  do  not  grow  at 
"  room  temperature  ;"  growth  on  potato  ;  growth  on  milk — coagulate 
milk,  do  not  coagulate,  etc.  ;  color  of  growth — chromogenic,  non-chro- 
mogenic  ;  spore-formation  ;  movement ;  pathogenic  power. 

Note.  For  further  information  concerning  technique  the  student  must  refer  to  the 
work  of  Abbott  on  the  "Principles  of  Bacteriology"  and  to  Sternberg's  "Manual  of 
Bacteriology"  for  an  exhaustive  account  of  the  technique,  and  the  morphological  and 
bacteriological  characteristics  of  all  bacteria,  pathogenic  and  non-pathogenic. 


CHAPTER    XVIII. 

THE  DATA  OBTAINED  BY  OBSERVATION— {Continued). 

FEVER.      THE  INFECTIOUS  DISEASES 

Infections  Not  Recognized  by  Bacteriological  or  Blood 
Examinations. 

This  group  includes  most  of  the  eruptive  fevers  which  are  conta- 
gious and  epidemic.  Their  recognition  must  be  based  on  data  of  the 
social  history,  the  duration  of  the  period  of  incubation,  and  upon 
the  mode  of  onset  and  course  of  the  respective  infection.  They  are  : 
typhus  fever,  smallpox,  varicella,  scarlet  fever ,  measles,  rubella,  mumps  or 
epidemic  parotitis,  glandular  fever,  whooping-cough,  rheumatic  fever, 
dengue,  beri-beri,  syphilis,  Weil's  disease,  milk-sickness,  miliary  fever ,  foot 
and  mouth  disease,  hydrophobia. 

It  must  be  remembered  that  other  infections  are  not  always  recog- 
nized by  bacteriological  examinations,  although  if  such  examination 
gives  a  positive  result  the  diagnosis  is  final.  The  following  data 
should  be  sought  for  in  the  diagnosis  of  any  infection,  but  especially 
in  case  of  failure  of  the  bacteriological  methods  ;  or,  if  such  methods 
are  successful,  as  a  control  in  the  diagnosis. 

Social  History.  In  the  diagnosis  of  the  infectious  diseases  valuable 
data  are  obtained  from  the  social  history. 

Age.  Thus  early  age  is  the  period  of  life  in  which  the  eruptive 
fevers  are  more  common  ;  adolescence,  that  of  typhoid  fever  and  tuber- 
culosis.    In  the  sex,  however,  we  find  but  little  of  diagnostic  value. 

Exposure.  Bearing  in  mind  the  possible  cause  of  the  disease,  we 
inquire  for  all  those  circumstances  which  contribute  to  the  origin  of 
the  infection.  Hence  we  inquire  into  the  food,  the  character  of  the 
water,  and  other  material  ingested.  We  inquire  if  an  opportunity  for 
inhalation  of  infectious  material  could  have  occurred,  as  dried  sputum 
from  a  case  of  tuberculosis,  or  if  exposure  to  the  patient  was  possible. 
We  learn  the  hygienic  conditions  and  place  of  residence  (malarial  dis- 
tricts, the  tropics).  The  occupation — wool-sorter,  hostler,  farrier — 
points  to  the  nature  of  the  infection.  In  short,  we  inquire  if  the 
patient  has  been  exposed  to  any  infection. 

The  Presence  of  an  Epidemic.  We  inquire  if  an  epidemic  of 
the  suspected  disease  prevails,  and  if  the  patient  has  been  exposed  to 
the  contagion.  We  consider  etiological  factors,  as  the  season  in  which 
the  infection  prevails. 

History  of  Previous  Infection.  In  the  history  of  previous  diseases 
we  inquire  if  the  patient  has  had  previous  infections.  Some  contagious 
disorders  rarely  take  place  a  second  time,  as  scarlet  fever,  or  measles. 


THE  DATA   OBTAINED  BY  OBSERVATION. 


247 


Hence,  if  the  patient  has  never  had  them — is  not  immune — his  sus- 
ceptibility is  of  diagnostic  importance.  Other  infections  predispose  to 
subsequent  attacks,  as  pneumonia  or  erysipelas,  hence  the  occurrence 
of  a  previous  attack  is  important. 

Having  secured  the  data  above  indicated,  we  proceed  to  an  exami- 
nation of  the  patient,  noting  the  length  of  time  since  he  had  been 
exposed  to  contagion,  the  mode  of  onset  of  the  symptoms,  and  the 
subjective  and  objective  symptoms  at  the  time  of  the  examination. 
These  separate  data  will  be  discussed  in  the  account  of  the  various 
infections  included  in  this  chapter. 


THE  ERUPTIVE  FEVERS. 

The  following  infections  are  characterized  by  a  specific  eruption 
which  permit  them  to  be  given  the  above  title.  They  are  also  mem- 
bers of  Class  I.,  spoken  of  in  Chapter  XVII.  The  fever,  in  a  measure, 
runs  a  definite  clinical  course,  and  is  of  diagnostic  significance.  The 
infection  bears  such  definite  relation  to  the  eruption,  however,  that  the 
diagnosis  is  usually  based  upon  the  latter. 

Typhus  Fever. 

In  this  infection  the  temperature  rises  rapidly,  reaching  to  104°  or 
105°  by  the  end  of  the  second  or  third  day.  It  is  an  acute  contagious 
fever,  occasionally  occurring  sporadically,  and  often  becoming  epidemic 
in  the  presence  of  destitution,  filth,  over-crowding,  and  bad  ventilation. 

Fig.  48. 


Typhus  fever— typical.    (Doty.) 


It  is  characterized  by  abrupt  onset  with  chill  or  with  chilliness,  a  rapid 
rise  of  temperature,  lassitude,  headache,  and  pains  in  the  back  and 
limbs.  On  the  fourth  or  fifth  day  a  peculiar  spotted  eruption  appears, 
which  at  first  is  macular  and  subsequently  petechial.  It  is  further 
characterized  by  adynamia  <>r  ataxia,  low  muttering;  delirium,  a  suf- 


248  GENERAL  DIAGNOSIS. 

fused,  heavy,  drunken  expression  of  countenance,  by  the  absence  of 
local  disease,  and  by  a  crisis  which  occurs  on  or  about  the  fourteenth 
day. 

Typhus  fever  is  variously  known  as  ship  fever,  jail  fever,  camp  fever. 

The  period  of  incubation  is  usually  about  twelve  days  ;  it  may  be 
five  or  eight  days,  or  even  a  shorter  time,  depending  upon  the  viru- 
lence of  the  poison  and  the  susceptibility  of  the  patient.  Malaise  may 
precede  by  a  day  or  two  the  onset  of  the  disease. 

Invasion  is  characterized  by  headache,  faintness,  vertigo,  chilliness, 
or  a  distinct  rigor,  pains  in  the  back  and  thighs,  loss  of  appetite, 
nausea,  constipation,  and  extreme  weakness.  The  prostration  is  some- 
times so  great  as  to  compel  the  patient  to  go  to  bed  at  once.  The 
pulse  is  frequent,  100  or  140,  and  in  grave  cases  shows  a  marked  ten- 
dency to  become  small,  soft,  and  feeble.  The  patient  is  restless  and 
sleepless,  and  is  annoyed  by  tinnitus.  The  expression  of  the  flushed 
face  is  listless  and  dull. 

About  the  fourth  or  fifth  day  the  typhus  eruption  begins  to  appear. 
It  consists  at  first  of  dull  red  spots  of  irregular  size  and  shape.  They 
are  most  numerous  on  the  covered  parts.  Moore l  says  they  are 
detected  first  near  the  axilla?  and  on  the  wrists,  then  on  the  sides  of 
the  abdomen,  afterward  on  the  chest,  back,  shoulders,  thighs,  and 
arms.  The  skin  is  also  mottled  by  another  crop  of  maculae  under  the 
skin  ("  mulberry  rash  "). 

When  the  disease  is  fully  developed  the  face  is  flushed,  the  conjunc- 
tivae red,  the  pupils  contracted,  so  as  to  resemble  pin-holes  ("  ferrety 
eye  "),  the  tongue  dry  and  brown,  the  teeth  covered  with  sordes,  the 
skin  dry,  hot,  and  stinging  to  the  touch.  The  patient  lies  upon  his 
back  oblivious  to  all  his  surroundings.  Headache  has  given  place  to 
delirium,  which  may  be  wild  and  fierce,  but  is  more  commonly  low 
and  muttering.  There  are  marked  ataxic  symptoms — subsultus  ten- 
dinum,  tremors,  picking  at  the  bedclothes.  Incontinence  of  urine  and 
faeces  sometimes  occurs.  The  breathing  is  frequent,  shallow,  and  noisy, 
and  the  pulse  frequent,  soft,  and  feeble.  The  macular  rash  now 
becomes  petechial.  The  patient  is  in  a  typical  "  typhoid  state."  The 
stupor  may  gradually  clear  up,  or,  on  the  other  hand,  deepen  into 
coma  ;  or  the  patient  may  die  from  progressive  weakening  of  the 
heart,  with  or  without  pulmonary  complications. 

In  the  majority  of  favorable  cases,  on  or  about  the  fourteenth  day, 
the  first  sign  of  recovery  is  a  sound  sleep,  from  which  the  patient 
awakes  refreshed  and  rational.  The  temperature  falls  with  ^  great 
rapidity,  the  pulse  and  temperature  improve ;  a  typical  crisis  has 
occurred. 

Certain  objective  phenomena  of  the  disease  require  special  mention. 
The  eruption  is  more  copious  in  severe  than  in  mild  cases.  A  dull  and 
livid  color  is  a  grave  sign.  Purpura  and  hemorrhages  are  sometimes 
met  with  in  bad  cases.    The  eruption  does  not  occur  in  successive  crops. 

The  patient  seems  to  be  surrounded  by  a  vapor  of  a  pungent,  musty 
odor  which  is  peculiar. 

1  Eruptive  and  Continued  Fevers,  by  J.  W.  Moore,  Dublin,  1892. 


THE  DATA  OBTAINED  BY  OBSERVATION.  249 

The  heart  early  shows  the  effect  of  the  poison.  The  impulse  is 
diminished,  and  the  first  sound  is  less  distinct.  In  grave  cases,  with 
threatening  heart-failure,  the  sounds  are  feeble  and  distant,  the  impulse 
imperceptible. 

The  pulse  is  usually  very  much  more  frequent  than  normal,  but  may 
be  abnormally  slow  (50  and  even  30  per  minute) ;  this  is  sometimes  a 
bad  sign. 

The  weak  heart  and  prostrate  position  of  the  patient  favor  conges- 
tion, with  oedema  of  the  lungs.     This  condition  is  common. 

Digestive  symptoms  have  already  been  referred  to.  Vomiting,  tym- 
panites, and  diarrhoea  are  rare,  and  still  more  so  is  intestinal  hemor- 
rhage. 

The  urine  is  scanty  and  high-colored.  Slight  albuminuria  is  common, 
and  a  few  casts  are  found,  but  distinct  nephritis  is  unusual.  Convul- 
sions, when  they  occur  after  the  first  week,  are  almost  always  urremic 
and  almost  invariably  fatal.  They  may  be  due  to  retention  of  the 
urine,  as  recorded  by  Stokes  and  Corrigan. 

The  duration  of  the  disease  is  from  six  to  fifteen  days  ;  the  average 
period  is  twelve  to  fourteen  days.  An  abortive  form  is  met  with  in 
some  epidemics,  the  disease  being  of  a  mild  type  and  subsiding  at  the 
end  of  a  week.  In  some  cases  so  large  a  dose  of  the  poison  is  absorbed 
by  the  patient  that  he  is  stricken  down  in  a  few  hours  or  a  few  days. 
To  this  form  the  name  "  blasting  typhus  "  has  been  appropriately 
given.  The  most  important  complications  are  hyperpyrexia,  laryngitis, 
bronchitis,  and  congestion  of  the  lungs,  extreme  ataxia  or  profound 
adynamia,  nephritis,  heart-failure,  and  parotitis,  or  other  inflammatory 
glandular  swellings. 

Laryngitis  with  oedema  is  a  very  rare  but  very  dangerous  complica- 
tion. 

Diagnosis.  Cerebrospinal  fever  is  distinguished  from  typhus  fever 
by  greater  intensity  of  the  headache,  by  retraction  of  the  head  and 
hyperesthesia,  by  greater  liability  to  vomiting,  and .  by  the  absence  of 
the  macular  petechial  eruption  and  the  drunken,  besotted  aspect  of 
typhus  fever.  In  cerebro-spinal  fever  the  patient  suffers  with  photo- 
phobia, and  is  liable  to  local  palsies  of  the  eye-muscles  (strabismus)  and 
to  general  convulsions.  Convulsions  do  not  occur  in  typhus  except 
from  a  complicating  nephritis  or  retention  of  urine. 

Uremia  is  distinguished  from  typhus  by  the  preceding  history,  by 
the  absence  of  high  temperature,  and  by  the  presence  of  oedema  of  the 
face  or  extremities,  a  history  of  vomiting  or  diarrhoea  preceding  the 
stupor.  The  condition  of  the  urine  and  the  absence  of  eruption  are 
the  final  tests. 

Pneumonia  is  distinguished  by  the  frequent  respiration  and  rela- 
tively slower  pulse,  and  by  the  local  physical  signs  and  absence  of 
eruption. 

TYPHOID  fever  is  distinguished  by  its  slow  onset  and  marked 
abdominal  symptoms.  The  eruption  of  typhus  is  petechial  and  comes 
out  on  the  fourth  or  fifth  day  ;  that  of  typhoid  fever  consists  of  rose- 
spots  and  appears  on  the  seventh  or  eighth  day.  In  typhus  fever 
the  severe  initial  chill,  the  sudden  onset,  the  greater  prostration,  and 


250 


GENERAL  DIAGNOSIS. 


the  earlier  appearance  of  cerebral  symptoms  are  helpful  in  distinguish- 
ing it  from  typhoid  fever. 

Variola. 

The  temperature  in  variola,  or  smallpox,  pursues  a  definite  course, 
which  renders  it  of  value  in  the  diagnosis.  Its  sudden  rise  to  an 
unusual  height  without  local  inflammation  but  with  severe  backache  is 
significant.  Its  fall  with  the  appearance  of  the  eruption,  followed  in 
two  or  three  days  by  a  secondary  rise,  is  very  characteristic. 


Fig.  49. 


Bale  •"•i  '■>     1<»  11  12  13  14  13  1G  17  IS  19  20  21  22  2:i  24  25  2C  27  _2^  29  30  SI  ^  2   3 

Temperature  in  smallpox.    Adult ;  mild  case. 

Variola,  or  smallpox,  is  a  specific  infectious  and  contagious  fever, 
beginning  abruptly  with  chill,  high  temperature,  headache,  vomiting, 
sweating,  and  intense  pain  in  the  back.  On  the  second  or  third  day 
of  the  disease  a  characteristic  shot-like,  papular  eruption  appears,  the 
papules  rapidly  developing  first  into  vesicles  and  then  into  pustules  ; 
with  the  appearance  of  the  rash  the  temperature  falls,  but  rises  again 
toward  the  end  of  the  week  in  the  pustular  stage  (fever  of  maturation 
or  suppuration).  The  contents  of  the  pustules  are  discharged,  crusts 
form  and  are  cast  off  about  the  eighteenth  day.  The  disease  may  be 
accompanied  by  a  number  of  complications,  particularly  hemorrhages 
into  the  skin  (purpuric  smallpox)  and  from  the  mucous  membranes 
(hemorrhagic  smallpox),  both  forms  being  popularly  called  black 
smallpox.  For  convenience  of  description  the  disease  may  be  divided 
into  four  stages  :  (1)  Incubation,  (2)  invasion,  (3)  eruption,  (4)  des- 
quamation. 

Incubation.  This  stage  lasts  from  ten  to  fourteen  days,  and  is 
usually  unaccompanied  by  any  symptoms  except,  toward  its  close,  by 
malaise. 

Invasion.  The  invasion  is  abrupt,  and  is  marked  by  chilliness  or 
a  distinct  rigor,  headache,  severe  pain  in  the  lumbar  region,  and  some- 
times delirium  or  convulsions,  especially  in  children.     The  most  promi- 


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THE  DATA  OBTAINED  BY  OBSERVATION. 


251 


nent  symptoms  are  the  excruciating  headache  and  backache.  The  tem- 
perature usually  rises  rapidly  to  104°  F.  or  higher  in  the  first  twenty- 
four  or  forty-eight  hours.  (See  Fig.  49.)  Headache  and  backache 
continue ;  there  are  pain  in  the  epigastrium,  a  coated  tongue,  loss  of 
appetite,  nausea  or  vomiting,  constipation,  and  copious  perspiration. 
Prostration  is  extreme.  Erythematous  eruptions  are  not  uncommon, 
especially  on  the  inner  surfaces  of  the  legs  and  thighs.  Petechia?  are 
found  in  Simon's  triangle,  the  base  of  which  is  at  the  umbilicus  and 
apex  at  the  knees. 

The  stage  of  invasion  lasts  generally  three  days  ;  but  it  may  be 
shortened  to  two  in  very  severe  cases  or  lengthened  to  four  in  very 
mild  ones,  and  in  complicated  and  hemorrhagic  cases  it  merges  into 
the  stage  of  eruption.     (See  Plate  IV.) 

Eruption.  The  characteristic  eruption  of  smallpox  appears  first  as 
minute  specks  resembling  flea  bites.  These  in  two  or  three  days 
develop  into  small  papules  which  feel  like  shot  under  the  skin.  In  a 
day  or  two  more  the  papules  become  vesicles,  at  first  containing  a 
clear  fluid,  which,  however,  rapidly  becomes  turbid  ;  they  are  umbili- 

FlG.  50. 


Discrete  variola  on  the  sixth  day  of  eruption.    (Welch.) 

cated.  In  the  course  of  another  day  or  two  the  vesicles  have  become 
pustules  and  are  globular  in  shape.  The  period  of  ripening  or  matu- 
ration, when  pustulation  is  at  its  height,  lasts  about  three  days  ;  it  is 
characterized  by  a  marked  secondary  fever,  the  temperature  rising  as 
high  as,  or  higher  than,  in  the  onset  of  the  disease.  The  pustules  now 
begin  to  dry  up  (desiccation)  and  form  dry  scales  or  scabs,  which  are 
cast  off  toward  the  end  of  the  third  week  of  the  disease  (eighteenth 


252  GENERAL  DIAGNOSIS. 

day)  ;  when  the  pustules  have  been  deep  enough  to  involve  the  true 
skin,  characteristic  scars,  called  pits,  are  left. 

The  eruption  appears  on  the  forehead,  along  the  margin  of  the  hair, 
and  in  the  scalp,  then  over  the  rest  of  the  face,  especially  about  the 
nose  and  lips,  subsequently  progressing  over  the  rest  of  the  body  from 
above  downward.  The  eruption  is  most  abundant  upon  the  face  and 
hands,  often  being  confluent  here  when  discrete  elsewhere.  The  face 
may  appear  horribly  swollen,  bloated,  and  disfigured,  and  both  face 
and  hands  are  extremely  painful  from  the  great  distention  and  the 
pustules,  which  are  really  small  dermal  abscesses. 

Varieties.  Three  varieties  of  variola,  depending  upon  the  number 
and  disposition  of  the  pocks  and  upon  the  presence  of  complications, 
are  recognized  :  (1)  Discrete  ;  (2)  confluent ;  (3)  malignant. 

In  discrete  variola  the  pocks  are  not  numerous,  and  are  separated 
from  each  other  by  intervening  healthy  skin. 

In  confluent  smallpox  the  pustules  are  close-set,  occupy  almost 
the  whole  body,  and  coalesce,  so  that  the  face  looks  as  though  covered 
with  a  black,  rough  mask  ;  the  mucous  membranes  are  also  covered. 
The  symptoms  of  the  invasion  are  intensified,  and  the  eruption  may 
appear  before  the  third  day.  Patients  are  liable  to  suffer  with  profuse 
salivation,  uncontrollable  vomiting  or  diarrhoea  (especially  in  children), 
and  with  delirium,  which  is  often  violent  and  destructive.  The  face  is 
dreadfully  swollen  and  the  eyelids  may  slough  ;  the  feet  and  lirnbs 
also  may  be  swollen  and  painful.  There  may  also  be  severe  bronchitis 
and  pneumonia,  abscesses,  extensive  sloughing,  and  a  pyaemic  condition. 

Malignant,  or  black,  smallpox  is  a  form  in  which  the  blood  is 
so  altered  that  hemorrhages  into  the  skin  or  from  the  mucous  mem- 
branes occur.  In  the  former  case  there  are  petechia?  and  ecchymoses 
upon  the  skin  ;  in  the  latter  more  or  less  profuse  hemorrhages  occur 
from  the  womb,  kidney,  bowels,  lungs,  and  stomach.  The  mind  of  the 
patient  remains  clear  and  he  is  conscious  of  his  peril.  The  eruption  is 
delayed  or  does  not  occur  at  all. 

Varioloid  is  a  mild  form  of  smallpox  occurring  in  a  person  protected, 
but  not  completely,  by  previous  vaccination,  or  in  a  person  who,  from 
other  causes,  does  not  possess  the  average  susceptibility.  It  is  charac- 
terized, apart  from  its  mildness,  bv  great  irregularity  in  the  develop- 
ment of  the  symptoms.  The  initial  symptoms,  as  a  rule,  are  as  severe 
as  in  ordinary  smallpox.  Prodromal  eruptions,  especially  the  erythe- 
matous, are  very  common.  The  eruption  may  appear  first  on  the  face, 
or  on  the  chest  and  trunk  first,  and  later  upon  the  face.  The  fever 
subsides  with  its  appearance.  The  eruption  passes  from  the  papular  to 
the  vesicular  stage,  as  in  ordinary  smallpox  ;  but  here  the  process,  as  a 
rule,  ceases,  the  vesicle  drying  up  on  the  fifth  or  sixth  day  of  the  erup- 
tion. If  pustules  form  they  do  not  reach  their  full  development.  The 
eruption  is  always  discrete.     There  is  usually  no  secondary  fever. 

Diagnosis.  When  fully  developed,  smallpox  will  not  be  mistaken 
for  any  other  disorder.  In  the  initial  stage,  however,  there  may  be 
doubt  whether  the  disease  will  prove  to  be  pneumonia,  cerebro-spinal 
meningitis,  or  typhus.  If  the  patient  has  been  exposed  to  smallpox 
and  is  unprotected  by  vaccination,  and  he  is  suddenly  seized  with  a 


THE  DATA  OBTAINED  BY  OBSERVATION.  253 

chill,  high  temperature,  and  excruciating  pain  in  the  lumbar  region, 
there  is  great  probability  in  favor  of  smallpox.  If  the  patient  has 
complained  of  headache,  pains  in  the  ankles  and  other  joints,  and  is 
seized  with  a  severe  rigor,  explosive  vomiting,  and  great  weakness  of 
the  limbs,  the  chances  favor  meningitis  in  the  absence  of  known  expo- 
sure to  smallpox.  In  pneumonia,  vomiting,  chill,  and  high  tempera- 
ture succeed  each  other,  but  excruciating  backache  is  wanting,  and,  on 
the  other  hand,  the  respiration  is  increased  out  of  proportion  to  the 
pulse,  and  even  in  this  early  stage  there  may  be  cough  and  roughening 
of  the  respiratory  murmur  on  one  side. 

Typhus  fever  begins  abruptly  with  chill  and  high  temperature  ;  but 
the  eruption  which  comes  out  on  the  fourth  or  fifth  day  is  first  macular 
and  later  petechial,  the  temperature  does  not  fall  with  the  appearance 
of  the  eruption,  the  aspect  of  the  patient  is  drunken  and  stuporous,  the 
conjunctivae  are  injected,  the  eye  ferrety,  the  skin  dry,  hot,  and  biting 
to  the  touch  (calor  mordex). 

In  the  papular  stage  of  the  eruption  it  may  be  mistaken  for  measles  ; 
but  the  red,  swollen,  blear-eyed,  photophobic  little  patient  with  measles, 
with  the  characteristic  coryza  and  obstinate  cough,  presents  a  very 
different  appearance  from  that  seen  in  variola.  Moreover,  the  eruption 
of  measles  is  relatively  flat,  smooth,  and  velvety  ;  that  of  smallpox  is 
acuminate,  hard,  and  shot-like.  The  temperature  in  smallpox  falls  as 
the  eruption  appears  ;  that  of  measles  remains  high  and  even  increases. 
The  papules  of  measles  do  not  develop  into  vesicles. 

In  the  vesicular  stage  varioloid  may  be  mistaken  for  chickenpox.  In 
the  latter  the  eruption  is  practically  vesicular  from  the  start,  occurs 
without  prodromata,  appears  first  upon  the  chest  and  neck,  later  upon 
the  face  and  scalp,  is  usually  very  scanty,  and  rarely  becomes  umbili- 
cated  or  pustular.  There  are,  however,  severe  forms  of  varicella,  in 
which  fever,  restlessness,  and  cough  precede  the  appearance  of  the  rash, 
which  is  copious,  some  of  the  vesicles  being  inflamed  at  the  base,  some 
umbilicated,  and  some  with  purulent  contents.  These  cases  are  most 
common  in  scrofulous  children  whose  hygienic  surroundings  are  bad. 
In  such  cases  the  diagnosis  cannot  be  made  from  the  eruption.  A  con- 
sideration of  the  following  points  must  decide  :  1.  History  of  exposure 
to  varicella  on  the  one  hand  or  smallpox  on  the  other.  2.  The  pres- 
ence or  absence  of  effective  vaccination  or  of  scars  of  antecedent  vari- 
cella. 3.  The  age  of  the  patient ;  smallpox  occurs  at  all  ages,  varicella 
only  in  childhood.  4.  The  discovery  among  neighboring  children  of 
varicella  or  varioloid.     5.  The  rapid  evolution  of  a  varicella  pock. 

Varicella. 

Varicella  is  one  of  the  infections  of  childhood  in  which  the  febrile 
course  is  very  mild.  It  is  an  acute  specific  infectious  fever,  occurring 
almost  exclusively  in  children,  and  characterized  by  the  appearance,  in 
successive  crops,  of  colorless  or  pearly  vesicles,  which  dry  up  and  are 
shed  in  from  two  to  five  days.  It  is  attended  with  very  little  constitu- 
tional disturbance.      A  second  attack  is  extremely  rare. 

The  incubation   is  generally  about  two  weeks,  but  may  be  one  or 


254  GENERAL  DIAGNOSIS. 

three  weeks.  In  ordinary  cases  the  first  evidence  of  the  invasion  of 
the  disease  is  the  appearance  of  the  eruption.  In  other  cases,  the 
severer  ones,  the  child  may  be  noticed  for  some  hours  or  several  days 
to  be  indisposed,  complaining  of  loss  of  appetite,  nausea,  headache,  and 
vague  muscular  pains.  The  fever  is  almost  always  moderate — 100° 
to  101°. 

The  eruption  consists  first  of  hypera?mic  macules,  compared  by  Trous- 
seau to  the  rose-rash  of  typhoid  fever.  These  macules  rapidly  become 
first  papules  and  then  vesicles.  The  papules  are  not  hard  as  in  variola. 
They  appear  at  first  upon  the  chest,  neck,  face,  and  scalp,  then  upon  the 
trunk  and  limbs.  The  development  of  the  vesicles  is  so  rapid  that  the 
eruption  appears  vesicular  from  the  start.  The  vesicles  vary  in  size 
from  a  pinhead  to  a  small  pea.     They  are  very  superficial,  and  usually 

Fig.  51. 


Varicella  on  the  fifth  day  of  eruption. 

rest  upon  a  base  that  is  slightly  or  not  at  all  hypersemic.  The  contents 
are  at  first  watery,  but  subsequently  become  pearly.  The  reaction  of 
the  fluid  is  alkaline.  Distinct  umbilication  is  rare,  and  pustulation 
still  more  rare,  but  both  occur.  The  vesicles  almost  always  dry  up  and 
form  scabs,  yellowish  or  brownish,  which  drop  off,  leaving  a  slightly 
reddened,  sometimes  depressed  spot.  Sometimes  the  vesicles  are  to  be 
seen  upon  the  buccal  mucous  membrane  and  upon  the  throat.  While 
most  of  the  eruption  appears  on  the  first  or  second  day,  fresh  vesicles 
continue  to  appear  for  several  days. 

Desiccation  usually  occurs  by  the  fourth  or  fifth  day,  and  may  be 
present  in  the  first  day  or  two.  As  the  eruption  appears  in  successive 
crops,  often  all  stages,  from  the  initial  macule  to  the  dried  scales,  can 
be  seen  in  one  case. 

Usually  the  vesicles  are  widely  scattered,  a  dozen  or  two  over  the 
entire  body.  They  are  most  numerous  upon  the  back,  and  may  be  as 
close  together  as  in  discrete  variola. 

In  scrofulous  and  badly  nourished  children  the  lesions  are  more  in- 
flammatory and  pustules  are  more  common.  If  they  are  scratched, 
ulceration  ensues.  A  gangrenous  form  has  been  described  by  Eustace 
Smith  and  others  ;  the  cases  are  apt  to  be  fatal. 


THE  DATA    OBTAINED  BY  OBSERVATION.  255 

In  ordinary  cases  during  the  eruption  the  child  is  rarely  more  than 
indisposed  ;  complications  are  rare,  and  the  prognosis  most  excellent. 
The  physician  is  not  often  consulted  except  to  have  his  opinion  as  to 
the  diagnosis.  (For  the  differential  diagnosis  from  smallpox,  see 
Variola.) 

It  is  distinguished  from  vesicular  and  pustular  eczema  by  the  fever, 
the  symmetrical  grouping  and  discrete  character  of  the  lesions,  the 
comparative  absence  of  itching  and  burning,  and  its  shorter  course. 

Impetigo  is  distinguished  by  the  absence  of  fever,  the  more  local 
character  of  the  eruption,  and  the  fact  that  it  is  generally  pustular.  It 
is  more  common  upon  the  face  and  hands  than  is  varicella. 

Scarlatina. 

In  this  eruptive  fever  the  course  of  the  temperature  varies  some- 
what with  the  severity  of  the  infection.  In  many  instances  fever 
would  not  be  detected  without  the  use  of  the  thermometer.  In  others 
it  may  rise  to  a  great  height,  and  even  be  hyperpyretic.  Its  onset  is 
sudden ;  it  reaches  its  greatest  height  when  the  eruption  is  complete. 

The  temperature  in  scarlet  fever  usually  conforms  to  a  clearly  defined 
type.  The  temperature  increases  gradually  to  the  third  or  fourth  day, 
when  the  acme  is  reached.  It  declines  by  lysis  in  a  period  of  four 
days.  A  seven  days'  chart  would  be  pyramidal  in  shape.  In  septic 
forms  (scarlatina  anginosa),  with  ulceration  of  the  fauces,  the  fever 
continues  and  becomes  remittent.  In  scarlatina  maligna,  hyperpyrexia 
is  likely  to  ensue  rapidly. 

Scarlet  fever  is  an  acute,  specific,  contagious,  and  infectious  fever, 
characterized  by  a  sudden  onset,  with  vomiting,  sore-throat,  and  high 
fever,  followed  in  twelve  or  twenty-four  hours  by  a  bright-red,  puncti- 
form  eruption,  by  a  very  frequent  pulse,  by  a  desquamation  which  is 
often  in  large  flakes,  by  a  very  variable  degree  of  severity,  and  by  a 
large  number  of  complications  and  sequela?,  especially  nephritis  and 
inflammation  of  serous  membranes. 

Scarlet  fever  preferably  affects  children  from  one  to  five  years  of 
age.  The  liability  to  it  diminishes  after  the  tenth  year  ;  but  it  is  very 
rare  under  the  age  of  six  months.  Puerperal  women  are  very  suscep- 
tible to  the  poison,  and  the  existence  of  open  wounds  favors  infection. 
The  disease  occurs  in  epidemics  at  longer  intervals  than  is  true  of 
measles.  Cases  are  most  numerous  in  the  autumn  and  winter  months. 
The  peculiar  poison  is  doubtless  a  living  organism,  but  it  has  not  been 
isolated  as  yet.  It  is  very  tenacious  of  life,  being  capable  of  infecting, 
through  clothing  in  which  it  has  been  retained,  months  after  the  cloth- 
ing absorbed  the  poison. 

Few  diseases  vary  so  greatly  in  severity  in  different  cases  and  in  dif- 
ferent epidemics.     It  may  be  the  mildest  or  most  malignant  of  diseases. 

The  period  of  hicubation  is  remarkably  short,  generally  from  three 
to  five  days  ;  but  it  may  be  a  few  hours,  and,  in  exceptional  cases,  six 
days. 

The  invasion  is  abrupt.  It  is  very  common  to  be  told  that  a  child 
was  apparently  well  on  going  to  bed,  but  awoke  in  the  middle  of  the 


256 


G ENEBA  L  DIA  GNOSIS. 


night,  vomiting  profusely  and  complaining  of  sore-throat.  The  child 
is  found  in  the  morning  with  a  temperature  of  103°  or  104°,  a  pulse 
of  120  to  140,  and  a  scarlatinal  eruption  beginning  to  show  upon  the 
neck  and  upper  part  of  the  chest.  Close  observation  in  such  cases 
might  have  discovered  that  the  child  was  feverish  on  going  to  bed,  and 
that  he  had  been  somewhat  chilly  before  that.  Onset  with  decided 
chill,  vomiting,  and  nervous  symptoms  indicate  a  severe  case. 


Fro.  52. 


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Scarlet  fever.    Mild  attack  ;  intense  eruption. 

The  subjective  symptoms  of  scarlatina  are  few  ;  they  consist  usually 
of  pain  in  swallowing,  with  stiffness  of  the  neck-muscles,  some  head- 
ache, thirst,  malaise,  and  a  moderate  amount  of  weakness.  In  the 
eruptive  stage  the  skin  itches,  burns,  and  is  frequently  hypera?sthetic. 

The  objective  symptoms  and  their  order  of  succession  are  very  charac- 
teristic. Vomiting  is  the  rule,  except  in  mild  cases,  and  hence  is  of 
importance  in  diagnosis,  especially  in  otherwise  doubtful  cases.  The 
temperature  is  high  at  the  onset, 'frequently  103°  or  104°.  It  falls  a 
degree  or  so  in  the  morning  ;  but  the  following  evening,  when  the 
eruption  is'  usually  at  its  height,  it  rises  to  104°  or  105°,  and  then 
gradually  falls  to  normal  in  the  course  of  a  week  in  ordinary  cases. 
(Figs.  34  and  52.) 

The  pjulse-rate  is  characteristically  frequent,  being  120  to  160  oftener 
than  slower.     This  frequency  is  not  an  indication  of  danger. 

The  blood  shows  a  leucocytosis,  beginning  on  the  first  day  and  con- 
tinuing through  convalescence.  A  close  relationship  exists  between 
the  degree  of  leucocvtosis  and  the  rash.  Suppurative  complications 
tend  to  increase  the  number  of  white  cells.  The  finely  granular  eosino- 
philes  are  greatlv  increased  during  the  first  few  days.  The  mononuclear 
cells  and  lymphocytes  are  diminished  at  first,  but  after  a  short  time 
their  percentage  increases. 

The  throat  exhibits  a  uniform  flush  extending  over  pharynx,  tonsils, 
soft  palate,  and  sometimes  forward  on  the  hard  palate,  nearly  to  the 


THE  DATA   OBTAINED  BY  OBSERVATION.  257 

teeth.  Sometimes  dark-red  points  can  be  distinguished  on  the  soft 
palate.  The  tonsils  are  inflamed  and  projected  toward  the  median  line 
from  each  side.  Frequently  the  mouths  of  the  follicles  are  blocked  by 
a  creamy-white  exudate.  It  is  not  uncommon  to  find  a  severe  follicu- 
lar tonsillitis  at  the  first  visit. 

The  tongue  is  at  first  covered  with  a  thick,  creamy  fur,  through  which 
enlarged  red  papilla?  show.  The  enlarged  papillae  look  like  small 
grains  of  red  pepper  sprinkled  on  the  tongue.  Sometimes  the  papilla? 
are  elevated  and  have  a  button-like  appearance.  The  symptoms 
appear  very  early  in  the  disease,  and  may  continue  for  three  or  four 
weeks.  The  coating  soon  disappears  from  the  tip,  leaving  it  bright 
red — the  "  strawberry  tongue." 

The  skin  is  hot  and  dry.  The  characteristic  eruption  usually  appears 
within  twenty-four  hours,  often  within  six  to  eighteen  hours,  of  the 
chilliness  or  vomiting  which  marks  the  onset.  Sometimes  it  comes 
out  very  slowly,  seeming  to  be  just  ready  to  appear,  but  not  appearing 
in  its  full  development  for  four  or  five  days. 

The  intensity  of  the  eruption  varies  from  a  scarcely  perceptible  ery- 
thema to  the  color  of  a  boiled  lobster.  Usually  its  intensity  varies 
with  the  severity  of  the  disease.  In  ordinary  cases  the  patient  appears 
to  be  covered  with  a  uniform  red  efflorescence  ;  but  a  closer  inspection 
shows  that  there  are  darker  red  spots  between  which  the  skin  is  more 
or  less  erythematous.  It  is  first  seen  about  the  ears  and  neck,  and 
spreads  with  great  rapidity,  covering  the  entire  body  in  a  day.  It  is 
most  intense  upon  the  trunk  and  flexor  surfaces.  Upon  the  extensor 
surfaces  the  punctate  character  is  better  seen.  Pressure  causes  the 
redness  to  disappear,  but  it  immediately  reappears.  Papular  and  vesic- 
ular forms  of  eruption  are  also  seen.  The  physiognomy  of  the  disease 
is  peculiar.  The  circle  about  the  eyes,  nose,  and  lips  remains  pale, 
and  in  marked  contrast  with  the  rest  of  the  fiery  red  face.  Itching 
and  burning  are  annoying  symptoms  at  times.  The  eruption  fades 
gradually,  in  ordinary  cases  disappearing,  except  when  there  is  press- 
ure or  irritation  toward  the  end  of  the  week. 

The  eruption  is  succeeded  by  desquamation,  which  is  extensive  in 
proportion  to  the  intensity  of  the  eruption.  The  flakes  are  larger  than 
in  measles,  and  in  severe  cases  the  epidermis  may  come  off  in  long 
strips.  About  the  hands  and  feet  this  shedding  is  sometimes  so  great 
as  to  be  compared  to  a  glove.  This  stage  may  be  protracted  for  sev- 
eral weeks,  danger  of  infection  lasting  as  long  as  desquamation  con- 
tinue-. 

The  urine  is  at  first  scanty,  high-colored,  and  febrile.  Later,  when 
desquamation  is  in  progress,  there  is  great  liability  to  albuminuria  as  a 
complication. 

Varieties.  In  addition  to  the  ordinary  form  already  described  scar- 
latina exhibits  many  irregular  tonus.  There  maybe  only  a  sore-throat 
or  follicular  tonsillitis.  If  a  rash  is  present,  it  is  very  faint,  and  hence 
easily  overlooked.  The  diagnosis  in  such  cases  must  be  made  from 
the  fact  of  exposure  to  infection  and  from  the  appearance  of  the  throat. 
The  occurrence  of  vomiting  is  very  important  in  the  diagnosis,  as  it  is 
rare  in-ordinary  pharyngitis  and  tonsillitis.     Often  such  cases  escape 

17 


258  GENERAL  DIAGNOSIS. 

detection  altogether,  until  possibly  a  dropsy  from  scarlatinal  nephritis 
indicates  their  nature. 

Severe  diarrhoea  may  prevent  the  eruption  from  developing  upon  the 
skin.  It  appears  upon  the  fauces,  and  the  diagnosis  is  based  upon  this, 
the  pulse  and  temperature,  and  the  fact  of  exposure. 

In  scarlatina  anginosa  the  strength  of  the  poison  is  spent  upon  the 
throat.  Pain  is  great  and  deglutition  difficult.  The  tonsils  are  greatly 
swollen,  so  as  almost  to  occlude  the  fauces,  and  their  surfaces  are  cov- 
ered with  creamy  exudate.  The  cervical  glands  are  swollen,  and  there 
is  a  tense  and  brawny  cellulitis.  Sometimes  the  tonsils  become  gan- 
grenous, and  the  cervical  or  submaxillary  glands  suppurate  or  become 
gangrenous,  with  resulting  pyaemia  and  death.  Suppuration  may 
extend  to  the  ears  and  maxillary  sinuses.  In  this  form,  also,  a  false 
membrane  is  sometimes  found  upon  the  fauces — post-scarlatinal  diph- 
theria. It  is  probably  not  due  to  the  Klebs-Loffler  bacillus,  but  to  a 
streptococcus. 

In  malignant  forms  the  attack  is  ushered  in  with  chill,  followed  by 
hyperpyrexia,  convulsions,  marked  ataxic  symptoms,  or  stupor.  The 
profound  blood-disturbance  is  shown  by  the  dusky  hue  of  the  eruption. 
Some  patients  lie  in  coma-vigil,  others  are  very  restless  and  delirious. 
Vomiting  and  diarrhoea  are  sometimes  superadded.  Patients  may 
emerge  from  this  condition  and  succumb  later  to  a  nephritis  or  to  grave 
anginose  symptoms  ;  but  death  in  a  few  days  is  the  rule.  In  rare  cases 
the  dose  of  poison  is  so  enormous  that  death  takes  place  in  a  few  hours, 
without  the  appearance  of  any  eruption. 

Complications  and  Sequelae.  The  severe  local  symptoms  men- 
tioned under  the  anginose  variety,  together  with  convulsions,  hyper- 
pyrexia, and  ataxic  symptoms,  may  properly  be  regarded  as  complica- 
tions. Apart  from  these  the  most  frequent  are  nephritis  and  endocar- 
ditis or  pericarditis.  Nephritis  generally  appears  with  the  beginning  of 
desquamation.  It  is  nearly  as  frequent  in  mild  as  in  severe  cases, 
probably  because  the  danger  of  exposure  to  cold  is  greater  in  the 
former,  although  the  scarlatinal  poison  unquestionably  has  a  selective 
affinity  for  the  epithelium  of  the  kidney.  The  symptoms  do  not  differ 
from  those  of  acute  parenchymatous  nephritis  occurring  under  other 
circumstances.  In  some  cases  we  have  weakness,  languor,  slight  fever, 
and  prolonged  convalescence  ;  in  others,  oedema,  anuria,  convulsions  or 
coma  from  urseniia.  Endocarditis  is  often  preceded  by  tenderness  and 
soreness  of  the  muscles  and  joints — scarlatinal  rheumatism. 

Endocarditis  and  pericarditis  develop  in  the  course  of  the  fever, 
giving  rise  to  an  increase  or  continuance  of  the  fever,  to  local  pain  or 
dyspnoea,  and  to  the  usual  physical  signs. 

Pleuritis  and  meningitis  also  may  occur.  Much  more  common  com- 
plications are  otitis,  peripheral  neuritis,  and  affections  of  the  joints, 
grouped  as  scarlatinal  rheumatism.  Paralyses,  peripheral  and  central 
in  origin,  are  occasional  sequels  of  the  disease.  Scarlatina  is  found 
also  in  association  with  other  diseases. 

Diagnosis.  Sudden  onset,  rapid  rise  of  temperature,  persistent  and 
causeless  vomiting,  and  sore-throat  lead  one  to  suspect  this  affection. 
The  characteristic  eruption  and  its  mode  of  evolution,  the  rapid  pulse, 


THE  DATA  OBTAINED  BY  OBSERVATION.  259 

the  peculiar  tongue,  the  circle  of  pallor  on  the  face,  are  characteristic 
of  the  eruptive  stage.  "  The  appearance  of  a  punctate  eruption  in  the 
axilla  and  in  the  groins,  together  with  the  congestion  of  the  tonsils  and 
a  punctate  eruption  in  the  roof  of  the  mouth,  no  matter  whether  there 
is  any  eruption  anywhere  else  or  not,  are  positive  proofs  of  scarlet 
fever"  (McCollom). 

Unfortunately,  all  cases  do  not  develop  to  the  same  degree,  so  that 
frequently  we  must  wait  for  the  period  of  desquamation  ;  more  unfor- 
tunately, for  the  occurrence  of  sequelae,  as  acute  nephritis,  otitis,  or 
adenitis. 

Scarlet  fever  is  distinguished  from  measles  by  the  mode  of  onset,  which 
is  sudden,  with  chilliness,  high  temperature,  vomiting,  and  sore-throat, 
and  great  rapidity  of  the  pulse  ;  whereas  the  onset  in  measles  is  gradual, 
with  coryza,  cough,  moderate  fever,  perhaps  looseness  of  the  bowels, 
but  no  sore-throat.  The  eruption  of  scarlatina  occurs  on  the  first  day, 
that  of  measles  on  the  fourth  ;  the  former  consists  of  dark-red  spots 
with  intervening  erythematous  skin,  the  whole  looking  at  a  distance 
like  a  uniform  bright-red  flush  ;  the  latter  consists  of  raised,  rounded, 
or  flattened  spots  or  blotches,  velvety  to  the  touch,  and,  upon  the  body 
and  extremities,  grouped  in  patches  with  crescentic  outlines.  The  tem- 
perature in  scarlatina  subsides  gradually  after  the  rash  has  reached  its 
height ;  that  of  measles  increases  until  the  eruption  is  complete,  then 
subsides  by  crisis.  The  rash  of  scarlet  fever  persists  for  six  or  eight 
days  ;  that  of  measles  fades  as  soon  as  it  is  complete,  on  the  fourth 
day.  In  the  former,  desquamation  is  in  flakes  or  large  strips  ;  in  the 
latter  it  is  branny  and  nearly  invisible.  Scarlatina  involves  by  prefer- 
ence the  serous  membranes  and  kidneys  ;  measles  the  mucous  mem- 
branes and  lungs. 

Scarlatina  has  to  be  differentiated  from  pharyngitis,  tonsillitis,  and 
digestive  disturbances,  attended  Math  vomiting,  high  temperature,  and 
occasionally  erythematous  eruptions. 

In  ordinary  pharyngitis  and  tonsillitis  the  redness  is  more  apt  to  be 
confined  to  the  pharynx,  tonsils,  and  arches  of  the  soft  palate  ;  in  scar- 
latina it  extends  as  a  flush  over  the  soft  and  hard  palate  and  buccal 
surfaces.  In  the  former,  high  temperature,  a  very  frequent  pulse,  and 
vomiting  are  unusual ;  in  the  latter  they  are  the  rule. 

The  glands  of  the  neck  also  are  more  apt  to  be  involved  in  the  latter. 

In  acute  gastritis  there  is  usually  a  history  pointing  to  indiscretion 
in  eating,  with  constipation.  The  pulse  is  not  so  frequent  as  to  suggest 
scarlatina,  sore-throat  is  absent,  and  any  erythema  present  lacks  the 
characteristic  dark-red  points,  and  is  not  followed  by  desquamation. 

The  diagnosis  from  rubella  is  difficult  at  times.  It  differs  from  scar- 
latina in  presenting  mild  catarrhal  symptoms,  sneezing,  suffusion  of 
the  eyes,  and  cough,  with  a  relatively  fleeting  eruption.  The  latter 
perhaps  appears  most  frequently  upon  the  back  and  chest.  Often  the 
eruption  is  the  first  thing  noticed  amiss  with  the  child.  It  more  com- 
monly resembles  the  rash  of  measles  than  that  of  scarlatina,  but  when 
it  resembles  the  latter  most  it  is  apt  to  be  discrete  and  of  a  darker  red. 
There  may  be  a  very  intense  rash  without  much  constitutional  disturb- 
ance, the   temperature   being  lower  and  the   pulse  much  slower  than 


260  GENERAL  DIAGNOSIS. 

would  be  expected  in  a  scarlatina  presenting  the  same  appearance. 
Nausea  may  be  present,  but  vomiting  is  very  rare.  The  post-cervical 
aud  post-auricular  glands  are  more  commonly  enlarged  in  rubella  than 
in  mild  scarlatina,  though  this  symptom  is  not  invariable. 

Diphtheria  is  distinguished  by  its  gradual  onset,  patches  of  false 
membrane  developing  upon  the  fauces  early.  In  anginose  scarlet  fever, 
with  severe  follicular  tonsillitis,  the  differential  diagnosis  is  essentially 
the  same  as  between  simple  follicular  tonsillitis  and  diphtheria  (q.  v.). 

In  addition,  the  pulse  and  temperature  have  a  much  higher  range  in 
scarlatina.  The  erythema  of  diphtheria  is  distinguished  from  the  erup- 
tion of  scarlatina  by  its  fleeting  character  and  the  absence  of  desqua- 
mation. 

Grave  cases  Avhich  begin  with  repeated  vomiting,  convulsions,  del- 
irium, and  insomnia  simulate  meningitis ;  but  a  satisfactory  cause  for 
the  latter  is  lacking,  while  the  excessive  heat  of  the  skin,  sore-throat, 
very  frequent  pulse,  and  early  eruption  clear  up  the  diagnosis. 

So,  also,  the  onset  with  vomiting,  convulsion,  and  high  temperature 
resembles  pneumonia;  but  in  the  latter  the  respiration  is  proportion- 
ately more  frequent  than  the  pulse,  with  altered  breath-sounds  and 
percussion-sounds,  while  sore-throat  and  eruption  are  wanting. 

Measles. 

The  course  of  the  fever  in  this  affection  resembles  that  of  smallpox 
in  that  after  the  initial  rise  of  the  first  twenty-four  hours  the  tempera- 
ture remains  normal  until  the  appearance  of  the  eruption  on  the  third 
day.  It  is  an  acute,  specific,  infectious,  and  highly  contagious  fever, 
characterized  by  coryza  and  bronchitis,  a  red  papular  eruption,  coming 
out  on  the  fourth  day  and  followed  by  a  branny  desquamation  about 
the  ninth  or  tenth  day.  The  mucous  membranes  are  especially  liable 
to  complications. 

Measles  occurs  in  epidemics,  especially  in  cold  weather,  but  indi- 
vidual cases  are  met  with  in  large  cities  at  all  seasons  of  the  year.  It  is 
so  contagious  that  when  one  case  develops  in  a  household  or  institution 
almost  every  person  exposed  to  it  and  not  protected  by  a  previous 
attack  acquires  it.  Children  from  one  to  five  years  of  age  are  most 
susceptible  to  the  poison,  but  it  may  occur  in  utero  and  in  old  age  ; 
moreover,  the  same  person  may  have  several  attacks,  showing  that  one 
attack  does  not  afford  the  same  protection  as  an  attack  of  scarlatina  or 
variola. 

Measles  is  sometimes  found  in  association  with  scarlatina  and  vari- 
cella, but  it  is  especially  liable  to  occur  after  pertussis. 

The  specific  cause  of  the  disease  has  not  yet  been  isolated. 

The  period  of  incubation  lasts  from  eleven  to  fourteen  days.  During 
this  time  the  patient  may  exhibit  no  symptoms,  or  may  be  irritable  and 
restless,  with  disturbed  sleep  and  occasional  cough,  and  looseness  of 
the  bowels. 

The  invasion  is  marked  by  cough  and  fever,  and  by  redness  of  the 
eyes  and  lacrymation,  sometimes  with  photophobia,  sneezing,  and  an 
irritating,  watery  discharge  from  the  nose,  which  subsequently  becomes 


PLATE    V. 


Fig.   I. 


Fig.   II. 


Fig.  III. 


Fig.    IV. 


The  Pathognomonic  Sign  of  Measles  (Koplik's  Spots). 

Fig.  i. — The  discrete  measles  spots  on  the  buccal  or  labial  mucous  membrane,  showing  the  isolated  rose- 
red  spot,  with   the  minute  bluish-white  centre,  on  the  normally  colored  mucous  membrane. 

Fig.  2.— Shows  the  partially  diffuse  eruption  on  the  mucous  membrane  of  the  cheeks  and  lips;  patches  of 
pale  pink  interspersed  among  rose-red  patches,  the  latter  showing   numerous    pale   bluish-white   spots. 

Fig.  3. — The  appearance  of  the  buccal  or  labial  mucous  membrane  when  the  measles  spots  completely 
coalesce  and  give  a  diffuse  redness,  with  the  myriads  of  bluish-white  specks.  The  exanthema  on  the  skin  is  at 
this  time  generally  fully  developed. 

Fig.  4.  Aphthous  stomatitis  apt  to  be  mistaken  for  measles  spots.  Mucous  membrane  normal  in  line. 
Minute  yello-w  points  are  surrounded  by  a  red  area.     Always  discrete. 


THE  DATA   OBTAINED  BY  OBSERVATION. 


261 


mucopurulent,  and  by  cough  and  fever.  In  short,  the  early  symp- 
toms are  those  of  a  severe  coryza.  These  symptoms  last  from  three  to 
five  days  (generally  four)  before  the  eruption  appears. 

But  an  eruption  is  commonly  visible  upon  the  base  of  the  uvula  and 
soft  palate,  as  raised,  discrete  dark-red  papules,  several  days  before  it 
appears  upon  the  body.  The  peculiar  appearance  of  this  eruption  has 
been  accurately  described  by  Koplik  (1897).  His  observations  have  been 
corroborated,  so  that  "  Koplik' s  sign  "  is  a  well-established  fact.  Its 
importance  can  be  understood  when  the  necessity  for  early  diagnosis  for 
quarantine  purposes  is  realized.  This  sign  appears  twenty-four  hours, 
forty-eight  hours,  and  even  three  to  five  days  before  the  skin  erup- 
tion. It  precedes  the  conjunctivitis  and  begins  at  the  first  rise  of 
temperature.  The  eruption  appears  on  the  mucous  membrane  of  the 
cheeks  and  lips.  It  is  not  seen  on  the  palate  or  the  fauces.  It  is  at 
first  discrete  and  then  becomes  confluent.  It  is  at  its  height  when 
the  skin  eruption  appears  and  is  spreading.  In  strong  daylight  this 
pathognomonic  eruption  is  seen  to  consist  of  small  irregular  spots  of  a 


Fig.  53. 


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made  higher  as  the  result  of  school  and  exertion. 


Measles.  Lower  temperature  second  and 
third  days.  Hyperpyrexia  sixth  day.  Abun- 
dant eruption.    Bronchitis  severe. 


bright-red  color,  in  the  centre  of  which  is  seen  a  minute  bluish-white 
speck.  The  bluish-white  speck  is  very  small  and  delicately  colored, 
requiring  direct  and  strong  daylight  to  see  it,  A  combination  of  the 
speck  on  the  rose-red  background  is  a  positive  sign  of  the  invasion  of 
measles.  The  spots  must  not  be  mistaken  for  sprue,  which  is  opaque, 
white,  coarse,  and  plaque-like.  When  the  rose-red  spots  coalesce, 
Koplik  describes  the  appearance  of  the  mucous  membrane  to  be  made 
up  of  large  areas  of  rose-red,  studded  all  over  with  minute  raised  bluish- 
white  specks,  relieved  here  and  there  by  the  normal  hue  of  the  uninvaded 
mucous  membrane.  The  accompanying  figures  from  Koplik's  latest 
paper  illustrate  this  important  sign.     (Plate  A".)     By  this  sign  measles 


262 


GENERAL  DIAGNOSIS. 


can  be  differentiated  from  rotheln,  scarlet  fever,  aphthous  stomatitis, 
forms  of  erythema  and  urticaria,  drug  eruptions,  the  antitoxin  eruption, 
and  forms  of  syphilis.  The  temperature  rises  during  the  first  day  to 
100°  or  102°,  or  higher,  if  the  case  is  to  be  a  severe  one.  The  bowels 
are  frequently  inclined  to  be  loose  and  the  passages  somewhat  greenish. 
The  temperature  falls  on  the  second  day  to  normal  or  nearly  normal, 
and  then  steadily  rises  until  it  reaches  its  acme  with  the  full  develop- 
ment of  the  eruption,  when,  in  uncomplicated  cases,  it  falls  rapidly  to 
normal.  With  the  coming  out  of  the  eruption  the  coryza  increases  in 
severity,  and  cough  is  a  prominent  and  annoy ing  symptom.  It  con- 
sists of  a  series  of  five  or  six  explosive  efforts  without  expectoration. 
In  severe  cases  the  cough  is  almost  incessant,  so  that  rest  is  much  inter- 
fered with.  It  depends  upon  a  catarrhal  inflammation  of  the  entire 
resjuratory  tract,  from  the  nose  to  the  bronchioles. 

Fig.  55. 


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Measles.    Characteristic  chart.    Female,  aged  twenty-seven. 


Objective  Symptoms.  The  eruption  on  the  body  appears  first 
about  the  neck,  face,  and  wrists,  and  spreads  in  two  or  three  days  over 
the  entire  body.  It  is  usually  most  copious  upon  the  face,  which  is 
swollen,  dark-red  in  color,  and  closely  set  with  papules,  which  are 
elevated,  rounded  at  the  summits,  and  feel  like  soft  velvet  to  the  touch. 
When  to  this  picture  is  added  that  of  a  severe  coryza  with  mucoserous 
exudate,  which  often  glues  the  eyelids  together  and  oozes  out  upon  the 
face,  and  a  corresponding  condition  of  the  nasal  orifices,  the  physiog- 
nomv  is  at  once 'seen  to  be  very  unusual.     At  this  staa^e,  moreover, 


THE  DATA  OBTAINED  BY  OBSERVATION.  263 

photophobia  is  often  considerable,  the  child  burrowing  its  head  in  the 
pillows  to  escape  light. 

The  eruption  is  not  apt  to  be  confluent  upon  the  body  ;  here  the 
dark-red,  elevated,  smooth  papules  are  very  distinct.  Sometimes  they 
are  grouped  so  as  to  form  crescentic  outlines.  The  eruption  fades  in 
the  order  in  which  it  appeared,  and  is  followed  by  a  fine  branny 
desquamation.  With  the  completion  of  the  eruption  the  fever 
falls  rapidly  to  or  below  normal,  the  coryza  and  bronchitis  im- 
prove correspondingly,  and  in  forty-eight  hours  convalescence  is  fully 
established. 

Complications.  The  complications  of  measles  affect  for  the  most 
part  the  mucous  membranes  of  the  respiratory  and  digestive  tracts. 
The  bronchitis,  which  is  always  present,  may  become  capillary,  or  be 
associated  with  oedema  or  with  areas  of  catarrhal  pneumonia.  These 
are  the  most  frequent  and  the  most  dangerous  complications.  Pneu- 
monia may  develop  while  the  eruption  is  coining  out,  in  which  case 
the  eruption  is  delayed  or  the  spots  have  a  dusky  or  bluish  hue  (black 
measles).  More  commonly,  perhaps,  pneumonia  is  discovered  when, 
the  eruption  being  complete,  a  crisis  should  occur. 

Epistaxis  is  not  usually  dangerous.  Profuse  diarrhoea  is  very  ex- 
hausting and  delays  the  evolution  of  the  eruption.  Severe  conjuncti- 
vitis, sometimes  with  ulceration  of  the  cornea,  is  not  uncommon. 
Otitis  media  occurs  oftener  as  a  sequel  than  as  a  complication.  Noma, 
or  cancrum  oris,  is  a  rare  complication  of  measles  occurring  in  ill-fed, 
badly  nourished  children.     It  is  frequently  fatal. 

Convulsions  may  occur  as  a  complication,  especially  when  pneu- 
monia is  developing. 

Sequelae.  In  cases  in  which  there  has  been  diarrhoea,  measles  is 
sometimes  followed  by  considerable  weakening  of  the  digestive  power. 
The  catarrh  of  the  respiratory  tract,  which  almost  invariably  accom- 
panies it,  predisposes  to  the  development  of  whooping-cough  and  tuber- 
culosis. 

Paralysis  may  follow  measles.  It  may  be  central  or  peripheral  in 
origin,  but  generally  is  of  the  hemiplegic  type  ;  cases  of  acute  polio- 
myelitis, acute  ascending  paralysis,  and  disseminated  myelitis  have  also 
been  reported. 

Varieties.  Measles  without  catarrh  is  rare.  It  cannot  be  recog- 
nized from  a  measles-like  rash,  seen  in  rotheln,  except  by  the  occur- 
rence in  the  neighborhood  of  other  cases  of  undoubted  measles. 

Measles  without  eruption  is  to  be  recognized  by  the  coryza,  possibly 
with  eruption  on  the  soft  palate,  the  course  of  the  temperature,  and  the 
exposure  to  specific  infection. 

Black  measles  is  the  name  given  to  malignant  forms  in  which,  owing 
to  complications,  particularly  pneumonia,  the  skin  is  dusky  and  the 
eruption  comes  out  poorly  and  lias  a  bluish  color.  In  rare  instances 
the  eruption  shows  a  hemorrhagic  tendency,  the  spots  being  livid  or 
ecchymotic.  Actual  hemorrhages  from  mucous  surfaces  may  occur, 
the  patient  dying  in  coma  or  convulsions. 


264  GENERAL  DIAGNOSIS. 


Rubella. 


In  a  few  instances  this  infection  may  run  its  course  without  fever. 
In  the  large  majority  of  cases,  however,  a  moderate  degree  of  fever 
prevails  and  in  some  it  may  reach  a  considerable  height. 

Rubella  is  an  acute,  specific,  contagious,  and  infectious  fever,  char- 
acterized by  a  gradual  onset,  with  moderate  fever,  sore-throat,  and 
slight  coryza.  The  eruption,  which  appears  without  prodromata, 
usually  resembles  measles  more  than  scarlatina.  The  duration,  how- 
ever, is  shorter  than  measles,  the  disease  milder,  and  complications  are 
rare. 

The  disease  is  amply  proved  not  to  be  a  hybrid  of  measles  and 
scarlet  fever.  The  incubation-period  varies  from  one  to  three  weeks, 
but  is  generally  about  two.  As  a  rule,  this  period  is  past  without 
symptoms. 

The  invasion  is  without  prodromata,  or  none  more  definite  than 
languor  and  indisposition,  the  first  thing  noticed  being  the  eruption. 
This  in  some  cases  consists  of  pale-red,  smooth,  slightly  raised  blotches, 
closely  resembling  measles,  but  more  pronounced  on  the  trunk,  and 
discrete.  This  is  probably  a  very  rare  form.  More  commonly  it 
consists  of  rose-red  macula?  or  papules,  occasionally  confluent,  but 
usually  discrete,  and  most  marked  upon  the  trunk.  In  still  other 
cases  the  eruption  closely  resembles  that  of  scarlatina,  differing  chiefly 
in  being  a  paler  red  and  accompanied  by  less  heat  of  skin.  Sometimes 
the  eruption  is  circumscribed,  as  upon  the  face  or  limbs.  It  is  usually 
the  seat  of  considerable  itching,  and  this  may  be  the  first  symptom 
that  attracts  the  patient's  attention.  It  will  be  seen  that  the  eruption 
is  multiform  in  character.  Concurrently  with  the  eruption,  there  is 
usually  slight  rise  in  temperature  (100°— 101°),  suffusion  of  the  eyes, 
with  slight  lacrymation  and  photophobia,  and  slight  pharyngitis ; 
nausea  is  not  uncommon,  but  vomiting  is  very  rare.  Higher  tempera- 
tures have  been  recorded  in  a  few  cases,  and  so  have  nervous  symp- 
toms, such  as  delirium  and  convulsions,  but  they  are  chiefly  interesting 
as  very  exceptional  possibilities.  On  the  other  hand,  the  disease  may 
run  its  course  without  any  fever. 

The  eruption  extends  over  the  body  in  twenty-four  to  thirty-six 
hours,  less  rapidly  than  in  scarlatina,  and  pales  much  more  quickly, 
fading  on  the  portions  of  the  body  first  attacked  before  reaching  its 
height  on  the  last,  and  being  completed  in  three  or  four  days.  Some- 
times a  branny  desquamation  succeeds. 

In  addition  to  the  mild  coryza  and  eruption,  the  most  important 
objective  symptom  is  swelling  of  the  cervical  glands,  all  of  them  being 
sometimes  swollen,  especially  those  behind  the  sterno-mastoid,  the 
auricle,  and  along  the  margin  of  the  hair.  This  adenopathy,  however, 
cannot  be  relied  upon  exclusively  in  the  differentiation  from  scarlatina 
and  measles. 

Rubella  has  few  complications  :  bronchitis,  pneumonia,  and  otitis 
occur  rarely,  and  still  more  rarely  false  membrane  on  the  throat,  and 
albuminuria.  The  prognosis  is  excellent.  It  ends  almost  invariably 
in  recovery,  except  in  very  feeble  children. 


THE  DATA  OBTAINED  BY  OBSERVATION.  265 


Infectious  Diseases  with  Local  Symptoms. 

The  following  infections  are  characterized  by  local  manifestations 
which  are  of  greater  diagnostic  significance  than  the  fever.  These 
local  manifestations  must,  therefore,  be  carefully  considered  in  the 
diagnosis,  and,  as  intimated,  must  be  relied  upon  for  recognition  of  the 
particular  infection.  The  infections  belong  to  Class  I.  and  Class  II. 
of  the  classification  in  Chapter  XVII. 

Mumps. 

This  infection  presents  marked  local  changes  about  the  jaws  coinci- 
dent with  the  rise  of  temperature.  The  infection  is  recognized  by  the 
swelling  of  the  parotid  and  submaxillary  glands  or  by  the  occurrence 
of  orchitis.  It  has  been  described  in  the  chapter  devoted  to  objective 
changes  of  the  face. 

Glandular  Fever. 

Glandular  fever  is  an  infectious  disorder,  the  cause  of  which  has  not 
been  accurately  determined.  It  is  characterized  by  fever,  usually 
occurring  abruptly,  with  headache,  pains  in  the  limbs  and  in  the  lymph 
glands  of  the  neck.  On  examination  of  the  fauces  a  slight  pharyngitis 
is  observed  and  the  tonsils  are  enlarged.  With  the  rise  of  temperature 
there  is  frequent  nausea  and  vomiting.  The  temperature  rises  abruptly 
to  about  102°.  In  the  second  twenty-four  hours  the  glands  of  the 
neck,  particularly  those  behind  the  sternocleidomastoid  muscles,  en- 
large. They  are  tender.  Although  there  may  be  some  slight 
oedema  there  is  no  redness  or  swelling  of  the  skin.  The  fever  contin- 
ues for  three  or  four  days  ;  the  enlarged  glands,  however,  may  remain 
for  several  weeks,  and  may  end  in  suppuration. 

The  infection  usually  occurs  in  children  between  the  age  of  five  and 
eight  years.  It  may  be  epidemic  and  occur  often  earlier  in  life  than 
just  mentioned.  The  other  lymphatic  glands  about  the  neck  and  in 
the  axilla  and  groin  may  be  enlarged.  In  not  a  few  instances  there  is 
enlargement  of  the  spleen,  and  cases  of  enlarged  liver  and  mesenteric 
glands  are  reported.  The  absence  of  an  eruption  serves  to  determine 
the  infection  from  the  eruptive  fevers  associated  with  adenitis,  particu- 
larly measles  and  rotheln. 

Pertussis. 

The  attention  of  the  physician  is  called  to  this  infection  by  the  pecu- 
liar character  of  the  respiratory  symptoms.  Fever  is  more  notable  as 
an  expression  of  one  of  the  complications — broncho-pneumonia — than 
of  the  general  infection.  It  may,  however,  be  a  serious  symptom  of 
the  infection. 

Whooping-cough  is  a  specific  catarrhal  inflammation  of  the  respira- 
tory passages,  involving  especially  the  trachea  and  bronchi,  and  char- 
acterized by  paroxysms  of  cough,  which  are  succeeded  by  spasmodic 
(•Insure  of  the  glottis  and  a  peculiar  inspiratory  whoop.  The  disease 
occurs  especially  in  childhood,  is  contagious  and  infectious,  and  is  some- 


266  GENERAL  DIAGNOSIS. 

times  epidemic.     Whooping-cough  may  be  conveniently  divided  into 
three  periods  : 

1.  The  catarrhal  stage. 

2.  The  spasmodic  stage. 

3.  The  stage  of  gradual  subsidence  of  the  disease. 

First  Stage.  The  patient  appears  to  have  an  ordinary  cold.  The 
amount  of  redness  of  the  mucous  membrane  of  the  eyes,  nose,  and 
throat  varies  considerably,  but  there  is  not  much  discharge  from  the 
mucous  surfaces.  The  cough  is  dry,  and  sometimes  a  ringing  quality 
can  be  detected.  The  patient  is  irritable,  has  slight  fever,  diminished 
or  capricious  appetite,  and  restless  sleep.  A  mild  bronchitis  of  the 
larger  tubes  can  be  detected  by  physical  exploration. 

The  cough  gradually  becomes  more  frequent  and  paroxysmal,  the 
eyes  are  red  and  suffused,  and  there  is  a  mucopurulent  discharge  from 
the  nose.  The  face  often  looks  slightly  swollen,  especially  about  the 
upper  part  and  under  the  eyes.     Lymphocytic  leucocytosis  is  common. 

The  Second  Stage.  Transition  from  the  first  to  the  second  stage  is 
marked  by  the  appearance  of  the  characteristic  whoop.  The  parox- 
ysmal cough  is  made  up  of  a  series  of  rapid  expiratory  efforts,  diminish- 
ing in  force  and  duration  ;  when  these  cease  there  succeeds  a  prolonged 
crowing  inspiration — the  whoop.  There  may  be  only  one  paroxysm 
of  coughing  at  a  time,  but  more  commonly,  and  always  in  severe  cases, 
one  paroxysm  is  succeeded  by  another.  During  the  coughing  the 
child's  eyes  become  suffused,  the  tears  overflow,  and  there  is  a  discharge 
.of  serum  or  mucopus  from  the  nose,  and  of  saliva  and  bronchial  secre- 
tion from  the  mouth.  The  face  becomes  swollen  and  dusky.  If  the 
child  is  walking  about,  it  catches  some  object  for  support  during  the 
paroxysm  ;  or,  if  old  enough,  rushes  for  the  water-closet  or  a  basin, 
because  the  seizure  usually  terminates  in  vomiting.  The  matters 
vomited  consist  of  tenacious  mucus  and  the  contents  of  the  stomach. 
"With  the  mucus  there  may  be  streaks  of  blood,  and  occasionally  there 
is  pure  blood.  During  severe  paroxysms,  hemorrhages  are  apt  to 
occur  ;  these  are  generally  small  and  most  frequently  submucous.  In 
well-marked  cases,  when  the  disease  has  lasted  some  time,  the  face  has 
a  characteristic  appearance — it  is  swollen,  sodden,  and  dusky,  with 
dull,  heavy,  red,  and  watery  eyes.  There  is  often  ulceration  of  the 
lingual  fraenum. 

The  number  of  paroxysms  varies  from  two  or  three  to  twenty  or 
thirty  or  more  in  twenty-four  hours,  and  they  are  worse  at  night. 

The  whoop,  while  characteristic,  is  not  present  in  every  case,  being 
absent  especially  in  babies  and  very  young  children.  Sometimes  chil- 
dren have  "  choking  spells  "  without  much  coughing  and  without  the 
whoop.  Again,  when  pneumonia  or  measles  occurs  as  a  complication, 
the  whoop  usually  ceases  for  the  time,  but  may  reappear  later. 

Third  Stage.  The  third  stage  is  less  well  defined  than  the  first  two. 
It  may  be  said  to  begin  when  the  nocturnal  exacerbations  become  less 
frequent  and  severe.  The  number  of  paroxysms  during  the  day  dimin- 
ishes, and  vomiting  is  a  less  frequent  accompaniment.  Appetite  begins 
to  improve,  and  the  child  begins  to  gain  in  flesh  and  to  pass  more 
restful  nights. 


THE  DATA   OBTAINED  BY  OBSERVATION.  267 

The  duration  of  the  disease  is  variable.  Ordinarily  it  lasts  from  six 
to  eight  weeks,  but  it  may  be  prolonged  for  several  months.  The 
patient  is  liable,  whenever  he  catches  a  fresh  cold,  to  a  temporary 
return  of  the  spasmodic  cough,  sometimes  with  the  whoop. 

The  great  majority  of  the  cases  occur  before  the  sixth  year,  and  most 
of  these  between  the  second  and  fourth  years. 

Rheumatic  Fever. 

Rheumatic  fever  is  an  infection  associated  with  local  symptoms  of 
joint-,  endo-,  and  pericardial  inflammation.  The  local  symptoms  are  so 
extreme  as  to  call  attention  at  once  to  the  nature  of  the  infection  apart 
from  the  course  of  the  fever,  as  it  is  largely  upon  these  symptoms  that 
the  diagnosis  is  made.  The  reader  is  referred  to  Chapter  XIII. ,  in 
which  the  diagnosis  of  rheumatic  fever  is  discussed. 

Dengue. 

The  peculiarity  of  the  fever  in  this  infection  is  that  it  is  attended  by 
severe  paius  in  the  muscles  and  joints.  It  is  an  acute  contagious  dis- 
ease, occurring  in  epidemics  and  characterized  by  severe  pains  in  the 
head,  back,  and  joints,  various  skin  eruptions,  a  prolonged  convales- 
cence, and  a  very  low  rate  of  mortality. 

The  disease  occurs  in  epidemics  in  tropical  and  subtropical  countries, 
and  rarely  in  cooler  climates.  It  derives  its  name,  dengue  (dandy), 
from  the  stiff  and  unnatural  gait  assumed  by  convalescent  patients. 
In  the  southern  parts  of  the  United  States  an  expressive  name  given 
to  the  disease  is  "  breakbone  fever." 

The  specific  cause  of  the  disease  is  believed  by  Dr.  McLoughlin  to 
be  a  micrococcus  which  is  isolated.  The  period  of  incubation  is  short, 
varying,  however,  from  a  few  minutes  to  several  days,  or  even  a  week. 
Invasion  is  very  sudden  and  is  rarely  preceded  by  any  prodromata. 
It  is  marked  by  chilliness  or  a  chill,  and  very  severe  pains  in  the  head, 
back,  and  limbs.  In  children  the  onset  may  be  by  convulsions,  which 
are  sometimes  followed  by  stupor  and  vomiting.  The  pains  are  some- 
times excruciating,  and  are  accompanied  by  tenderness  of  the  muscles  ; 
there  is  extreme  debility.  The  temperature  rises  to  102°  or  103°,  but 
rarely  is  much  higher. 

The  pulse  is  frequent — 110,  120,  or  more.  In  from  one  to  three 
or  five  days  the  temperature  falls  to  or  below  normal  (the  remission), 
accompanied  by  sweating  or  diarrhoea,  and  fluctuates  about  this  level 
for  several  days,  when  a  second  and  moderate  rise  in  temperature, 
which  is  of  short  duration,  occurs.  During  the  first  rise  in  tempera- 
ture there  is  a  transient,  generally  scarlatiniform  rash,  which  is  not 
followed  by  desquamation.  The  urine  is  febrile  but  not  albuminous. 
During  the  remission  eruptions — scarlatiniform,  herpetic,  urticarial,  or 
like  miliaria — begin  to  appear,  accompanied  by  the  secondary  rise  in 
temperature.  The  eruptions  may  be  in  successive  crops,  and  are  fol- 
lowed by  desquamation.  Convalescence  is  now  established,  but  may  be 
interrupted  by  relapses.  Strength  is  regained  very  slowly.  The  most 
frequent  complications  arc  disorders  of  the  nervous  system,  but  bron- 
chitis and  diarrhoea  occasionally  occur. 


268  GENERAL  DIAGNOSIS. 


Beri-beri. 


Beri-beri  is  a  febrile  infectious  disorder  which  prevails  in  epidemic 
form,  limited  to  tropical  and  subtropical  countries.  It  is  characterized 
by  multiple  neuritis  associated  with  anasarca.  By  most  observers  it  is 
believed  to  be  an  acute  infection,  although  not  a  few  think  it  is  an 
intoxication  due  to  certain  kinds  of  food.  This  is  the  view  which  pre- 
vails in  Japan.  The  circumstances  predisposing  to  infections  generally 
prevail,  however,  such  as  overcrowding,  the  prevalence  in  hot  and 
moist  seasons,  and  the  exposure  of  the  patient  to  climatic  influence. 
It  is  far  more  common  in  men,  and  usually  attacks  subjects  whose  ages 
range  from  sixteen  to  twenty-five. 

Several  clinical  forms  are  seen.  In  the  most  complete  form  there  is 
rapid  loss  of  power  in  the  legs  and  arms,  with  atrophy  of  the  muscles. 
The  patients  complain  of  pain,  and  later  oedematous  symptoms  may 
appear.  With  the  loss  of  power  in  the  legs  there  is  paresthesia,  with 
frequent  palpitation  of  the  heart  and  dyspnoea.  The  pain  in  the  mus- 
cles is  associated  with  weakness  and  tenderness.  In  milder  degrees  of 
this  form,  pain,  weakness  in  the  legs,  diminishing  of  the  sensibility, 
and  paresthesia  are  the  most  common  symptoms.  Their  onset  will 
be  gradual  and  be  accompanied  by  catarrhal  symptoms.  The  symp- 
toms may  recur  from  time  to  time,  and  are  much  more  aggravated 
during  the  warm  season.  Its  recurrence  and  incomplete  form  may 
continue  ten  or  fifteen  years. 

Following  the  pain  and  weakness  of  the  muscles,  in  some  cases 
oedema  becomes  very  pronounced,  associated  with  effusions  into  the 
serous  cavities.  General  anasarca  is  attended  by  palpitation  and  rapid 
action  of  the  heart  and  dyspnoea.  In  this  so-called  wet  or  dropsical 
form  atrophy  of  the  muscles  is  not  observed  until  the  oedema  disap- 
pears. In  some  instances  the  infection  is  very  intense,  and  is  charac- 
terized by  more  marked  cardiac  symptoms.  In  these  instances  acute 
dilatation  may  be  followed  by  cardiac  paralysis  and  death  in  twenty- 
four  or  forty-eight  hours. 

The  diagnosis  is  based  upon  the  occurrence  epidemically  or  endemi- 
cally  in  tropical  regions  of  peripheral  neuritis  with  oedema.  Thus  far 
no  bacteriological  diagnosis  obtains. 

Constitutional  Syphilis. 

Intermittent,  remittent,  or  continuous  fever  is  attendant  upon  this 
infection  sometime  during  its  course.  (See  Afebrile  Infections,  Chap- 
ter XVI.)  Want  of  recognition  of  the  cause  of  this  febrile  phenomena 
leads  to  many  mistakes  in  diagnosis.     (See  Fig.  63.) 

Constitutional  syphilis  may  be  acquired  or  congenital. 

Acquired  syphilis  is  characterized,  first,  by  the  initial  lesion,  or 
chancre,  which  appears  usually  in  a  week  after  contagion  ;  second,  by 
a  'period  of  incubation  generally  lasting  six  weeks,  but  varying  from 
one  to  three  months  ;  third,  by  so-called  secondary  symptoms,  com- 
prising febrile  symptoms,  polymorphous  skin-eruptions,  ulcers  upon 
the  tonsils,  adenitis,  less  frequently  mucous  patches  in  the  mouth,  or 
condylomata  about  the  anus,  iritis  and  retinitis,  and  loss  of  hair.  The 
lesions  of  this  period  are  symmetrical.     Fourth,  after  an  interval  vary- 


THE  DA  TA  OB  TA  IN  ED  B  Y  OBSER  VA  TION.  269 

ing  from  several  months  to  twenty  years,  by  so-called  tertiary  phenom- 
ena, which  manifest  themselves  in  some  cases.  These  are  clue  to  chronic 
inflammatory  indurations  of  the  skin  and  subcutaneous  tissue,  resulting 
in  suppuration  and  ulceration  ;  or  of  the  bones,  producing  periostitis 
and  necrosis  ;  or  of  organs,  producing  gummata  and  cirrhosis  ;  or  of 
the  nervous  system,  resulting  in  gummata  or  chronic  degenerative 
changes.     The  lesions  of  this  period  are  unsymmetrical.1 

The  course  of  syphilis  in  different  persons  varies  as  widely  as  any 
of  the  eruptive  fevers.  In  some  the  chancre  is  a  mere  papule  which 
heals  almost  unnoticed  ;  no  secondary  symptoms  appear,  and  tertiary 
symptoms  also  are  altogether  wanting,  or  a  chronic  degeneration  of 
the  nervous  system  develops  after  the  lapse  of  many  years,  the  patient 
in  the  meantime  remaining  in  apparent  health.  All  this  may  occur, 
too,  without  the  aid  of  specific  treatment.  In  other  cases  the  disease 
is  malignant ;  tertiary  symptoms  appear  very  early  or  appear  to  take 
the  place  of  secondary  symptoms  ;  ulceration  may  rapidly  melt  down 
and  destroy  the  alee  of  the  nose  or  the  soft  palate  ;  or  rebellious  perios- 
titis with  necrosis  may  attack  the  tibiae,  the  nasal  bones,  or  the  cranium. 

In  an  ordinary  case  of  acquired  syphilis,  in  about  six  weeks  after 
the  appearance  of  the  chancre,  the  patient  complains  of  languor,  weari- 
ness, slight  fever,  pains  in  the  bones,  impaired  digestion,  and  a  ten- 
dency to  anaemia.  An  eruption  now  appears.  It  is  most  marked  on 
the  trunk  and  upper  extremities,  especially  the  chest  and  forehead 
(corona  Veneris).  The  eruption  may  be  roseolous,  squamous,  vesico- 
papular,  papular,  pustular,  bullous,  or  tubercular.  The  color  has  been 
aptly  compared  to  that  of  a  slice  of  raw  ham.  The  enlargement  of  the 
inguinal,  epitrochlear,  and  postcervical  glands,  which  precedes  the 
eruption,  persists.  Shallow  ulcers  with  a  sharply  defined  grayish  out- 
line appear  on  both  tonsils.  They  are  painless  and  do  not  spread. 
Ulcers  are  also  liable  to  appear  upon  the  pharynx,  buccal  surfaces, 
tongue,  angles  of  the  mouth,  penis,  vulva,  vagina,  and  around  the 
anus.  In  the  mouth  these  are  apt  to  be  very  painful,  and  may  persist 
in  spite  of  treatment  for  weeks  or  months.  Relapses  are  not  uncom- 
mon. Sometimes  there  are  raised  white  patches  upon  the  pharynx. 
Sometimes  the  hair  becomes  very  thin  and  falls  out,  leaving  the  patient 
without  eyebrows  and  more  or  less  bald.  Iritis  and  retinitis  are  usually 
later  symptoms.  Other  symptoms  occasionally  occurring  at  this  stage 
are  periostitis,  usually  slight,  and  onychia. 

The  most  common  of  the  symptoms  enumerated  are  the  eruption  and 
the  tonsillar  ulceration. 

The  eruption  comes  out  gradually  during  two  or  three  weeks,  and 
persists  for  about  two  months.  Rarely,  hoAvever,  it  is  fleeting,  or,  on 
the  other  hand,  is  unduly  prolonged. 

The  secondary  symptoms  last  from  six  to  eighteen  months.  After 
their  disappearance  the  patient  may  remain  entirely  well  for  life.  In 
other  cases  after  apparent  health,  lasting  for  months  or  years,  the 
I  ciliary  phenomena  already  mentioned  appear.  In  the  interval  the 
patient  may  have  suffered  with  various  local  skin  eruptions  or  with 
ulcers  upon  the  buccal  mucous  membrane. 

1  Fever  is  a  constant  accompaniment  of  all  forms  of  syphilis.     (See  Fever.) 


270  GENERAL  DIAGNOSIS. 

The  tertiary  lesions  of  syphilis  are  the  late  sypkilides  (see  Skin)  and 
gummata  of  the  skin,  subcutaneous  connective  tissue,  muscles  or  inter- 
nal organs.  Visceral  syphilis  is  seen  at  this  stage.  In  the  brain  and 
spinal  cord  gummatous  tumors,  gummatous  meningitis,  gummatous 
arteritis,  and  localized  scleroses  are  found.  The  symptoms  are  those 
of  brain  tumor  when  the  cerebrum  is  affected,  and  of  tumor,  menin- 
gitis, or  sclerosis  when  the  cord  is  affected.  In  syphilis  of  the  lung 
we  may  find  gummata  scattered  through  the  lung  or  a  fibrous  inter- 
stitial pneumonia  beginning  at  the  root  of  the  lung.  Diffuse  syphilitic 
hepatitis  or  gummata  may  be  found  when  the  liver  is  affected.  The 
rectum  is  the  most  common  seat  of  syphilis  of  the  digestive  tract. 
Myocarditis  and  localized  gummata  and  endarteritis  occur  in  cardiac 
syphilis,  while  in  vascular  syphilis  obliterating  endarteritis  and  gum- 
matous periarteritis  are  found.  Syphilitic  orchitis  often  occurs.  Its 
presence  may  aid  in  the  diagnosis  of  obscure  visceral  syphilis. 

Hereditary  syphilis  differs  in  some  respects  from  the  acquired  form. 
At  birth  the  syphilitic  infant  usually  exhibits  no  evidence  of  its  inher- 
ited taint.  In  the  course  of  from  one  to  twelve  weeks  it  develops  a 
catarrhal  inflammation  of  the  nasal  mucous  membrane,  which  causes 
snuffling  in  breathing,  and  hence  is  called  "  snuffles."  An  eruption 
soon  appears,  symmetrical  in  distribution.  It  is  most  frequently  ery- 
thematous or  papular,  but  it  may  be  squamous,  vesicular,  pustular,  or 
bullous.  In  hereditary  syphilis  it  is  more  apt  to  be  moist  and  to  favor 
the  genitalia  and  flexures  of  the  thigh  than  in  acquired  syphilis.  It  is 
of  the  same  ham-color  as  in  acquired  syphilis.  Coincident  with  the 
"  snuffles  "  and  eruption  appear  stomatitis  and  ulcers  at  the  angles  of 
the  mouth,  and  sometimes  condylomata  around  the  anus.  Meantime 
the  child  has  begun  to  waste,  to  be  peevish,  to  be  anaemic,  and  gradu- 
ally to  assume  the  appearance  of  a  wizened,  dried-up  old  man.  As  in 
acquired  syphilis,  there  may  be  iritis,  though  it  is  uncommon,  and 
inflammation  of  the  other  structures  of  the  eye,  but  nodes  and  disease 
of  the  liver  are  rare.  The  infant  very  frequently  dies  during  this 
period  from  exhaustion  and  inanition. 

If  the  child  survives  for  a  year  the  secondary  symptoms  usually 
disappear  and  the  disease  becomes  latent.  Relapses  may  occur,  and 
in  them,  according  to  Mr.  Hutchinson,  condylomata  are  likely  to 
appear.  The  same  observer  states  that  the  tertiary  period  may  begin 
at  any  time  after  the  fifth  year,  but  it  is  commonly  delayed  till  about 
the  period  of  puberty.  In  the  meantime  the  patient  may  appear  fairly 
well,  but  usually  his  development  is  retarded,  there  is  a  tendency  to 
ansemia,  and  he  has  often  nasopharyngeal  catarrh,  flattening  of  the 
bridge  of  the  nose,  premature  decay  of  the  upper  incisor  teeth,  and 
protuberant  forehead. 

The  teeth  may  be  perfectly  normal,  in  other  cases  characteristically 
syphilitic.  The  malformation  affects  especially  the  upper  central  in- 
cisors of  the  permanent  set.  It  was  first  described  by  Mr.  Hutchin- 
son. It  "  consists  in  a  dwarfing  of  the  tooth,  which  is  usually  both 
narrow  and  short,  and  in  the  atrophy  of  its  middle  lobe.  This  atro- 
phy leaves  a  single  broad  notch  (vertical)  in  the  edge  of  the  tooth,  and 
sometimes  from  this  notch  a  shallow  furrow  passes  upward  in  both 
anterior  and  posterior  surfaces  nearly  to  the  gum.     This  notching  is 


THE  DATA   OBTAINED  BY  OBSERVATION. 


271 


It  mav  vary  much  in  degree  in  different  cases 


the  teeth  diverge,  and  at  others   they  slant  toward  each 


usually  symmetrical 

sometimes 

other."     (See  Part  II.,  Chapter  IV.) 

Further,  the  patient  may  have  had  or  may  now  be  attacked  with 
keratitis,  affecting  both  eyes,  producing  cloudy  opacities  and  accom- 
panied by  great  photophobia.  Again,  there  may  be  nodes  upon  the 
long  bones,  with  nocturnal  exacerbations  of  pain.  Cerebral  deafness, 
according  to  Hutchinson,  is  not  rare,  but  cerebral  blindness  is.  There 
may  be  ulceration  upon  the  legs,  and  periostitis  and  necrosis.  The 
patient  usually  recovers  completely,  but  he  is  more  liable  to  be  carried 
off  by  intercurrent  disease  than  a  healthy  person,  and  in  general  has 
less  resisting  power,  especially  to  tuberculosis. 

Diagnosis.  The  diagnosis  of  hereditary  syphilis  is  based  upon  the 
occurrence  of  snuffles  and  skin  eruptions,  and  the  existence  of  keratitis 
or  of  cicatrices,  especially  about  the  angles  of  the  mouth.  A  history 
of  repeated  miscarriages  is  suggestive  of  maternal  syphilis.  The  diag- 
nosis of  acquired  syphilis  is  based  upon  the  history  of  chancre,  when  that 
history  is  obtainable  ;  upon  the  existence  of  polymorphous  eruptions, 
or  of  non-traumatic  ulcers  upon  the  legs  of  young  adults,  or  of  scars 
in  the  groins  or  over  the  tibia,  or  of  nodes,  or  of  alopecia  associated 
with  sore-throat  or  mucous  patches.  The  presence  of  obscure  disease 
of  the  bones,  glands,  or  spinal  cord  should  lead  to  the  search  for  a 
possible  syphilitic  infection.     (See  Malaria,  Chapter  XIX.) 

Fig.  56. 


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X  =  MERCURIAL  INUNCTION 

Reduction  of  haemoglobin  after  mercurial  inunction  in  syphilis. 

Examination  of  the  blood  during  mercurial  treatment  may,  in  accord- 
ance with  Justus'  observations,  show  the  presence  of  syphilis.  If  this 
disease  is  present  the  percentage  of  haemoglobin  falls  suddenly  and 
rapidly  during  the  hours  immediately  following  the  first  administration 
of  the  drug.  Cabot  has  confirmed  his  observations.  The  accompany- 
ing chart  shows  the  effect  of  mercury  upon  the  blood.     (See  Fig.  56.) 

Weil's  Disease. 

The  occurrence  of  jaundice  without  local  hepatic  symptoms  during 
the  course  of  fever  suggests  an  infectious  process.  It  is  a  well  known 
symptom  of  pyaemia  and  septicaemia.  In  the  following  infection 
fever  and  jaundice  are  coordinate  symptoms.  Acute  febrile  jaun- 
dice, which  rapidly  becomes  malignant,  occurring  in  butchers,  laborers, 


272  GENERAL  DIAGNOSIS. 

and  brewers,  has  been  described  by  Weil.  After  exposure  to  cold 
generally,  as  in  a  beer-vault,  the  patient  is  seized  with  a  chill,  fol- 
lowed by  fever,  with  headache,  vomiting,  and  epigastric  pain.  Jaun- 
dice sets  in  rapidly.  The  temperature  remains  high,  or  may  be  inter- 
mitting. Stupor,  delirium,  and  coma,  albuminuria,  with  suppression  of 
urine,  subcutaneous  hemorrhages,  and  hemorrhages  from  mucous  mem- 
branes, rapidly  ensue.  Black  vomit  occurs  early.  In  one  of  my  cases 
there  was  enlargement  of  the  liver,  with  subcutaneous  oedema  over  the 
hepatic  area.  The  microscopical  appearances  were  those  of  acute  dif- 
fused parenchymatous  inflammation.  In  another,  a  brewery  man,  the 
liver  was  enlarged,  but  without  unusual  change,  save  congestion. 

The  delirium  is  sometimes  violent.  The  appearance  and  symptoms 
suggest  acute  yellow  atrophy  of  the  liver.  The  etiological  distinctions 
are  noteworthy  :  the  liver  is  not  small ;  leucin  and  tyrosin  are  not 
found  in  the  urine  ;  the  jaundice  is  more  intense.  The  diagnostic  cir- 
cumstances of  epidemic  and  contagious  diseases  serve  to  exclude  yellow 
fever.     (See  Yellow  Fever.) 

Miliary  Fever. 

The  occurrence  of  fever  in  association  with  profuse  sweating  is  rarely 
seen  without  attendant  signs  of  pyogenic  infection.  When  several  cases 
with  these  symptoms  occur  at  the  same  time,  suggesting  an  epidemic, 
the  infection  we  are  about  to  consider  must  be  thought  of. 

Miliary  fever,  or  sweating-sickness,  is  an  infectious  disease,  occur- 
ring in  epidemics,  and  characterized  by  moderate  fever,  profuse  sweat- 
ing, tenderness  and  a  sense  of  oppression  at  the  epigastrium,  and  a 
vesicular  eruption.  The  disease  has  occurred  epidemically  in  Eng- 
land, but  is  not  met  with  now  outside  of  France  and  Italy. 

After  mild  prodromal  symptoms  the  disease  sets  in  suddenly  with 
moderate  fever,  profuse  sweating,  and  epigastric  distress,  sometimes 
amounting  to  anguish.  The  characteristic  eruption  appears  on  the  third 
or  fourth  day.  It  consists  first  of  small  reddish  macula?,  in  the  centre 
of  which  a  vesicle  develops.  The  latter  varies  in  size  from  a  pinhead 
to  a  pea.  The  contents  are  at  first  clear,  but  subsequently  become 
purulent.  Desiccation  and  desquamation  follow.  The  eruption  is 
most  profuse  generally  upon  the  neck  and  trunk.  Sometimes  there 
are  marked  nervous  symptoms,  and  even  convulsions  and  fatal  collapse. 

It  is  distinguished  from  rheumatism  by  the  moderate  fever  and 
absence  of  joint-swellings,  and  from  malarial  fever  by  the  absence  of 
chills,  of  periodicity  in  the  febrile  movement,  and  absence  of  malarial 
organisms  from  the  blood. 

The  duration  of  the  disease  is  from  one  to  four  weeks.  The  mor- 
tality in  some  epidemics  has  been  very  high,  in  others  very  low. 

Infections  Transmitted  from  Animals  to  Man. 

When  fever  occurs  in  persons  in  contact  with  animals  or  their  prod- 
ucts the  possible  occurrence  of  the  infections — milk-sickness,  foot-and- 
mouth-disease,  and  rabies,  as  well  as  glanders  and  anthrax — must  be 
thought  of.  The  infections  which  follow  are  of  uncertain  bacteriology, 
and  are  recognized  not  alone  by  the  fever  but  also  by  the  local  symp- 
toms and  a  history  of  infection. 


THE  DATA  OBTAINED  BY  OBSERVATION.  273 

Milk-sickness. 

It  is  an  acute  disease  affecting  cattle,  and  transmitted  from  them  to 
human  beings  in  the  milk  or  meat.  The  disease  is  limited  to  a  few 
sparsely  settled  localities  west  of  the  Allegheny  Mountains.  It  is  char- 
acterized by  great  debility,  with  muscular  tremor  upon  motion  (hence 
the  name  "  trembles  "),  vomiting  (hence  called  "  puking  fever "),  a 
peculiar  foetor  of  the  breath,  obstinate  constipation,  and  moderate  fever 
or  subnormal  temperature.  The  vomited  matters  are  said  to  be  of  a 
peculiar  soapy  material  of  yellowish  or  greenish  color.  The  duration 
is  usually  less  than  a  week.  The  patient  may  sink  into  a  typhoid  con- 
dition and  die  in  coma,  or  he  may  die  in  a  few  hours.  Convalescence 
is  protracted. 

Foot-and-mouth  Disease. 

A  specific,  infectious  disease,  communicated  to  man  through  cattle, 
sheep,  or  pigs,  and  characterized  by  a  stomatitis.  It  is  communicable 
by  milk  ;  the  period  of  incubation  is  from  three  to  five  days.  Inva- 
sion is  characterized  by  slight  fever,  heat,  and  soreness  of  the  mouth, 
and  the  development  of  vesicles,  which  burst  and  leave  shallow  ulcers. 
Saliva  is  freely  poured  out.  The  tongue  swells  greatly,  and  eating  is 
painful.  Vesicles  sometimes  appear  about  the  fingers,  but  not  upon 
the  feet.  The  disease  lasts  from  one  to  two  weeks,  and  ends  almost 
invariably  in  recovery. 

Hydrophobia. 

An  acute,  specific  disease  communicated  to  human  beings  by  the 
bites  of  animals  similarly  affected.  The  animals  most  frequently 
affected  are  the  dog,  fox,  wolf,  cat,  and  skunk ;  90  per  cent,  of  the 
cases  in  human  beings  are  due  to  dog-bites. 

The  period  of  incubation  is  uncommonly  long  and  very  variable — from 
two  weeks  to  two  months  usually.  It  is  said  in  some  cases  to  be  a 
year  or  more.  The  disease  has  been  divided  into  three  stages — the 
melancholic,  the  spasmodic,  and  the  paralytic. 

In  the  melancholic  stage  there  is  pain,  hyperesthesia,  or  even  reopen- 
ing of  the  healed  wound.  The  patient  is  extremely  depressed  in  spirits, 
and  may  be  irritable.  He  seems  to  be  laboring  under  a  constant  ten- 
sion of  fear,  and  is  keenly  sensitive  to  light,  sounds,  or  draughts.  He 
is  affected  with  thirst,  but  attempts  to  swallow  water  cause  intensely 
painful  spasm  of  the  larynx. 

The  second  stage  is  reached  usually  on  the  second  day.  The  laryn- 
geal spasms  are  increased  and  lead  to  intense  dyspnoea  and  to  pitiable 
struggling  and  gasping  on  the  part  of  the  patient.  In  addition  to  the 
convulsive  seizures,  the  patient  foams  and  froths  at  the  mouth,  and  his 
face  expresses  the  extreme  terror  and  mental  anguish  he  feels.  The 
second  stage  lasts  from  one  to  three  days,  and  is  followed  by  the  third 
stage,  exhaustion  intermitting  with  paroxysms  of  less  severity.  The 
patient  may  now  be  able  to  swallow  easily,  but  there  is  great  weakness 
of  the  heart,  and  death  may  occur  from  failure  of  the  heart,  from 
asphyxia,  or  in  a  convulsion.  The  duration,  as  indicated,  is  only  a  few 
days.  The  result  is  practically  always  fatal,  but  recovery  may  be 
possible.     Bites  of  the  face  are  the  most  likely  to  be  fatal. 

18 


CHAPTER    XIX. 

THE  DATA  OBTAINED  BY  OBSEEVATION— {Continued). 

FEVER.     THE  INFECTIOUS  DISEASES. 

Infections  Recognized  by  Examination  of  the  Blood. 

Microscopical  Examination.  The  following  infections  are  recog- 
nized by  the  examination  of  fresh  blood  :  Relapsing  fever,  malaria, 
yellow  fever,  anthrax.  Typhoid  fever  is  also  recognized,  but  is  more 
frequently  diagnosticated  by  means  of  serum  diagnosis  and  by  culture 
methods.  By  staining  cover-slip  preparations  of  the  blood  the  diagnosis 
by  the  direct  method  is  confirmed. 

Serum  diagnosis  enables  us  to  determine  the  presence  of  typhoid 
fever,  yellow  fever,  and  Malta  fever. 

Bacteriological  examination  of  the  blood  corroborates  the  diag- 
nosis of  typhoid  fever  made  by  the  above  methods.  By  it  we  are  also 
enabled  to  determine  the  presence  of  gonorrheal  infection,  of  cerebro- 
spinal meningitis,  of  the  pneumococcus  infection,  and,  in  many  in- 
stances, of  infection  due  to  the  staphylococcus,  streptococcus,  and  bacil- 
lus coli  communis.  The  gonococcus  infection  alone  will  be  considered. 
It  must  be  remembered  that  the  micro-organisms  cannot  be  found  in 
the  blood  until  late  in  the  course  of  the  disease,  and  even  then  the 
infection  must  have  a  certain  degree  of  intensity.  Unfortunately,  they 
cannot  be  demonstrated  in  the  majority  of  cases.  Positive  cultures 
for  the  above  reasons  are  very  valuable.  Negative  cultures  do  not 
exclude  septic  infections. 

Relapsing  Fever. 

Relapsing  fever  is  the  first  infection  which  we  will  consider,  because 
historically  it  is  the  most  important.  It  is  the  first  infection  in  which 
a  micro-organism  was  found  to  be  causal,  and  is  one  to  which  Koch's 
laws  can  be  applied.  It  is  an  acute,  infectious,  and  contagious  fever, 
occurring  in  epidemics,  and  characterized  by  the  sudden  onset  of  a 
febrile  period  lasting  five  or  seven  days,  which  is  followed  by  an  inter- 
mission lasting  usually  a  week,  and  this  in  turn  by  a  relapse  lasting 
three  days.  Its  development  is  favored  by  filth  and  famine,  but  the 
specific  cause  is  believed  to  be  the  spirillum  of  Obermeier,  which  is 
constantly  present  in  the  blood  during  the  febrile  stage. 

The  stage  of  incubation  lasts  from  five  to  eight  days  (Pepper),  during 
which  the  patient  may  complain  of  malaise,  lassitude,  and  flying  pains. 
The  invasion  is  sudden.  It  manifests  itself  by  a  chill  or  chills,  frontal 
headache,  pains  in  the  back  and  limbs,  vertigo,  and  great  physical 
weakness.     The  temperature  rises  very  rapidly,  reaching  105°,  106°, 


THE  DATA  OBTAINED  BY  OBSERVATION.  275 

or  even  higher,  in  the  first  day  or  two.  The  face  is  flushed,  epistaxis 
sometimes  occurs,  the  headache  and  other  pains  persist,  but  delirium 
is  not  common.  The  appetite  is  usually  lost,  thirst  intense,  the  tongue 
coated  white  but  moist,  the  bowels  constipated.  A  mild  catarrhal  jaun- 
dice is  not  infrequent.  Pepper  states  that  nausea  and  vomiting  are 
prominent  symptoms,  the  matters  vomited  at  times  containing  blood. 
Tenderness  with  pain  in  the  epigastrium  is  frequently  complained  of. 

The  urine  is  scanty,  high-colored,  and  frequently  contains  albumin 
and  casts  ;  when  jaundice  exists  the  urine  contains  bile-pigment  and 
sometimes  blood. 

There  is  no  peculiar  eruption  in  relapsing  fever,  but  in  this,  as  in 
other  fevers,  erytheniata,  petechias,  and  sudamina  may  be  present. 

The  pulse  is  often  very  frequent  and  soft,  and  hsemic  murmurs  may 
be  audible. 

The  objective  symptoms  are  few.  They  consist  of  the  flushed  face, 
sometimes  with  slight  jaundice  and  epistaxis,  tenderness  in  the  epigas- 
trium, with  moderate  enlargement  of  the  spleen  and  liver,  and  consid- 
erable cutaneous  hyperesthesia,  with  tenderness  along  the  nerve-trunks. 

Bronchitis  and  sometimes  hypostatic  congestion  of  the  lungs,  with 
their  usual  physical  signs,  may  be  present. 

These  symptoms  continue  without  much  change  until  the  fifth  or 
seventh  day,  when  a  decided  crisis  occurs.  Sometimes  this  is  deferred 
until  the  tenth  day.  The  temperature  within  twelve  hours  falls  from 
106°  or  108°  to  or  below  normal ;  the  pulse  diminishes  in  frequency 
from  120  or  130  to  60  or  70  ;  vertigo,  headache,  and  other  pains  dis- 
appear as  by  magic.  The  crisis  is  marked  most  frequently  by  a  pro- 
fuse sweat,  sometimes  by  diarrhoea,  epistaxis,  metrorrhagia,  or  intesti- 
nal hemorrhage.  The  patient  now  enters  upon  convalescence  without 
fever,  and  apparently  makes  rapid  strides  toward  complete  recovery. 
On  the  seventh  day  from  the  crisis,  however,  a  sudden  relapse  occurs, 
with  a  repetition  of  the  symptoms  of  the  first  attack.  The  temperature 
may  be  higher  and  the  febrile  symptoms  more  severe,  but  the  duration 
is  shorter — only  three  or  four  days.  The  spirilla,  which  disappeared 
in  the  apyretic  interval,  are  again  found  in  abundance.  A  second 
crisis,  with  its  associated  symptoms,  now  occurs.  The  spirilla  again 
disappear,  and  in  the  majority  of  the  cases  there  is  no  further  bar  to 
complete  recovery.  A  second,  third,  and  even  a  seventh  relapse  may 
occur,  as  in  a  case  reported  by  Pepper.  Organic  lesions  are  not  usually 
left  behind,  unless  they  have  occurred  as  complications;  but  even  in 
ordinary  cases  the  patient  is  left  weak,  anemic,  and  with  poor  circulation. 

Examination  of  the  Blood.  Microscopical  Examination.  In 
the  blood  at  the  height  of  the  disease  the  spirillum  of  Obermeier  is 
found. 

These  are  slender,  wavy,  thread-like  organisms  of  spiral  shape,  seven 
or  eight  times  the  length  of  a  red  blood-cell,  with  a  very  lively  forward 
movement  in  the  direction  of  the  long  axis.  They  are  from  16  to  40// 
by  0.1//.  Under  a  low  power  the  blood  may  appear  to  be  in  motion,' as 
the  result  of  their  movement,  They  have  so  far  been  found  only  in  the 
height  of  the  febrile  attacks  ;  but  Yon  Jaksch  states  that  as  long  as  a 
relapse  is  to  be  feared  the  blood  contains  peculiar,  highly  refracting  bodies 


276  GENERAL  DIAGNOSIS. 

resembling  diplococei,  which  are  especially  numerous  before  the  attack ; 
in  some  cases  it  has  seemed  to  him  that  these  diplococci  at  the  very 
beginning  of  an  attack  develop  into  short,  thick  rods,  from  which  the 
spirilla  develop  ;  they  may,  therefore,  prove  to  be  spores.  Staining  is 
unnecessary  for  the  detection  of  spirilla,  but  cover-glass  preparations  of 
the  blood  can,  if  desired,  be  stained  with  fuchsia  or  gentian-violet  or 
L5ffler's  methylene-blue.     (Plate  III.,  Fig.  4,  a.) 

Serum  Diagnosis.  It  sometimes  happens  that  a  diagnosis  should 
be  made  during  the  afebrile  period  when  the  organisms  have  disap- 
peared entirely  from  the  peripheral  circulation.  Lowenthal's  method 
is  as  follows  :  A  drop  of  the  suspected  blood  is  mixed  with  one  con- 
taining the  living  micro-organisms.  The  mixture  is  sealed  up  with 
wax  between  slide  and  cover-glass  and  left  in  the  thermostat  at  37° 
for  half  an  hour.  Blood  from  a  patient  who  has  just  had  a  paroxysm 
will  destroy  the  spirilla,  so  that  they  lose  their  motility  and  spiral  curl 
and  accumulate  in  bunches.  The  reaction  is  like  that  of  Pfeiffer's 
phenomena  rather  than  agglutinative.  It  is  to  be  remembered  that 
the  bactericidal  power  of  the  blood  dies  out  before  the  next  paroxsym. 

Ixoculatiox.  As  further  aid  to  diagnosis  typical  relapsing  fever 
can  be  produced  by  injecting  the  infected  blood  into  monkeys. 

The  most  frequent  complications  are  on  the  side  of  the  lungs,  kid- 
neys, and  heart.  Lobar  pneumonia  is  the  most  frequent.  The  heart 
becomes  weakened  by  the  very  high  fever  and  thrombosis,  or  sudden 
failure  results.  Embolism  is  very  frequent.  Suppurative  parotitis, 
abscess  of  the  spleen,  profuse  epistaxis,  abortion  in  pregnant  women, 
and  neuritis  deserve  mention. 

Relapsing  fever  occurs  at  all  ages,  but  is  most  common  in  adults. 

The  duration  varies  according  to  the  munber  of  paroxysms.  If 
there  is  only  one,  it  is  about  eighteen  days.  Under  the  name  "  bilious 
typhoid  "  a  malignant  form  of  relapsing  fever  has  been  described.  It  is 
characterized  by  intensity  of  the  symptoms  of  the  ordinary  form,  and 
by  bilious  or  bloody  vomiting,  jaundice,  and  delirium,  or  by  collapse, 
with  purple  nose,  a  small,  frequent  weak  pulse,  rigidity  of  the  abdomi- 
nal muscles,  tenderness  in  the  epigastrium,  and  cold,  clammy  skin.  In 
some  of  the  cases  described  by  Graves,  intussusception  of  the  intestines 
was  found  after  death.     In  other  cases  uraemia  is  an  active  factor. 

Diagnosis.  The  earlier  cases  in  an  epidemic  may  not  be  recognized, 
unless  the  blood  be  examined,  until  the  occurrence  of  the  characteristic 
relapse.  The  diagnosis  is  based  upon  the  occurrence  of  an  epidemic, 
the  presence  of  the  predisposing  factors,  the  clinical  course,  and  the 
examination  of  the  blood.  It  is  most  likely  to  be  mistaken  for  typhus 
fever,  which  occurs  under  similar  conditions.  The  aspect  of  the  two 
diseases  is  very  different.  In  typhus  there  is  a  heavy,  stupid,  some- 
times besotted  expression,  with  slight  redness  of  the  eyes  and  a  con- 
tracted pupil.  The  patient  lies  oblivious  of  his  surroundings,  with 
low  muttering  delirium  and  ataxic  symptoms.  In  relapsing  fever,  on 
the  other  hand,  the  sensorium  is  rarely  much  disturbed,  the  spleen  and 
liver  are  enlarged,  and  there  is  hyperesthesia.  Moreover,  in  typhus 
there  is  a  spotted  eruption,  later  becoming  petechial.  In  relapsing 
fever  this  is  absent. 


THE  DATA  OBTAINED  BY  OBSERVATION.  277 

Anthrax. 

The  next  infectious  disease,  the  cause  of  which  can  be  determined  by 
an  examination  of  the  blood,  is  anthrax.  This  affection  is  also  of  his- 
torical importance,  and  is  probably  the  best  worked  out  of  any  of  the 
infections  common  to  man  and  the  lower  animals.  It  is  also  called 
malignant,  pustule,  charbon,  wool-sorter's  disease,  splenic  fever.  It  is 
derived  principally  from  herbivorous  animals,  and  characterized  by  the 
development  of  a  pustule  or  boil,  with  extensive  brawny  oedema  and 
subsequent  toxaemia ;  or  toxaemia  may  appear  first  and  metastatic 
abscesses  subsequently.  The  disease  also  attacks  the  gastro-intestinal 
mucous  membrane  and  the  lungs. 

Anthrax  is  caused  by  the  anthrax-bacillus  and  its  toxins.  Outside 
of  the  body  it  forms  endogenous  spores,  which  are  extremely  tenacious 
of  life,  and  to  which  infection  is  invariably  due.  They  infect  not  only 
the  carcasses  of  animals,  but  also  the  soil,  all  utensils  used  in  the  care 
of  the  animals  or  the  soil,  and  they  persist  with  infective  power  in  the 
hides,  hair,  hoofs,  and  wool  ("  wool-sorter's  disease  ").  It  is  possible 
that  it  may  be  transmitted  to  man  by  stings  of  insects,  particularly 
flies  and  mosquitoes. 

The  period  of  incubation  varies  from  a  few  hours  to  several  days. 
In  the  form  known  as  malignant  pustule  the  patient  has  a  pricking  or 
burning  feeling,  which  may  lead  him  to  think  he  has  been  stung  by 
an  insect  at  some  exposed  part  of  the  body,  particularly  the  hand,  face, 
or  neck.  At  the  seat  of  irritation,  first  a  papule,  then  a  vesicle,  de- 
velops. The  vesicle  may  attain  considerable  size.  The  contained 
fluid  quickly  passes  from  clear  to  bloody,  and  then  escapes,  leaving  a 
dark-brown  or  black  scab  (anthrax). 

The  original  vesicle  may  be  surrounded  by  a  series  of  smaller  ones. 
Instead  of  disappearing,  the  base  of  the  vesicle  becomes  inflamed  and 
indurated,  the  induration  extending  to  surrounding  tissue  and  causing 
a  condition  of  brawny  oedema.  A  whole  arm  or  one  side  of  the  face 
and  neck  may  be  swollen.  There  may  or  may  not  be  an  associated 
lymphangitis  and  adenitis. 

The  general  health  does  not  suffer  at  first,  but  in  a  day  or  two  fever 
sets  in,  accompanied  by  delirium,  sweating,  great  weakness,  enlarge- 
ment of  the  spleen,  severe  pains  in  the  limbs,  and  diarrhoea.  Death, 
preceded  by  collapse,  may  occur  in  from  five  to  eight  days  (Fagge), 
or  the  tissue  occupied  by  the  pustule  may  slough  out. 

Bollinger  and  others  have  called  attention  to  anthrax  oedema,  in 
which  there  is  no  pustule,  but  only  a  yellowish  or  greenish  swelling  of 
the  tissues.  Gangrene  may  ensue.  It  is  seen  most  frequently  in  the 
eyelids,  but  may  be  on  the  head,  hand,  or  arm. 

Intestinal  Form.  Anthrax  of  the  gastro-intestinal  mucous  mem- 
brane, as  described  by  Bollinger,  presents  the  following  symptoms  : 
the  patient  first  complains  of  malaise,  loss  of  appetite,  pains  in  the 
limbs,  giddiness,  and  headache.  Then  vomiting  may  set  in,  and  a 
more  or  less  severe  diarrhoea,  the  evacuations  often  containing  blood. 
There  may  be  pain  in  the  abdomen,  which  becomes  somewhat  tumid  ; 
the  spleen  is  enlarged.     Dyspnoea  and  lividity  appear,  with  restlessness 


278  GENERAL  DIAGNOSIS. 

and  with  excitement  or  stupor.  Epileptiform  convulsions  may  occur, 
the  upper  limbs  may  be  affected  with  tetanic  spasms,  there  may  be  opis- 
thotonos, and  the  pupils  may  be  widely  dilated.  The  pyrexia  is  slight, 
and  death  is  preceded  by  extreme  collapse.  The  duration  of  the  disease 
is  usually  from  two  to  seven  days,  but  sometimes  it  is  scarcely  twenty- 
four  hours. 

Wool-sorter's  Disease.  Still  another  form  of  anthrax  occurs  among 
the  wool-sorters  of  Bradford,  England  ;  it  is  characterized  by  intense 
dyspnoea  and  a  feeling  of  oppression  or  constriction.  Breathing  is 
labored,  but  not  much  accelerated.  Only  a  few  coarse  rales  are  to  be 
heard  on  auscultation.  The  expectoration  may  be  abundant  and 
bloody,  or  absent.  There  is  a  tendency  to  collapse,  with  cold,  bluish 
skin,  and  a  subnormal  axillary  temperature.  The  rectal  temperature, 
however,  is  raised  two  or  three  degrees.  Death  may  occur  in  coma 
and  convulsions,  or  suddenly,  the  mind  being  clear.  The  duration  of 
the  disease  is  from  one  to  five  days.  Dr.  Bell  says  that  those  who 
survive  for  a  week  generally  recover. 

Examination  of  Blood.  The  bacillus  anthracis  is  found  in 
the  blood  of  the  patient  or  the  pus  of  the  lesions  of  anthrax  or  malig- 
nant pustule. 

Morphology.  A  bacillus,  2  to  3^  up  to  20  to  25//  in  length  and 
1  to  \\{x  in  breadth.  The  bacilli  are  often  joined  end  to  end  in  long 
threads,  and  these  threads  are  massed  together  in  bundles.  As  found 
in  animals  they  are  short  rods  with  square  ends.  They  stain  best  with 
Loffler's  blue,  but  also  with  the  basic  anilines  and  by  Gram's  method. 
When  in  the  stage  of  spore-formation  the  threads  look  like  strings  of 
beads. 

Fig.  57. 


Bacillus  anthracis  highly  magnified,  to  show  swellings  and  concavities  at 
extremities  of  the  single  cells.    (Abbott.) 

Cultures.  Biological  Properties.  It  is  aerobic,  non-motile, 
and  liquefies  gelatin.    (See  Plate  III.,  Fig.  2,  a  ;  Plate  VI. ;  Fig.  57.) 

It  grows  best  in  neutral  or  slightly  alkaline  media  (gelatin,  agar, 
milk,  meat-infusion,  etc.)  at  20°  to  38°  C.  The  growth-limits  are  12° 
and  45°  C. 

Cultures  on  agar  are  quite  characteristic,  consisting  of  a  dense  cen- 
tral mass  with  twisting  and  crossing  bundles  all  around  it.  In  gelatin 
stab-cultures  a  fine  branching  threadwork  grows  out  alongside  the 
puncture.  The  gelatin  soon  liquefies  and  the  bacilli  settle  in  white 
masses.  The  growth  is  abundant  on  potato,  and  is  grayish,  dry, 
rough,  and  irregular.  The  virulence  is  attenuated  by  cultivation. 
Drying  does  not  kill  the  spores.  Very  toxic  substances  are  found  in 
the  culture-medium. 


PLATE    VI. 

FIG.    1. 


\^  ^\rA^      "*,5 

..  ^    f/      *■*• 

Anthrax-bacilli  from  Rabbit's  Spleen. 

(Oc.  4,  ob.  y'w  immersion.)     Drawn  by  J.  D.  Z.  Chase. 


FIG.   2. 


*$%*?'" 


Protozoa  of  Malaria,  Intracellular  and  Crescentic  Forms. 

(Oc  4,  nb.  ,'.,  immersion.)     Drawn  by  J.  I).  X.  Chase. 


THE  DATA  OBTAINED  BY  OBSERVATION. 


279 


Inoculation.  "When  inoculated,  the  organism  produces  the  pus- 
tule of  anthrax.  If  inoculated  into  the  abdominal  wall  of  a  guinea- 
pig:  or  rabbit  death  follows  in  forty-eiffht  hours.  No  reaction  is  seen 
at  the  point  of  inoculation,  but  beyond  this  the  tissues  are  cedematous. 
Ecchymoses  are  seen,  and  the  underlying  muscles  are  pale.  The 
spleen  is  enlarged,  dark  in  color,  and  soft.  Cover-slip  preparations 
confirm  the  diagnosis. 

Anthrax  bacilli  are  not  so  numerous  in  human  blood  as  in  that  of 
the  lower  animals.  They  are  most  likely  to  be  found  in  the  spleen, 
which  is  apt  to  be  much  swollen. 


Fig.  58. 


Bacillus  anthracis  in  the  blood  of  a  guinea-pig.    X  10-10.    (Gibbes.) 

Diagnosis.  In  doubtful  cases  a  mouse  or  guinea-pig  should  be 
inoculated  with  the  blood.  Carbuncle  is  distinguished  by  its  tendency 
to  develop  upon  the  back  or  shoulders  and  other  covered  portions  ; 
anthrax  on  uncovered  portions.  In  carbuncle  there  is  a  series  of  open- 
ings resembling  a  sieve,  filled  with  pus  and  plugs  of  necrotic  tissue. 
In  anthrax  there  is  at  first  a  central  black  crust.  The  boggy  feeling 
of  carbuncle  is  different  from  that  of  the  brawny  oedema  of  anthrax. 
Finally,  in  carbuncle,  anthrax-bacilli  are  not  found  in  the  blood. 

The  intestinal  and  thoracic  forms  are  distinguished  by  the  occupa- 
tion of  the  patients,  the  absence  of  other  adequate  cause,  and  the  result 
of  the  blood-examination,  cultures,  and  inoculation  experiments. 

Malarial  Fevers. 


The  next  infection  which  we  are  about  to  consider  is  one  of  the  most 
common  the  world  over.  In  its  various  forms  it  is  recognized  by  direct 
examination  of  the  blood.  Its  clinical  features  are  such  that  often  but 
little  difficulty  surrounds  its  recognition,  but  no  case  should  be  unqual- 
ifiedly pronounced  malaria  without  an  examination  of  the  blood.  It 
comprises  a  group  of  fevers  associated  with  the  protozoan  organism  of 
Laveran,  and  is  characterized  by  periodic  paroxysms  of  chill,  fever,  and 
sweat.    They  are  not  contagious,  but  can  be  transmitted  by  inoculation. 

Malarial  fevers,  while  most  prevalent  in  tropical  and  subtropical 


280  GENERAL  DIAGNOSIS. 

regions,  are  found  also  throughout  the  temperate  zone,  especially  in 
autumn  and  spring.  In  Europe  their  favorite  habitat  is  Italy,  and  in 
the  United  States  the  Southern  and  Southwestern  States.  Conditions 
that  especially  favor  their  development  are  marshes  and  swamps,  fed 
partly  by  sea-water  ;  low  ground  along  streams  of  slow  current,  and 
freshly  upturned  soil.     The  poison  is  carried  in  the  air. 

The  specific  poison  in  malarial  fevers  is  no  doubt  organic.  The 
protozoan  organism  described  by  Laveran  exhibits  several  different 
forms,  which  he  regards  as  stages  in  the  development  of  one  organism, 
but  which  may  be  different  species.  Golgi  maintains  that  there  are 
several  distinct  varieties  of  parasites  whose  periodicity  hi  development 
and  sporulation  corresponds  with  the  different  types  of  fevers. 

Intermittent  Fever.  This  is  a  type  of  malarial  fever  in  which  the 
temperature  remains  normal  between  the  paroxysms. 

A  malarial  paroxysm  is  characterized  by  (1)  chill,  (2)  fever,  and  (3) 
sweating,  occurring  in  the  order  named  and  in  immediate  succession. 
The  time  between  the  beginning  of  one  paroxysm  and  the  beginning  of 
the  next  is  called  the  "  interval,"  that  between  the  conclusion  of  a  par- 
oxysm and  the  beginning  of  the  next  the  "  intermission."  The  interval 
varies  in  different  forms  of  intermittent  fever :  in  the  quotidian  there 
is  a  paroxysm  every  day,  with  an  interval  of  twenty-four  hours  ;  in  the 
tertian  there  is  a  paroxysm  on  alternate  days,  with  an  interval  of  forty- 
eight  hours  ;  in  the  quartan  there  is  a  paroxysm  every  third  day,  with 
an  interval  of  seventy-two  hours.  In  double  quotidian  there  are  two 
paroxysms  in  the  twenty-four  hours,  but  not  of  the  same  intensity. 

In  the  double  tertian  there  is  a  paroxysm  every  day,  the  first  and 
third  and  second  and  fourth  corresponding  as  to  hour  and  intensity. 
That  is  to  say,  if  there  be  a  paroxysm  at  10  a.m.  Monday  there  will 
be  another  severe  paroxysm  at  10  a.m.  Wednesday,  while  on  Tuesday 
and  Thursday  there  will  be  milder  paroxysms,  but  at  another  hour 
than  10  a.m. 

In  the  double  quartan  severe  and  mild  paroxysms  succeed  each  other 
every  other  day,  but  each  third  day  is  free  from  any  paroxysm. 

While  the  rule  is  for  malarial  fevers  to  occur  periodically  at  the  same 
hour,  the  second  paroxysm  may  occur  an  hour  or  two  earlier  (anticipa- 
tion) if  the  disease  is  growing  worse,  or  an  hour  or  two  later  (postpone- 
ment) if  it  is  growing  better.     (See  Figs.  30,  31,  32.) 

Quotidian  intermittents  are  slightly  more  common  than  tertian,  while 
the  quartan  variety  is  rare. 

The  incubation-jyeriod  probably  varies  widely,  depending  upon  the 
intensity  of  the  poison.  As  a  rule,  repeated  exposure  is  necessary  to 
develop  the  disease  in  temperate  climates.  During  this  period  the 
patient  may  suffer  with  headache,  drowsiness,  pains  and  aching  in  the 
limbs  and  back,  constipation,  a  coated  tongue,  and  thirst. 

The  onset  of  a  typical  malarial  paroxysm  is  marked  by  chilly  sensa- 
tions, especially  along  the  spine,  accompanied  by  yawning  and  the 
development  of  "  goose-flesh."  Then  a  decided  chill  sets  in,  the  patient 
shaking  violently.  The  face  is  pale  and  pinched,  the  lips  blue,  the 
nose  pointed  ;  as  the  chill  becomes  worse  the  teeth  chatter,  the  whole 
body  feels  cold,  the  skin  feeling  rough,  dry,  cold,  and  harsh.     The 


THE  DATA  OBTAINED  BY  OBSERVATION. 


281 


finger-nails  and  toe-nails  are  blue,  the  skin  being  wrinkled  upon  the 
palmar  and  plantar  surfaces.  The  superficial  bloodvessels  are  so  con- 
tracted that  a  drop  of  blood  is  obtained  with  difficult)'.  The  voice  is 
thin  and  weak,  almost  inaudible. 

The  volume  of  blood  driven  from  the  surface  leads  to  congestion  of 
the  viscera,  particularly  the  spleen,  liver,  and  stomach.  Nausea  and 
vomitiug  are  not  uncommon.  The  spleen  is  perceptibly  enlarged,  and 
frequently  the  liver  also. 

Although  the  surface  temperature  is  depressed,  the  internal  tempera- 
ture is  rising,  and  may  be  two  or  three  degrees  above  normal.  By 
degrees  the  severity  of  the  chill  abates  and  the  patient  asks  to  have 
the  extra  bedclothing  removed.  Reaction  has  set  in.  The  surface- 
bloodvessels  dilate  and  the  skin  becomes  flushed.  The  temperature 
continues  to  rise,  often  reaching  103°  to  106°,  pulse  and  respiration 
increasing  correspondingly  in  frequency.  The  patient  complains  of  a 
throbbing,  dizzy  headache,  and  vomiting  may  recur.  The  bowels 
remain  constipated.  The  temperature  now  begins  to  fall,  and  the 
sweating-stage  succeeds.  Perspiration  appears  first  upon  the  forehead, 
face,  and  neck,  and  gradually  extends  over  the  rest  of  the  body.  The 
perspiration  becomes  more  and  more  profuse,  until  the  whole  body  is 
drenched  with  it.     All  the  subjective  symptoms  vanish  with  wonder- 


FlG.  59. 


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Intermittent  fever. 


Temperature  every  six  hours.    Morning  and  evening  temperature 
and  highest  at  chill. 


ful  rapidity,  and  the  patient,  with  the  exception  of  exhaustion,  seems 
to  be  restored  to  complete  health.     The  hot  stage  lasts  from  one  to  two 


282 


GENERAL  DIAGNOSIS. 


hours,  the  cold  stage  from  three  to  eight  hours,  and  the  sweating-stage 
from  two  to  six  hours. 

In  the  interval  between  paroxysms  the  patient  is  free  from  fever, 
but  is  anaemic,  weak,  and  has  impaired  appetite  and  constipation. 
During  the  entire  paroxysm  the  mind  remains  clear. 

The  chief  objective  symptom,  apart  from  the  phenomena  of  chill,  fever, 
and  sweat  already  described,  is  the  occurrence  of  plasmodia  in  the 
blood.     (See  Plate  VI.,  Fig.  2  ;  and  Fig.  61.) 

Examination  of  the  Blood.  The  plasmodia  of  malaria  were  first 
pointed  out  by  Laveran.  They  have  been  studied  in  Italy,  especially 
by  Marchiafava  and  Golgi,  and  in  this  country  by  Councilman,  Osier, 
and  Dock.  Minute  amoeboid  bodies  are  found  in  the  red  corpuscles. 
These  become  pigmented  with  altered  haemoglobin,  and  grow  until 
they  fill  nearly  the  whole  of  the  cell,  the  pigment  being  arranged 
chiefly  in  a  peripheral  ring.  Later,  the  amoeboid  bodies  become  spheri- 
cal and  transparent,  the  pigment  collecting  in  the  centre.  Sporulation 
now  begins  and  a  fresh  crop  of  small,  rounded  parasites  appears,  to 
begin  the  same  cycle  over  again  in  fresh  corpuscles.  (Plate  VI., 
Fig.  2.) 

Three  forms  of  parasites  are  described  :  1.  The  tertian,  which  sporu- 
late  at  the  end  of  four  hours,  begin  as  small  amoeboid  intracorpuscular 
bodies,  gradually  enlarge,  produce  fine  brownish  pigment-granules,  and 
finally  completely  fill  the  corpuscle.  In  sporulation  the  segments 
number  fifteen  to  twenty. 


Ftg.  60. 


Malarial  plasmodia.  (Reproduced  from  colored  plate.)  To  the  right  two  normal  red  blood-cells 
with  central  depression.  In  addition,  several  others  with  bluish  contained  bodies  and  pigment- 
sprinkled  cells,  which  show  the  endogenous  development  of  the  plasmodia.  Besides,  two  of 
Laveran's  bodies,  one  exhibiting  a  delicate  little  basket  appearance.  Near  the  centre  a  poly- 
nuclear  white  cell  with  bluish  nuclei  and  red  granulation.    (H.  Rieder.) 


2.  The  quartan,  which  sporulate  at  intervals  of  seventy-two  hours, 
are  smaller ;  amoeboid  movement  is  not  so  marked  ;  when  full  groAvn 


THE  DATA  OBTAINED  BY  OBSERVATION. 

Fig.  61. 


283 


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The  first  twelve  figures  show  the  malarial  Plasmodium.  It  is  a  pale  amceboid  body  inside  the 
red  corpuscle.  It  increases  in  size  at  the  expense  of  the  corpuscles.  In  the  last  four  of  the  twelve 
it  is  enlarged  and  contains  pigment-granules  derived  from  the  haemoglobin.  The  figures  of  the 
fourth  row  show  progressive  stages  in  the  process  of  cleavage  of  the  Plasmodium  and  shifting  of 
the  pigment-granules.  In  the  fifth  row  the  process  of  cleavage  is  seen  to  be  completed,  and  final 
isolation  of  the  spores  has  taken  place.  The  dark  granules  are  pigment-granules.  The  last  row 
shows  oval  parasites— Laveran's  corpuscles  observed  in  atypical  cases  of  malaria.  (From  Golgi, 
"Studien  liber  Malaria,"  Fortschritte  der  Medicin,  Bd.  iv.  Tafel.,  in.) 


284  GENERAL  DIAGNOSIS. 

the  parasites  are  smaller,  and  the  corpuscles  tend  to  shrink  about  them 
and  to  become  a  deeper  greenish  color.  They  sporulate  with  five  to 
ten  segments  in  a  very  beautiful  characteristic  roseate  appearance. 

3.  The  sestivo-autunmal  are  smaller,  and  contain  less  pigment.  The 
period  of  sporulation  is  still  hi  dispute.  They  usually  form  ovoid- 
crescentic  or  round  bodies  with  coarse  pigment-granules  in  the  centre. 

Golgi  maintains  that  in  tertian  malarial  fever  the  period  between 
invasion  of  the  corpuscles  and  the  sporulation  is  two  days  ;  in  quartan, 
three  days,  the  difference  in  cycle  being  due  to  a  difference  in  the 
parasites. 

The  onset  of  the  fever  corresponds  in  time  to  the  division  of  the 
parasites. 

The  crescentic  form  described  by  Laveran  is  said  to  be  more  common 
in  the  irregular  forms  of  malarial  fever.  Canalis  says  that  it  only 
makes  its  appearance  several  days  after  the  first  access  of  fever.  It  is 
somewhat  longer  than  a  red  blood-cell,  and  the  pigment  tends  to  collect 
in  a  focus  about  the  middle  of  the  parasite.  Subsequently  it  becomes 
oval  and  divides  into  eight  or  more  daughter-cells. 

Another  form  with  nagella  is  occasionally  found.  Councilman  says 
it  is  most  common  in  blood  drawn  directly  from  the  spleen. 

The  plasmodium  of  malaria  may  be  stained  as  follows  :  Cover-glass 
preparations  of  the  blood  spread  very  thinly  are  dried  in  the  air  and 
fixed  by  immersion  for  twenty  minutes  or  half  an  hour  in  a  mixture 
of  equal  parts  of  alcohol  and  ether.  They  are  then  stained  for  twenty 
to  thirty  minutes  in  concentrated  aqueous  solution  methylene-blue,  60 
parts  ;  J  per  cent,  solution  eosin  in  75  per  cent,  alcohol,  20  parts  ; 
distilled  water,  40  parts  ;  20  per  cent,  solution  potassium  hydroxide, 
12  drops.  The  cover-glasses  are  then  washed  in  water,  dried,  and  are 
then  ready  for  mounting.  The  red  blood-cells  are  stained  rose,  the 
nuclei  of  leucocytes  a  deep  dark-blue,  and  any  plasmodia  a  delicate 
sky-blue. 

Aronson  and  Phillips'  staining  method  is  as  follows  :  Make  concen- 
trated aqueous  solutions  of  orange  G.,  acid  rubin,  and  crystallized 
methyl-green,  leave  them  to  settle,  then  mix  in  these  proportions  : 
Orange  G.,  55  ;  acid  rubin,  50 ;  distilled  water,  100  ;  and  alcohol,  50. 
To  this  add  methyl-green,  65  ;  distilled  water,  50  ;  and  alcohol,  12. 
Leave  the  mixture  standing  for  a  week.  A  well-diluted  solution 
should  be  used  for  staining  purposes  ;  one  drop  of  the  mixture  should 
be  added  to  25  cubic  centimetres  of  water  ;  the  stain  shoidd  be  left  on 
for  twenty-four  hours  and  the  fixing  of  the  preparations  carried  out  at 
a  temperature  of  120°  C.  In  the  result  the  red  corpuscles  are  stained 
orange,  nuclei  greenish  blue,  neutrophile  corpuscles  violet,  and  eosin- 
ophile  red. 

The  examination  of  the  blood  discloses  the  presence  of  a  high  degree 
of  aneemia.  The  haemoglobin  is  usually  diminished  in  greater  propor- 
tion than  the  corpuscles.  There  is  a  marked  reduction  in  the  leuco- 
cytes. Thus  leucopenia  is  most  marked  after  a  paroxysm.  There  is 
a  relative  diminution  of  the  polvnuclear  forms  and  a  relative  increase 
in  the  mononuclear  forms.  In  severe  post-malarial  anaemias,  as  Thayer 
points  out,  the  blood  is  characteristic  of  pernicious  anaemia. 


THE  DATA   OBTAINED  BY  OBSERVATION. 


285 


Irregular  Form.  Irregular  forms  of  intermittent  fever  are  more 
common  in  Philadelphia  than  the  typical  form  just  described. 

In  the  mild  form  the  patient  complains  of  great  lassitude,  irritability 
of  temper,  and  drowsiness  during  the  day,  but  at  night  tosses  upon  his 
bed  and  gets  up  in  the  morning  more  tired  than  when  he  went  to  bed. 
The  back  and  limbs  ache,  and  the  latter  feel  as  though  they  would 
give  way  under  him.  There  is  severe  throbbing  headache,  with  some 
dizziness  and  faintness.  The  bowels  are  constipated ;  the  tongue 
heavily  coated  with  yellow  fur.  The  temperature  is  moderately  eleva- 
ted and  the  patient  has  great  thirst.  Nausea  and  vomiting  are  absent, 
though  there  is  little  desire  for  food.  There  may  be  a  burning  feeling 
referred  to  the  splenic  region.  The  patient  is  worse  on  alternate  days, 
and  the  attacks  may  be  preceded  by  slight  creeping  chills.  On  inquiry 
the  patient  will  be  found  to  live  in  a  low-lying  district  near  one  of  the 
rivers,  or  in  a  damp  house  over  an  unclean,  moist  cellar,  or  adjoining 
a  place  where  fresh  soil  has  been  upturned. 

In  the  form  known  as  "  dumb  ague"  there  is  a  periodically  great 
depression,  with  aching  in  the  head  and  limbs,  a  sensation  of  coldness 
rather  than  chilliness,  but  no  marked  fever  and  sweating.  Nausea 
and  vomiting  may,  however,  be  present.  Da  Costa  says  he  has  seen 
it  manifest  itself  by  excruciating  pain  over  the  kidney,  and  almost 
entire  suppression  of  urine.  There  may  also  be  severe  paroxysms  of 
gastralgia.     It  is  more  common  in  old  residents  of  malarious  districts. 

In  mashed  malarial  fever  the  poison  manifests  itself  in  an  attack  of 
neuralgia,  especially  of  the  supraorbital  nerve  and  gastric  nerves. 
Malaria  may  also  be  latent  until  some  impairment  of  the  resisting 
power  brings  it  to  light.  Hence  it  appears  as  a  complication  of  pneu- 
monia and  dysentery   and    typhoid  fever  (Fig.  62),  especially  in  the 


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Cold  tub-batbs 


Abundant  malarial 
organisms. 

Malarial  fever  associated  with  enteric  fever.    (Thompson.) 


southern  and  southwestern  portions  of  the  United  States.  Moreover, 
women  who  have  previously  had  intermittent  fever  may  suffer  a  recur- 
rence after  confinement. 

Diagnosis.  The  essential  points  in  the  diagnosis  of  intermittent 
fever  are  the  periodical  recurrence  of  paroxysms  of  chill,  fever,  and 
sweating,  or  of  attacks  of  dumb  ague,  or  of  paroxysms  of  neuralgia, 
without  organic  lesion,  associated  with  the  presence  in  the  blood  of 
pigment  and  plasmodia,  and  with  enlargement  of  the  spleen  and  possi- 
bly of  the  liver.     The  so-called  therapeutic  diagnosis  may  be  made — 


286 


GENERAL  DIAGNOSIS. 


an  intermittent  fever  which  does  not  yield  to  proper  doses  of  quinine 
in  three  days  is  not  malarial.  A  typical  malarial  intermittent  fever  is 
not  likely  to  be  mistaken  for  anything  else.  (See  Fever,  pages  205, 
206.)  It  needs,  however,  to  be  distinguished  from  septicemic  fever, 
due  to  absorption  into  the  blood  of  pus  and  the  toxins  produced  by 
bacteriological  growth.  Such  fever  occurs  in  tuberculosis,  especially 
in  the  stage  when  cavities  form  and  pus  collects  ;  in  the  puerperal 
state,  in  empyema,  subphrenic  abscess,  abscess  of  the  liver,  or,  indeed, 
in  any  form  of  suppuration.  Here  also,  then,  are  recurring  chills, 
with  fever  and  sweating,  but  the  attacks  are  not  regularly  periodical 
and  intermittent ;  sometimes  the  fever  is  intermittent  and  sometimes 
remittent,  the  chills  recur  at  irregular  intervals,  and  are  not  so  violent 
as  in  the  malarial  attack.  The  essential  difference,  howrever,  lies  in 
the  fact  that  a  local  cause  can  be  found  to  explain  them,  tuberculosis 
either  of  the  lung  or  of  some  other  viscus,  or  a  collection  of  pus  in  an 
organ  or  cavity,  or  a  foetid  discharge  from  the  womb,  with  local  ten- 
derness or  peritonitis  ;  moreover,  the  patient  loses  flesh  more  or  less 
rapidly,  his  blood  is  free  from  malarial  germs  and  pigment,  and  quinine 
does  not  control  the  fever.     (Plate  VI.,  Fig.  2.) 

From  the  intermittent  fever  of  hepatic  origin  (described  elsewhere 
by  the  author)  the  diagnosis  is  more  difficult,  in  that  physical  signs  of 
any  local  trouble  may  be  wanting.  But  the  fever  is  not  regularly 
intermittent,  is  not  controlled  by  the  quinine,  but  may  be  by  measures 
directed  to  the  origin  of  the  trouble,  and  jaundice  may  be  present. 

Pig.  63. 


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A  form  of  intermittent  fever  from  syphilis.    J.  D.,  aged  twenty-six  years.    Secondary  period. 
Mercury  and  iodide  of  potassium  relieved  it.    Observe  that  the  pulse-frequency  is  not  increased. 


Urethral  fever,  occurring  as  the  result  of  operations  upon  the  urethra, 
or  simply  from  the  passage  of  a  catheter  or  bougie,  may  be  mistaken 
for  malarial  fever  ;  but  the  paroxysm  is  usually  single,  and  the  history 


THE  DATA   OBTAINED  BY  OBSERVATION.  287 

of  the  operation  and  the  absence  of  plasmoclia  from  the  blood  clear  up 
the  diagnosis. 

Syphilitic  fever  is  distinguished  by  a  tendency  for  the  chill,  fever, 
and  sweating  to  be  nocturnal  in  recurrence,  and  by  evidence  of  a  syph- 
ilitic infection  coupled  with  absence  of  malarial  germs  from  the  blood. 

Remittent  Malarial  Fever.  Estiva-autumnal  Types.  A  type 
of  malarial  fever  characterized  by  a  remission  instead  of  an  intermis- 
sion in  the  febrile  paroxysms.  It  is  due  either  to  a  greater  intensity  of 
the  malarial  poison  or  to  a  different  species  of  organism.  It  is  much 
more  rare  in  temperate  climates  than  either  quotidian  or  tertian  inter- 
mittent, and  is  attended  with  more  gastric  disturbance  and  a  much 
larger  mortality  (twelve  times  greater,  according  to  the  statistics  of 
the  civil  war). 

The  onset  is  more  abrupt  than  in  intermittent  fever.  Prodromata 
are  not  so  common,  but  when  they  occur  they  are  of  the  same  charac- 
ter. The  chill  is  not  usually  so  violent,  nor  the  cold  stage  so  long  as 
in  intermittent  fever ;  on  the  other  hand,  nausea  and  vomiting  are 
common,  and  in  some  cases  there  are  bilious  vomiting  and  diarrhoea, 
tenderness  over  the  stomach  and  spleen,  and  sometimes  jaundice.  The 
temperature  rises  rapidly  from  103°  to  106°,  and  remains  high  for  a 
longer  time  than  in  intermittent  fever,  the  hot  stage  lasting  in  severe 
cases  from  six  to  eighteen  or  twenty  hours. 

During  this  time  the  patient  suffers  from  headache,  pains  in  the  back 
and  limbs,  great  thirst,  and  gastric  irritability.  A  remission  now  suc- 
ceeds. The  temperature  falls  two  or  three  degrees,  but  not  to  normal ; 
free  sweating  occurs,  the  nausea  and  vomiting  cease,  and  the  patient 
becomes  much  more  comfortable.  He  may  fall  asleep  from  exhaus- 
tion, but  if  awake  is  conscious  of  weakness,  aching  in  the  limbs,  and 
perhaps  nausea.  In  the  course  of  some  hours  the  temperature  again 
rises,  often  to  a  higher  point  than  before,  but  frequently  without  ante- 
cedent chill.  The  same  subjective  symptoms  are  repeated,  and  another 
remission  follows.  Daily  paroxysms  usually  occur,  those  on  alternate 
days  being  severe.  The  temperature  often  reaches  its  highest  point  at 
the  third  paroxysm.  The  disease  generally  runs  its  course  in  from 
nine  to  twelve  days,  but  it  may  last  much  longer.  The  type  of  fever 
may  change  to  intermittent,  which  is  a  favorable  sign,  or  become  con- 
tinued and  again  remittent,  or  remain  remittent  throughout ;  finally,  the 
fever  may  subside  gradually,  or,  less  commonly,  by  crisis.  The  urine 
is  febrile  but  not  albuminous.     (See  Examination  of  Blood,  page  282.) 

Pernicious  Malarial  Fever.  This,  as  the  name  implies,  is  a  form 
of  malarial  fever  with  destructive  tendency.  It  is  also  called  malig- 
nant and  congestive  fever.  It  may  be  intermittent  or  remittent.  Nearly 
24  per  cent,  of  the  cases  occurring  in  the  U.  S.  Army  from  May  1, 1860, 
to  June  20,  1866,  proved  fatal. 

Bemiss  *  divides  it  into  three  classes  :  the  algid,  or  congestive,  form  ; 
(2)  the  comatose  form  ;  (3)  the  hemorrhagic  form.  To  this  another 
class,  (4)  the  gastro-enteric  form,  may  be  added.  It  is  important  to 
remark  that  the  first  paroxysm  does  not  usually,  in  any  of  these  forms, 

1  Pepper's  System  of  Medicine,  1885,  vol.  i.  666. 


288  GENERAL  DIAGNOSIS. 

indicate  that  the  type  of  the  disease  is  pernicious.     The  first  seizure 
niay,  however,  prove  fatal. 

1.  The  algid  form,  according  to  Beniiss,  occurs  more  frequently 
than  any  other,  its  perniciousness  being  due  to  an  aggravation  of  the 
cold  stage  of  an  intermittent  attack.  The  patient  is  extremely  weak, 
with  cold  extremities,  pinched  features,  blue  lips,  and  faint  voice. 
Respiration  is  shallow,  the  pulse  rather  slow,  feeble,  and  irregular  ;  he 
is  further  exhausted  by  vomiting  and  liquid,  offensive  diarrhoea,  the 
passages  sometimes  being  involuntary.  There  may  be  copious  per- 
spiration, but  the  internal  temperature  is  very  high.  The  mind  may 
be  clear,  or  there  may  be  deep  stupor.  Unless  speedy  relief  can  be 
afforded  the  attack  ends  fatally. 

2.  In  the  comatose  form  the  patient  is  completely  unconscious,  the 
skin  hot  "  and  of  a  muddy,  semi-jaundiced  hue "  (Bemiss).  Both 
pulse  and  temperature  are  increased.  In  other  cases  coma  is  preceded 
by  wild  delirium,  resembling  acute  meningitis. 

The  comatose  form  is  most  apt  to  occur  in  those  who  continue  to 
reside  in  a  malarious  region  without  proper  safeguards  against  its 
poisonous  influences. 

3.  In  the  hemorrhagic  form  there  has  been,  as  a  rule,  previous  alter- 
ation of  the  blood,  the  bloodvessels,  and  other  tissues,  by  long-con- 
tinued malarial  poisoning  or  cachexia.  Then,  when  intense  congestion 
of  these  parts  occurs  as  the  result  of  the  surface-chill,  hemorrhage 
follows.  In  some  districts,  however,  and  at  certain  seasons,  there  has 
been  a  special  predilection  of  the  poison  for  the  kidney,  with  resulting 
hematuria.  The  prominent  symptoms  are  a  prolonged  chill  with  high 
temperature  ;  nausea  and  vomiting,  sometimes  with  the  expulsion  of  a 
greenish-black  fluid  ;  oedema  of  the  lower  extremities  ;  general  anasarca 
and  occasionally  oedema  of  the  lungs,  and  hydrothorax  ;  bloody  and 
albuminous  urine,  with  tube-casts  ;  and  intense  jaundice.  Pain  in  the 
right  hypochondrium  or  over  the  kidneys  is  common. 

Bemiss  asserts  that  uncomplicated  malarial  fever  has  not  a  hemor- 
rhagic tendency. 

4.  The  gastro-enteric  form  has  for  its  prominent  symptoms  nausea, 
vomiting,  diarrhoea,  intense  thirst,  extreme  restlessness,  a  frequent, 
feeble  pulse,  and  urgent  dyspnoea.  "  The  breathing  is  deep-drawn  ; 
to  each  expiration  succeed  two  respirations  "  (Da  Costa).  The  patient 
is  cold  and  partly  collapsed.     Reaction  may  or  may  not  occur. 

The  patient  may  have  several  paroxysms  of  pernicious  malarial 
fever  and  succumb  in  any  one  of  them.  Convalescence  is  slow.  The 
most  frequent  sequela?  of  malarial  fevers  are  anaemia,  neuritis,  and 
paralyses,  and  malarial  cachexia. 

Typhoid  fever  is  distinguished  from  pernicious  malarial  fever  by  its 
gradual  onset,  the  absence  of  chills  and  vomiting,  as  a  rule,  and,  on  the 
other  hand,  the  presence  of  epistaxis,  delirium,  and  ataxic  symptoms, 
tympanites  and  diarrhoea,  with  pale-yellow  watery  stools,  and  rose- 
colored  spots.  The  temperature  in  typhoid  is  more  continuously  high, 
the  daily  oscillations  being  of  shorter  range.  A  history  of  exposure  to 
malarial  infection  and  of  previous  attacks  can  often  be  obtained.  The 
urine  of  typhoid  exhibits  the  diazo  reaction ;  malarial  fever  does  not. 


THE  DATA   OBTAINED  BY  OBSERVATION.  289 

Malarial  cachexia  occurs  especially  in  those  who  have  lived  for  a 
long  time  in  malarious  regions.  They  may  or  may  not  have  had 
typical  malarial  attacks.  The  patient  suffers  with  dyspepsia  and  con- 
stipation, with  occasional  bilious  attacks  ;  the  faee  is  of  a  pale  lemon- 
yellow  color,  and  may  be  slightly  jaundiced  ;  there  is  marked  anaemia, 
with  pigment  and  crescentic  and  flagellate  forms  of  plasmodia  in  the 
blood,  together  with  great  enlargement  of  the  spleen  (ague-cake)  and 
some  enlargement  of  the  liver.  The  patient  is  weak  and  languid,  and 
sometimes  has  considerable  mental  depression. 

Serum  Diagnosis. 

The  infections  just  described  are  recognized  by  an  examination  of 
fresh  blood  or  cover-slip  preparations.  The  next  group  of  infections 
may  be  recognized  by  serum  diagnosis.  Too  much  stress  must  not  be 
placed  upon  this  method  of  diagnosis,  yet  its  value  is  so  great  that 
one  is  fully  justified  in  giving  it  a  high  place  in  the  precise  method  of 
diagnosis  of  infections. 

Typhoid  Fever. 

The  first  of  the  infections  to  which  such  diagnosis  has  been  applied 
in  extenso  is  typhoid  infection  or  typhoid  septiceemia.  This  infection 
is  caused  by  the  bacillus  typhosus.  The  most  common  expression  of 
it  is  seen  in  a  symptom  complex  which  attends  a  septic  process  and 
local  intestinal  ulceration,  which  symptom  complex  we  know  as 
typhoid  fever.  This  infection,  it  is  stated  by  some,  is  unattended  in 
rare  instances  by  fever.  More  frequently  a  febrile  course,  following 
a  definite  continued  type  of  a  duration  of  from  twenty-one  to  twenty- 
eight  days,  prevails.  In  mild  or  abortive  forms  fever  rarely  reaches 
103°,  and  declines  from  the  seventh  to  the  fourteenth  day.  In  the 
grave  forms  the  fever  is  often  very  high  and  attended  by  cerebro-spinal, 
renal,  pulmonic,  or  severe  gastro-intestinal  symptoms. 

The  most  important  infection  prevailing  in  the  temperate  zone  is  the 
one  we  are  now  about  to  consider.  It  is  an  acute,  specific,  infectious, 
and  mildly  contagious  fever,  characterized  by  a  gradual  onset,  a  con- 
tinued fever,  an  eruption  of  rose-colored  spots,  marked  nervous  and 
abdominal  symptoms,  and  an  average  duration  of  three  or  four  weeks. 

It  occurs  sporadically  and  epidemically,  and  in  large  cities  is  apt  to 
be  epidemic.  Its  special  habitat  is  in  temperate  climates,  but  it  may 
occur  anywhere.  It  is  relatively  rare  in  the  southern  and  southwestern 
portions  of  the  United  States.  It  is  more  frequent  in  the  latter  part 
of  the  summer  and  in  the  autumn  and  winter,  and  following  hot  and 
dry  summers.  Young  adults  arc  especially  prone  to  it,  but  cases  have 
occurred  at  all  ages.  Change  <>f  residence  from  the  country  to  the  city 
predisposes  to  it.  Those  living  in  cities  often  acquire  immunity,  but 
they  may  lose  it  upon  moving  elsewhere.  The  state  of  previous  health 
does  not  seem  to  have  any  influence. 

The  period  of  mcubaMon  in  typhoid  lexer  varies  from  four  or  five 
day-  to  three  weeks  ;  more  commonly  it  is  from  one  to  two  weeks. 
During  this  time  the  patient   usually  is  languid,  becomes  tired  easily 

19' 


290  GENERAL  DIAGNOSIS. 

upon  exertion,  lias  severe  headache,  sleeps  poorly,  and  has  bad  dreams. 
There  is  often,  even  thus  early,  a  dull  and  listless  expression  of  the  face. 
Toward  the  close  of  this  period,  and  in  severe  cases,  there  may  be 
colicky  pain  in  the  abdomen,  a  tendency  to  looseness  of  the  hovels, 
cough,  epistaxis,  mental  sluggishness,  and  chilliness.  Dr.  Pepper  says 
he  has  been  led  repeatedly  to  anticipate  the  approach  of  typhoid  fever 
by  the  unusual  dulness  of  hearing  and  by  the  persistent  occipital  head- 
ache coming  on  after  a  few  days  of  general  malaise. 

While  the  disease  may  begin  abruptly,  a  gradual  onset  is  so  much 
the  rule  that  it  becomes  important  in  the  diagnosis  from  other  disease- 
conditions. 

Invasion  is  not  sharply  marked.  There  may  be  chilliness,  but  a 
decided  chill  is  unusual  except  when  pneumonia  is  part  of  the  initial 
process.  Muscular  weakness,  headache,  and  mental  sluggishness  are 
more  pronounced,  and  the  physician  is  consulted  because  these  symp- 
toms persist,  or  because  fever  is  discovered.  The  beginning  of  fever 
is  the  most  constant  indication  of  the  onset  of  the  disease,  and  two 
very  important  early  symptoms  are  cough  from  bronchitis  and  en- 
largement of  the  spleen. 

The  most  prominent  and  constant  subjective  symptom  during  the 
first  week  is  headache.  Other  very  common  symptoms  are  tenderness, 
rarely  pain,  in  the  iliac  region,  more  or  less  prostration,  and  impaired 
appetite  or  loss  of  appetite. 

The  objective  symptoms  are  therefore  the  most  important.  The  face 
is  pale  rather  than  flushed,  and  has  a  dull,  listless,  apathetic  expres- 
sion. The  tongue  is  heavily  coated  with  a  white  fur  which  later 
becomes  yellow.  The  abdomen  is  somewhat  distended  and  tympanitic 
on  percussion.  There  is  usually  tenderness  in  the  right  iliac  region, 
and  gurgling  upon  palpation  is  pretty  constant.  Constipation  may 
be  present  at  first,  and  sometimes  persists  throughout  the  disease.  A 
tendency  to  diarrhoea  is,  however,  characteristic  of  the  disease.  Even 
if  constipation  exists  at  first,  a  laxative  is  apt  to  produce  an  excessive 
effect.  The  number  of  stools  varies  from  two  or  three  to  a  dozen  or 
more  in  twenty-four  hours.  They  are  light  yellow  in  color  (resem- 
bling pea-soupj,  thin,  watery,  and  offensive.  The  movements  are  not 
usually  attended  with  pain,  and  in  severe  cases  may  occur  involuntarily. 
Enlargement  of  the  spleen  is  a  very  constant  symptom.  It  may  be 
detected  at  the  onset,  increases  up  to  the  height  of  the  fever,  subsides 
during  convalescence,  but  recurs  during  a  relapse.  It  covers  a  percus- 
sion-area in  the  left  hypochondrium  of  four  to  eight  finger-breadths. 

The  temperature-euxxe,  when  not  modified  by  treatment,  shows  a 
gradual  ascent  during  the  first  four  or  five  days  of  the  disease,  with 
morning  remissions.  The  temperature  rises  a  degree  or  two  in  the 
evening  and  falls  half  a  degree  or  a  degree  hi  the  morning.  This 
"  step-ladder  "  ascent  is  very  characteristic.  By  the  end  of  a  week  a 
temperature  of  103°,  104°,  or  105°  has  been  reached,  and  it  remains 
continuously  high,  with  slight  morning  remissions,  during  the  second 
and  less  frequently  during  the  third  week.  In  the  third  or  fourth 
week  the  morning  fall  of  temperature  gradually  becomes  greater,  and 
by  the  end  of  the  week  sinks  below  the  normal  in  the  morning. 


THE  DATA  OBTAINED  BY  OBSERVATION. 


291 


The  temperature  in  mild  cases  may  never  rise  above  103°  at  any 
time,  and  most  of  the  time  varies  between  100°  and  102°.     Or  it  may 


Fig.  64. 


104° 
103° 
102° 
101 
100° 
99 

DAY  OF  DIS. 
DATE 

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September  Oct. 

Temperature  ranges ;  first  week  of  typhoid  fever.    (Dock.) 


be  104°  from  the  start ;  more  frequently  during  the  second  and  third 
weeks  there  are  marked  oscillations  of  the  temperature — a  sudden  fall 
from  104°  to  101°,  or  a  rise  from  103°  to  105°  or  106°.  Hyperpy- 
rexia is  a  temperature  above  105°. 


Fig.  65. 


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The  pulse  is  full,  and  in  favorable  cases  slower  than  the  pyrexia 
would  lead  one  to  expect.  It  is  more  frequently  under  110  than  over 
120.      In  the  second  week  it  is  markedly  dicrotic 


292 


GENERAL  DIAGNOSIS. 


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THE  DATA  OBTAINED  BY  OBSERVATION. 


293 


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294  GENERAL  DIAGNOSIS. 

The  heart  sounds  are  unchanged  apart  from  complications,  but  in  the 
second  and  third  weeks  the  first  sounds  often  are  feeble,  indicating 
heart  weakness.  A  pulse  of  120  or  more  is  a  graver  sign  in  typhoid 
fever  than  in  other  diseases.  Therefore,  when  it  becomes  very  frequent 
and  feeble,  the  extremities  cool  and  the  lips  bluish,  the  outlook  is 
gloomy. 

The  urine  is  at  first  scanty  and  high-colored.  A  slight  degree  of 
febrile  albuminuria  is  not  uncommon,  and  in  rare  cases  the  whole  force 
of  the  poison  seems  to  be  spent  upon  the  kidneys,  the  urine  containing, 
besides  the  usual  blood  and  casts,  biliary  coloring-matter.  In  condi- 
tions bordering  on  coma  the  patient  may  have  retention  of  urine,  or, 
on  the  other  hand,  he  may  pass  it  involuntarily.  To  obtain  the  diazo 
reaction  of  Ehrlich  two  solutions  are  necessary.  The  first  (a)  consists 
of  2  grams  of  sulphanilic  acid,  50  c.c.  hydrochloric  acid,  and  distilled 
water  1000  c.c.  The  second  (6)  consists  of  a  J  per  cent,  solution  of 
sodium  nitrite.  These  solutions  are  kept  in  separate  bottles.  Fifty 
parts  of  solution  a  and  one  part  of  solution  6  are  poured  into  a  test- 
tube  and  an  equal  volume  of  urine  added.  The  test-solutions  and 
urine  are  now  thoroughly  shaken  and  then  carefully  overlaid  with  1 
c.c.  of  ammonia.  At  the  junction  of  the  two  a  pink  or  ruby  ring 
develops.  Upon  agitation  the  foam  on  the  top  of  the  mixture  is  also 
colored  red.  Xormal  urine  gives  a  light  brown  ring.  This  reaction 
is  helpful  in  diagnosis,  but  may  occur  in  acute  phthisis,  tubercular 
meningitis,  and  other  diseases.  According  to  Pepper,  it  is  rarely 
absent  in  measles.  The  reaction  is  fairly  constant  in  typhoid  fever 
after  the  first  week. 

The  respiration  in  uncomplicated  cases  increases  in  frequency  with 
the  rise  in  temperature.  It  usually  ranges  between  24  and  36.  The 
slight  bronchitis  present  in  the  beginning  in  most  cases  causes  no 
trouble  ;  sometimes  it  lasts  throughout  and  contributes  to  the  tendency 
to  hypostatic  congestion,  which  is  always  present.  The  physical  signs 
are  those  described  elsewhere  in  these  conditions. 

The  nervous  symptoms  are  often  very  prominent.  In  mild  cases 
they  consist  of  hebetude  and  nocturnal  delirium,  or  they  may  be  absent 
altogether.  Usually,  however,  by  the  beginning  of  the  second  week, 
there  is  some  mental  confusion,  with  nocturnal  delirium.  In  more 
severe  cases,  and  later  in  the  disease,  the  delirium  is  of  a  low,  mutter- 
ing character,  with  hallucinations  of  sight  and  sound  more  or  less 
continuous.  The  patient  can  be  roused  by  a  question,  and  makes  an 
intelligent  answer,  but  speedily  lapses  into  semi-consciousness.  Pick- 
ing at  the  bedclothes  or  efforts  to  catch  imaginary  objects  are  very 
common.  Sometimes  the  delirium  is  wild  and  noisy,  and  the  constant 
presence  of  some  one  is  needed  to  keep  the  patient  from  getting  out  of 
bed.  Patients  have  jumped  out  of  windows,  or  run  long  distances 
before  being  captured.  Rarely  the  delirium  has  been  so  active  as  to 
simulate  acute  mania.  Stupor  may  alternate  with  delirium.  Rarely 
the  patient  lies  with  wide-open  eyes,  apparently  staring  fixedly  at 
some  object,  but  really  unconscious  (coma-vigil). 

In  ataxic  cases  the  patient  has  marked  twitching  of  the  tendons  and 
jactitation.      He  is  wakeful  and  restless,  wearing  himself  out.     The 


THE  DATA   OBTAINED  BY  OBSERVATION. 


295 


hands  and  lips  tremble,  and  he  keeps  muttering  to  himself  all  the 
time. 

Convulsions  are  rare,  but  may  occur  in  children.     Sometimes  there 
are  considerable  hyperesthesia  and  tenderness  along  the  spine. 


Fig.  68. 


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Grave  typhoid  fever.    Death.    M.,  aged  22  years.    Ataxic  symptoms. 
Fig.  69. 


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Typhoid  fever  in  a  child  aged  12  years.    Chart  from  twelfth  to  twenty-third  day.  . 
Repeated  crises.    (Frequent  mode  of  termination  in  children.) 

The  extent  of  the  nervous  symptoms  depends  upon  the  habit  of  the 
patient  as  well  as  upon  the  height  of  the  temperature  and  gravity  of 


296 


GENERAL  DIAGNOSIS. 


pro- 


the  disease.     In  children  and  neurotic  individuals  they  may  be 
nounced,  with  only  moderate  fever. 

On  the  seventh  or  eight  day  the  eruption  appears.  It  consists  of 
small,  very  slightly  elevated,  rose-colored  papules,  which  disappear 
upon  pressure  and  come  out  in  successive  crops,  each  papule  lasting 
three  or  four  days.  The  spots  are  most  common  over  the  abdomen 
and  back,  but  are  occasionally  found  elsewhere.  They  are  usually  few 
in  number,  a  half-dozen  or  dozen,  but  sometimes  the  eruption  is  very 
copious,  especially  in  severe  cases.     Sometimes  it  is  wholly  absent. 

During  the  latter  part  of  the  second  week,  and  through  the  third 
week,  the  symptoms  are  apt  to  be  intensified.  The  temperature  keeps 
up  or  even  reaches  a  higher  point.  Delirium  is  more  decided  and  con- 
stant, The  heart  grows  weak  and  the  pulse  increases  in  frequency. 
Some  degree  of  hypostatic  congestion  of  the  lungs  is  usual.  Diarrhoea 
may  be  troublesome  ;  intestinal  hemorrhages,  announced  by  sudden 
fall  of  temperature  and  symptoms  of  collapse,  may  occur.  Tympanites 
may  become  so  great  as  to  interfere  with  respiration  and  circulation. 
This  is  the  period  when  ulceration  of  Peyer's  patches  in  the  intestine  is 
deepest,  and  when  perforation  is  imminent.  There  is  rarely  any  desire 
for  food,  though  it  is  taken  and  assimilated.  Nausea  and  vomiting  are 
rare.  The  tongue  is  dry,  brown,  sometimes  glazed  and  fissured,  and 
sordes  often  collect  on  the  teeth. 


Fig.  70. 


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Course  of  temperature  in  a  relapse  beginning  on  the  twenty-sixth  day.     First  attack  mild. 

In  cases  ending  in  recovery  the  temperature  begins  to  fall  in  the 
mornings  ;  delirium  grows  less  ;  sleep  is  more  refreshing.  Diarrhoea 
ceases,  and  constipation  may  even  require  treatment.  The  pulse  does 
not  usually  improve  as  rapidly  as  the  other  symptoms.  There  is  some- 
times very  marked  anaemia  without  leukocytosis  (Osier).     When  the 


THE  DATA  OBTAINED  BY  OBSERVATION. 


297 


temperature  sinks  to  normal  or  subnormal,  convalescence  has  set  in. 
This  is  very  rapid  as  far  as  digestive  symptoms  are  concerned,  but 
strength  returns  very  slowly.  It  may  be  interrupted  by  a  relapse,  in 
which  the  original  symptoms  are  reproduced,  with  high  temperature, 
but  the  duration  is  shorter. 

Varieties.  It  is  now  well  known,  as  Osier  forcibly  states,  "  that 
typhoid  fever  is  no  more  primarily  intestinal  than  is  smallpox  prima- 
rily a  cutaneous  disease."  Studies  in  bacteriology,  promoted  especially 
by  Chiari,  Flexner,  Kraus,  Nicholls,  and  others,  enables  us  to  divide 
the  infection  into  three  varieties  :  1.  Typhoid  fever  with  intestinal 
lesions,  as  described  above.  2.  Typhoid  fever  with  general  infection 
or  typhoid  septicaemia.  The  symptoms  are  entirely  those  of  an  infec- 
tion, and  the  diagnosis  must  rest  upon  the  serum  reaction  and  culture 
methods.  3.  Typhoid  fever  with  more  intense  infection  of  other  organs 
than  the  intestines.  The  lungs,  the  spleen,  the  kidneys,  and  the  cere- 
bro-spinal  meninges  are  the  structures  invaded,  so  that  we  may  have  a 
pneumo-,  nephro-,  spleno-,  or  cerebro-spinal  typhoid. 


Fig.  71. 


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Grave  typhoid  fever.    Daily  rigors.    Death  on  nineteenth  day.    No  complications. 

Varieties  are  also  based  upon  the  severity  of  the  disease,  hence  we 
have  the  abortive,  grave,  and  ambulatory  forms. 

The  abortive  form  is  so  named  because  of  the  abbreviated  course  of 


298  GENERAL  DIAGNOSIS. 

the  disease.  The  symptoms  are  sufficiently  well  marked  to  make  the 
diagnosis  clear,  but  the  type  is  mild,  and  in  a  week  or  two  convales- 
cence is  established.  In  rare  instances  an  afebrile  form  with  intestinal 
s)rmptoms  and  eruption  is  seen. 

In  the  ambulatoiy  form,  commonly  called  "  walking  typhoid/'  the 
patient,  from  ignorance  of  the  gravity  of  his  ailment  or  from  apparent 
necessity,  keeps  at  his  work  until  weakness  and  incessant  headache  lead 
him  to  consult  a  physician  in  his  office  or  at  a  dispensary.  He  may 
then  be  well  into  the  second  week  of  the  disease.  The  majority  of 
such  cases  prove  fatal. 

Grave  forms  are  due  to  especial  severity  of  some  symptoms  or  group 
of  symptoms,  such  as  hyperpyrexia  ;  profound  stupor,  coma,  or  intense 
ataxia  ;  inability  to  take  or  retain  sufficient  nourishment ;  profuse  diar- 
rhoea and  intestinal  hemorrhage  ;  great  adynamia  with  weak  heart  and 
a  tendency  to  cyanosis.  In  other  cases  the  gravity  results  from  the 
existence  of  complications. 

In  the  malignant  form  there  has  been  a  large  dose  of  the  poison  or 
a  very  weak  organism,  or  both,  the  result  being  an  acute  toxaemia;  this 
is  not  so  common  as  in  scarlatina  and  typhus  fever. 

In  the  pulmonary  form  the  onset  may  be  so  obscured  by  severe 
bronchitis  or  lobar  pneumonia  that  the  primary  disease  is  not  suspected 
at  first.  Severe  bronchitis  seems  to  be  more  common  in  children. 
Chill  and  initial  high  temperature  are  common  in  these  cases. 

Typhoid  Fever  without  Intestinal  Lesions.  This  rare  form  may 
present  the  clinical  symptoms  of  typical  typhoid,  or  may  be  of  spleno- 
typhoid  type,  or  of  nervous  type  with  extreme  intoxication.  The  first 
type  is  rare.  The  second  type,  described  by  Eiselt,  is  characterized  by 
an  excessively  large  spleen,  with  local  inflammation  and  remitting 
fever.  In  the  third  class  the  symptoms  of  the  typhoid  state  with  sub- 
cutaneous and  visceral  hemorrhage  occur.  Jaundice  is  more  or  less 
common. 

Complications  and  Sequelae.  Typhoid  fever  may  be  accompanied 
by  a  number  of  complications,  the  most  frequent  and  important  being 
severe  bronchitis,  hypostatic  congestion  with  oedema,  and  true  lobar 
pneumonia  ;  bed-sores  ;  parotitis  ;  phlebitis,  especially  of  the  femoral 
vein  ;  peritonitis  from  perforation  of  the  bowel ;  meningitis,  acute 
mania,  or  mental  decay  ;  jaundice  ;  myocarditis  ;  periostitis  and  oste- 
itis. Secmelse  are  not  frequent.  Sometimes,  however,  the  foundation 
is  laid  for  permanent  ill  health.  There  may  be  impairment  of  the 
senses,  mental  weakness,  and  even  insanity.  Paralyses,  neuritis,  hyper- 
esthesia, chorea,  and  epilepsy  are  occasional  sequels. 

Examination  of  the  Blood.  The  infection  is  due  to  Eberth's 
bacillus,  the  bacillus  typhosus.  The  bacillus  is  found  in  colonies  in 
the  spleen,  liver,  mesenteric  glands,  kidneys,  and  intestines.  It  is  also 
found  in  the  feces  and  rarely  in  the  urine.  It  may  be  seen  in  the 
blood.  It  may  be  recognized  by  staining  methods,  although  rarely. 
It  has  been  isolated  from  the  blood  successfully,  by  culture  methods,  by 
Gwyn  in  a  small  number  of  cases. 

Morphology.  A  bacillus  1  to  3//  long  by  0.5  to  0.8,«  broad,  with 
rounded  ends.     It  is  motile,  facultative    anaerobic,  does    not   liquefy 


THE  DATA  OBTAINED  BY  OBSERVATION. 


299 


gelatin.  It  has  flagella  3  to  5  times  as  long  as  the  bacilli.  It  stains 
with  the  anilines,  best  with  Loffler's  bine.  The  flagella  are  stained 
by  Loffler's  special  method.     (See  Plate  III.,  Fig.  6,  b.) 


Fig.  72. 


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Renal  typhoid.    Nephritis  on  the  twenty-fifth  day.    Course  of  temperature  during 
three  days  preceding  death. 


Serum  Diagnosis.  This  method  of  diagnosis  has  been  more  success- 
fully employed  in  typhoid  fever  than  in  any  other  infection.  The 
methods  have  been  previously  described.  The  agglutinative  reaction 
takes  place  as  early  as  the  eighth  day,  rarely  as  early  as  the  third  day, 
but  sometimes  not  until  the  fifteenth  or  twentieth  day,  and  even  may 
not  occur  until  convalescence  is  established.  By  this  means  typhoid 
fever  can  be  distinguished  from  the  infection  due  to  the  bacillus  of 
Gartner  (bacillus  enteritidis).     (See  Lancet,  January  15,  1898.) 

The  paracolon  bacillus  infection,  as  shown  by  Gwyn  (Bulletin  of  the 
Johns  Hopkins  Hospital,  1898,  vol.  ix.  No.  84),  who  studied  a  case 
which  resembled  typhoid  clinically,  docs  not  give  this  reaction.  Influ- 
enza and  Malta  fever  and  forms  of  tuberculosis  can  also  be  distin- 
guished from  typhoid  fever  by  this  method. 

LEUCOCYTOSIS.  A  determination  of  the  number  of  leucocytes  is  of 
value  in  the  diagnosis  of  typhoid  fever.  It  is  one  of  the  infections  in 
which  leucocytosis  docs  not  occur.  In  a  differential  count  some  varia- 
tion from  the  normal  is  >w\\.  The  large  mononuclear  and  transitional 
forms  are  decreased  ;  the  polvnuclear  neutrophiles  are  decreased.  The 
absence  of  leucocytosis  aids  in  distinguishing  typhoid  fever  from  vari- 
ous septic  fevers  and  acute  inflammations.     On  the  other  hand,  in  a 


300  GENERAL  DIAGNOSIS. 

case  of  typhoid  fever  if  leucocvtosis  occurs  an  inflammatory  complica- 
tion or  mixed  infection  is  possible.  Perforation  and  peritonitis  are 
attended  by  leucocvtosis. 

In  addition  to  the  absence  of  leucocytosis  we  find,  after  the  second 
or  third  week,  gradual  reduction  of  the  red  cells,  and  by  the  time  con- 
valescence is  established  a  marked  anaemia  develops.  Both  the  red 
cells  and  the  haemoglobin  are  reduced. 

Culture  Methods.  The  bacillus  can  be  isolated  from  the  blood,  the 
stools,  and  the  urine. 

Biological  Properties.  The  bacillus  grows  readily  in  acid 
media  as  well  as  in  the  neutral  or  alkaline  media,  best  at  a  tempera- 
ture of  38°  C.     Death-point,  60°  C. 

The  colonies  develop  in  twenty-four  to  forty-eight  hours.  On  gela- 
tin plates  they  are  small  and  white,  nearly  spherical ;  irregular,  granu- 
lar, and  yellowish-brown. 

In  stab-cultures  there  is  a  whitish  semi-transparent  layer  on  the  sur- 
face, with  sharply  denned  irregular  edges,  and  along  the  puncture  a 
grayish-white  growth.  (See  Plate  VII.,  Fig.  5.)  It  develops  abund- 
antly in  milk.  On  potato  it  forms  an  "  invisible  growth,"  manifested 
only  by  increase  in  moisture,  which  is  quite  characteristic. 

Bacteriological  Diagnosis.  It  would  be  most  desirable  if  a 
means  of  diagnosis,  that  would  have  no  element  of  uncertainty  about 
it,  could  be  found.  Bacteriologists  have  sought  for  such  means,  and 
at  present  seem  to  have  found  two  methods,  one  of  which  at  least  has 
been  brought  to  such  a  degree  of  perfection  as  to  be  of  value  to  the 
clinician.  They  are  Eisner's  culture  and  Pfeiffer's  bactericidal  serum 
methods.  Eisner's  method  1  consists  in  the  preparation  of  a  culture- 
medium  upon  which  no  species  of  micro-organism  can  grow  except  the 
typhoid  bacillus  and  the  bacillus  coli  communis.  For  a  description 
of  this  complicated  method  the  reader  is  referred  to  the  recent  works 
on  bacteriology. 

Recently  bacteriologists  have  been  successful  in  isolating  the  typhoid 
bacillus  from  the  stools  and  the  urine.  Unfortunately,  the  methods 
are  too  complicated  for  clinical  work.  P.  H.  His,  Jr.,  recovered  the 
bacillus  typhosus  and  distinguished  it  from  members  of  the  colon  group 
by  a  combined  plate  and  tube  method.2 

For  differentiation  of  the  typhoid  from  the  colon  bacillus  the  method 
of  Proskauer  and  Capaldi  may  be  used.  They  employ  two  solutions. 
In  solution  No.  1  the  typhoid  bacillus  does  not  grow  at  all.  The  colon 
bacillus  grows  rapidly,  produces  a  marked  acid  reaction,  and  the  blue 
color  gives  way  to  red.  Solution  No.  2  both  bacilli  grow,  but  the 
typhoid  bacillus  is  the  only  one  which  gives  an  acid  reaction.  Note, 
the  solutions  are  neutral  in  reaction  and  colored  with  litmus. 

Another  method  is  that  of  Thoinot.  He  prepares  a  medium  of 
bouillon,  to  which  he  adds  y^o  Per  cen^-  °f  arsenious  acid.  On  it  the 
typhoid  bacilli  do  not  grow,  while  the  colon  bacilli  multiply  rapidly. 

1  Zeit.  Hygien.  und  Infection  kr. ,  B.  xxi.  H.  1. 

2  P.  H.  His,  Jr.,  "On  a  Method  of  Isolating  and  Identifying  Bacillus  Typhosus," 
etc.     Journal  of  Experimental  Medicine,  vol.  ii.  No.  6,  p.  677. 


PLATE    VII. 


Fig.  1. 


Fig.  2. 


Fig.  3. 


Streptococcus — Erysipelas.        Streptoccocus  Septicus. 
Fig.  4.  Fig.  B. 


Staphylococcus. 
Fig.  6. 


Diphtheria-bacilli. 


I 


Typhoid-bacilli.  Tuberculosis-ijac  illi. 


THE  DATA   OBTAINED  BY  OBSERVATION.  301 

Mark  Richardson  isolated  bacilli  in  the  urine  of  about  25  per  cent. 
of  the  cases  of  typhoid  examined.  They  were  present  in  large  numbers 
and  in  pure  culture.  They  appeared  late  in  the  disease,  and  persisted 
into  convalescence.  The  bacilli  were  always  associated  with  albumin 
and  casts.  After  disinfection  of  the  meatus  the  urine  is  passed  in  two 
portions  into  sterilized  test-tubes.  The  second  portion  is  used.  It  is 
immediately  plated  upon  plain  agar.  At  the  end  of  twenty-four  hours 
the  characteristic  colonies  appear.  Richardson  relies  upon  the  active 
motility  of  the  bacilli,  which  are  set  free  in  a  typhoid  colony  by  scar- 
ring with  a  platinum  needle  to  distinguish  them  from  the  colon  bacilli. 
He  also  used  the  dry  serum  reaction  test.1 

Pfeiffer's  method,  while  of  interest  and  full  of  suggestions  as  to  its 
future  usefulness,  cannot  be  applied  with  sufficient  ease  to  render  it 
practical  for  clinical  work. 

Inoculation.  Thus  far  the  results  of  inoculation  have  not  proved 
satisfactory,  and  are  certainly  not  of  diagnostic  value. 

Diagnosis.  A  typical  case  of  typhoid  fever  ought  not  to  be  mis- 
taken for  any  other  affection,  but  atypical  cases  are  numerous.  The 
most  common  sources  of  error  are  a  hurried  diagnosis  and  a  willing- 
ness to  accept  a  demonstrable  local  affection  as  sufficient  to  account  for 
the  condition.  In  this  way  the  significance  of  bronchitis,  pneumonia, 
and  diarrhoea  is  overlooked.  In  the  symptomatic  form  there  will 
almost  always  be  found  a  history  of  gradual  onset  and  a  degree  of 
fever  and  prostration  greater  than  should  attend  the  purely  local  affec- 
tion. Moreover,  in  bronchitis  and  pneumonia,  which  are  a  part  of 
typhoid  fever,  there  may  be  found  tenderness  with  gurgling  in  the 
right  iliac  region,  enlargement  of  the  spleen,  and  epistaxis,  to  aid  in 
the  diagnosis  ;  while  in  cases  in  which  the  diarrhoea  leads  to  uncer- 
tainty, bronchitis,  enlargement  of  the  spleen,  and  epistaxis  may  coexist. 
Examination  of  the  blood,  extended  over  a  period  of  several  days,  i& 
necessary  to  exclude  the  cestivo-autumnal  type  of  malarial  fever,  which 
often  resembles  typhoid  fever. 

New  Diagnostic  Sign  of  Typhoid  Fevek.  Dr.  Simon  Baruch 
writes  as  follows  :  "  As  soon  as  the  patient  shows  a  rectal  temperature 
above  102.5°  in  the  morning  and  103°  in  the  evening  for  three  succes- 
sive days,  especially  if  this  be  accompanied  by  headache,  dulness,  or 
apathy,  he  is  placed  in  a  full  bath  at  90°,  which  is  reduced  to  80°, 
with  constant  friction  over  the  body.  In  three  hours,  the  temperature 
still  being  above  102.5°,  he  receives  another  bath  5°  cooler.  This  is 
repeated  until  the  temperature  of  the  bath  is  75°.  If  one  or  more  of 
these  baths  fail  to  reduce  the  rectal  temperature  2°  in  half  an  hour,  the 
diagnosis  of  typhoid  fever  is  almost  certain,  and  the  bath-treatment  is 
continued.  The  resistance  of  the  rectal  temperature  to  a  bath  of  75° 
for  fifteen  minutes,  with  friction,  is  an  almost  certain  tost  of  typhoid 
fever." 2  Dr.  Baruch  considers  that  the  diagnosis  of  this  disease  should 
no  longer  be  obscure,  even  in  the  first  days  of  its  course. 

1  Richardson,  M.  W.,  "On  the  Presence  of  the  Typhoid  Bacillus  in  the  Urine." 
Journal  of  Experimental  Medicine,  vol.  iii.  No.  3,  p.  349. 

2  New  York  Medical  Journal,  September  2,  1893. 


302  GENERAL  DIAGNOSIS. 

Appendicitis  is  more  likely  to  be  mistaken  for  typhoid  fever  than 
the  converse.  There  is  usually  a  history  of  constipation,  though  the 
occurrence  of  several  inadequate  movements  a  day  may  conceal  the  fact 
that  there  is  a  fsecal  accumulation.  In  appendicitis  the  onset  is  more 
abrupt  and  the  local  symptoms  more  pronounced  than  in  typhoid. 
Pain  and  tenderness  are  prominent  in  appendicitis,  and  while  they  may 
be  general  over  the  abdomen  at  first,  they  are  found  to  be  more  acute 
in  the  iliac  region  and  loin.  Here,  in  place  of  gurgling,  we  find  some 
increase  of  resistance  on  palpation,  and  a  relatively  dull  note — a 
wooden  sort  of  tympany — or  there  may  be  a  demonstrable  tumor. 
The  patient  lies  with  the  right  leg  drawn  up,  has  moderate  fever,  and 
vomiting.  In  fact,  the  attack  is  often  introduced  by  chilliness  and 
vomiting.  Headache  is  not  a  prominent  symptom,  while  bronchitis 
and  enlargement  of  the  spleen  are  absent. 

Acute  right-sided  salpingitis  simulates  typhoid  fever.  It  is  distin- 
guished by  the  history  of  a  preceding  vaginitis,  endometritis,  or  abor- 
tion, by  the  absence  of  diarrhoea,  of  enlargement  of  the  spleen,  and  of 
the  characteristic  eruption.  A  digital  examination  through  the  vagina 
discovers  the  womb  pressed  to  one  side  and  fixed,  and  a  tender  mass 
blocking  up  the  pelvis. 

Simple  continued  fever  is  distinguished  from  typhoid  fever  of  a  mild 
type  principally  by  the  absence  of  bronchitis,  of  enlargement  of  the 
spleen,  of  epistaxis,  and  of  the  characteristic  eruption  of  typhoid  fever. 
In  simple  continued  fever  constipation  is  more  common  than  looseness 
of  the  bowels,  and  gurgling  is  absent. 

Typhus  fever  is  distinguished  by  its  sudden  onset,  the  besotted  ex- 
pression of  the  face,  with  reddened  eyelids  and  small  pupils,  the 
absence  of  abdominal  symptoms,  and  the  occurrence  on  the  fourth  day 
of  maculae,  which  are  subsequently  converted  into  petechia?.  It  is  of 
shorter  duration,  and  terminates  very  abruptly  by  crisis. 

Relapsing  fever  differs  from  typhoid  fever  in  its  sudden  onset  with 
chill,  pain  in  the  epigastrium,  but  absence  of  abdominal  symptoms  and 
eruption  ;  in  the  absence  of  marked  nervous  symptoms,  in  spite  of  the 
high  fever  ;  the  short  duration  and  termination  by  crisis,  and  the  char- 
acteristic relapse  at  the  end  of  a  week.  The  conclusive  test  is  finding 
spirilla  in  the  blood. 

Acute  tuberculosis  of  the  lungs,  at  times,  closely  resembles  typhoid 
fever.  In  both  the  onset  is  gradual,  with  cough  and  fever.  In  the 
former,  however,  the  bronchial  symptoms  are  more  prominent,  there 
are  apt  to  be  recurring  chills  and  sweats,  the  temperature  is  remittent 
and  irregular,  emaciation  is  rapid,  and  constipation  instead  of  diarrhoea 
is  the  rule. 

In  peritoneal  tuberculosis  there  is  persistent  diffused  pain  hi  the 
abdomen ;  the  belly  is  swollen.  If  effusion  occurs,  the  physical  signs 
disclose  its  presence.  The  temperature  is  irregular  and  may  be  below 
normal ;  nervous  symptoms  comparable  to  those  of  typhoid  are 
wanting. 

Meningitis  before  the  stage  of  effusion  exhibits  exaggeration  of  the 
reflexes  and  marked  hyperaesthesia.  There  may  also  be  muscular 
rigidity.     The  patient  is  restless,  easily  annoyed,  and  "  fussy  "  about 


THE  DATA  OBTAINED  BY  OBSERVATION.  303 

things  that  would  be  unnoticed  by  a  typhoid  patient.  Vomiting  is 
often  present,  whereas  it  is  rare  in  typhoid  fever.  The  temperature 
does  not  maintain  so  high  an  average  range  as  in  typhoid  fever,  and  is 
subject  to  greater  oscillations.  The  pulse  varies  greatly,  and  may  be 
irregular. 

In' septic  meningitis  the  headache  and  vomiting  are  more  persistent, 
the  bowels  are  confined,  and  the  abdominal  walls  are  retracted.  There 
may  be  double  optic  neuritis.  In  tubercular  meningitis  the  knee-jerk 
and  other  reflexes  are  variable,  irregularly  absent  or  present.  In 
typhoid  fever  they  are  always  present.  In  the  former  choroidal  tuber- 
cles may  be  seen  with  the  ophthalmoscope.  In  tuberculosis  in  all 
forms  leucocytosis  is  present ;  in  typhoid  it  is  absent.  Typhoid  fever 
must  not  be  confounded  with  trichiniosis  ;  the  peculiar  muscular  pain 
and  oedema  do  not  occur  in  the  former.  TJrcemia  may  simulate  typhoid 
fever  when  it  becomes  chronic  ;  but  the  age,  the  character  of  the  urine, 
the  cardio-vascular  symptoms,  are  diagnostic,  and,  with  the  absence  of 
the  specific  typhoid  symptoms,  render  the  diagnosis  easy. 

Mountain  Fever  is  an  infection  which  has  been  described  as  pecu- 
liar to  the  mountains  of  our  Western  States,  characterized  by  a  con- 
tinued fever  with  intestinal  symptoms  not  unlike  those  of  typhoid 
fever.  Irregularity  of  the  temperature-range  and  the  occurrence  usually 
of  constipation  rather  than  diarrhoea  make  it  difficult  to  classify  the 
infection  from  typhoid  fever  on  the  one  hand  and  from  forms  of  ma- 
laria on  the  other.  Recent  observations  of  Woodruff,  who  studied  the 
serum  reaction  in  a  large  series  of  cases,  show  conclusively  that  the 
infection  is  typhoid  fever,  confirming  the  prior  observations  of  Hoff, 
Smart,  and  Raymond. 

Yellow  Fever. 

The  infection  which  we  are  about  to  consider  is  the  latest  of  the 
epidemic  and  contagious  disorders  for  which  a  definite  causal  micro- 
organism has  been  discovered.  It  is  an  acute,  specific,  contagious, 
miasmatic  disease,  endemic  and  epidemic  on  the  tropical  and  subtropi- 
cal shores  of  the  Atlantic  Ocean,  characterized  by  a  sudden  onset,  a 
duration  of  a  week  or  less,  a  characteristic  facics,  a  fall  in  the  pulse- 
rate  preceding  a  fall  in  temperature,  and  by  albuminuria,  jaundice,  and 
vomiting,  with  a  tendency  to  hemorrhages.  The  specific  micro-organ- 
ism is  the  bacillus  icteroides  described  by  Sanarelli. 

Yellow  fever  is  endemic  in  Havana  and  other  seaport  cities  of  Cuba, 
and  in  Rio  Janeiro,  Brazil.  From  these  centres  it  is  liable  to  become 
epidemic,  and  to  be  carried  in  ships  and  by  persons  and  clothing  to 
other  places.  In  this  way  epidemics  have  developed  in  the  seaports 
of  the  United  States,  especially  iu  the  south  around  the  Gulf  of  Mexico, 
but  sometimes  as  far  north  as  Philadelphia  and  New  York.  The 
disease  becomes  epidemic;  in  the  hot  season  and  ceases  upon  the  appear- 
ance of  frost.     The  specific  germ  lias  not  yet  been  isolated. 

In  countries  in  which  the  disease  is  endemic  it  is  the  custom  to 
regard  the  native  children  as  immune.  Dr.  John  Guiteras,  however, 
is  strongly  of  the  opinion  that  the  disease  is  kept  alive  between  epi- 
demics by  cases  among  these  children.     He   lias  also  shown    that  it 


304  GENERAL  DIAGNOSIS. 

prevails  among  white  children  before  it  becomes  epidemic  among 
adults. 

The  period  of  incubation  varies  from  a  few  hours  to  two  weeks. 
Guiteras  states  that  the  cases  in  which  it  extends  beyond  the  seventh 
day  are  exceptional. 

The  invasion  is  abrupt,  and  occurs  usually  in  the  night.  It  is  marked 
by  chilliness  oftener  than  by  a  decided  chill.  The  temperature  rises 
rapidly  to  102°  to  103°  or  104°,  not  often  higher  in  favorable  cases. 
The  pulse  is  correspondingly  increased  in  frequency  at  first,  but  very 
commonly  begins  to  fall  before  the  temperature,  so  that  later  the  pulse 
is  relatively  slow.  The  face  is  peculiar  and  characteristic — it  is  flushed 
and  somewhat  swollen  ;  the  eyelids  are  somewhat  swollen,  with  red- 
dened edges  ;  the  eyes  are  watery,  glistening,  and  slightly  but  dis- 
tinctly tinged  with  yellow  ;  the  pupil  is  small  and  brilliant.  Guiteras 
says  : l  "  The  appearance  of  the  face  is  often  sufficiently  characteristic 
on  the  first  day  of  the  disease  to  warrant  a  positive  diagnosis."  "  The 
early  manifestation  of  jaundice  is  undoubtedly  the  most  characteristic 
feature  of  the  facies  of  yellow  fever."  He  also  says  that  these  phe- 
nomena are  often  better  observed  at  a  slight  distance  than  on  close 
inspection. 

The  tongue  is  large,  moist,  and  coated  with  white  fur.  The  stomach 
is  irritable  and  the  epigastrium  tender.  Nausea  with  repeated  vomit- 
ing occurs.  The  fluid  is  at  first  of  a  light  greenish-yellow,  subse- 
quently becoming  decidedly  bilious.     The  bowels  are  constipated. 

The  urine  almost  invariably  contains  albumin  at  some  time  during 
the  first  three  days.  Its  presence  may  be  very  transient.  It  may  be 
found  in  the  evening  and  not  at  other  times.  The  amount  of  albumin 
is  sometimes  very  large,  and  abundant  blood  and  tube-casts  are  found. 

The  nephritis  subsides  rapidly,  without  leaving  traces.  The  urine 
is  acid  in  reaction  and  scanty  in  amount.     It  is  sometimes  suppressed. 

During  this  febrile  period  the  patient  complains  of  headache,  pains 
in  the  back  and  limbs,  and  intense  thirst.  The  mind,  however,  is 
usually  perfectly  clear.  Contrary  to  expectation,  Guiteras  asserts  that 
the  nervous  symptoms  are,  perhaps,  more  prominent  in  the  adult  than 
in  the  child.  "  The  loquacity,  the  short-cut  phrases  and  precipitate 
speech,  the  excitement,  the  show  of  indifference  with  unmistakable  evi- 
dences of  fear — all  these,  that  are  such  prominent  features  of  the  dis- 
ease in  the  adult,  are  absent  in  the  young."  2 

In  from  two  to  five  days  the  temperature  falls  to  or  below  normal, 
headache  and  pains  in  the  limbs  disappear,  and  the  patient  is  cheerful 
and  thinks  himself  convalescent.  This  is  the  fact  in  mild  cases,  but 
in  more  severe  cases  the  period  of  remission  or  stage  of  calm  is  followed 
by  a  return  of  symptoms  in  a  few  hours  or  at  most  a  day  or  two.  The 
jaundice  deepens,  vomiting  becomes  more  urgent  and  in  adults  is  accom- 
panied by  much  retching.  It  is  bilious,  streaked  with  blood,  or  thick 
and  wholly  black  ("  black  vomit ")  ;  the  temperature  may  rise  again 

1  "Report  of  the  Surgeon-General  of  the  Marine-Hospital  Service,  1888  ;"   Keat- 
ing's  Cyclopaedia  of  Diseases  of  Children,  1889,  vol.  i. 
-  Keating's  Cyclopaedia,  loc.  cit. 


THE  DATA   OBTAINED  BY  OBSERVATION.  305 

as  high  as,  or  higher,  than  in  the  original  paroxysm,  or  it  may  remain 
depressed.  In  any  event  the  pulse  is  apt  to  be  slow,  often  from  40  to 
60.  The  urine  contains  albumin,  blood,  and  casts,  and  may  be  sup- 
pressed, adding  uraemia  to  the  other  toxaemia.  Convulsions  at  this 
stage  are  usually  ursemic.  Hemorrhages  may  occur  from  any  mucous 
surface.  The  gums  are  tender,  swollen,  and  bleed  easily.  There  may 
be  epistaxis,  hemorrhage  from  the  ear,  bowel,  uterus,  or  vagina.  Preg- 
nant women  miscarry.  Ecchymoses  also  may  form.  Death  may  take 
place  in  coma  or  convulsions.  If  the  patient  lingers  beyond  the  fifth 
or  sixth  day  he  sinks  into  a  typical  typhoid  state,  with  diarrhoea  and 
marked  adynamia,  from  which  he  may  or  may  not  emerge. 

As  in  scarlet  fever,  the  patient  may  be  smitten  down  and  die  in  a 
few  hours  from  the  time  he  was  in  apparent  health.  In  other  grave 
cases  the  temperature  remains  high,  and  rises  instead  of  falls  on  the 
third  or  fourth  day.  The  duration  of  the  disease  is  from  two  to  five  or 
six  days  ;  if  a  typhoid  state  develops,  it  may  last  ten  days  or  two  weeks. 

Complications  are  not  common.  Phlebitis  and  lymphangitis  occur, 
and  Guiteras  says  he  has  noticed  hepatitis,  insanity,  and  paralysis 
(probably  from  neuritis).     Second  attacks  are  extremely  uncommon. 

Examination  of  Blood.  The  bacillus  icteriodes  is  a  slender  rod 
from  two  to  four  micromes  in  length.  It  is  ciliated  and  motile.  By 
staining  a  drop  of  blood  with  Gram's  method  it  is  seen  in  more  than 
half  the  cases. 

Sebum  Diagnosis.  Woodson  and  the  Archinards  have  found  agglu- 
tination to  take  place  in  a  large  proportion  of  cases  of  yellow  fever. 
The  blood,  taken  as  early  as  the  second  day,  gave  a  prompt  reaction  in 
from  75  to  80  per  cent,  of  all  cases.  Dilutions  of  1  to  40  were  used, 
but  reaction  took  place  in  dilutions  as  low  as  1  to  5.  Pothier  and 
Lerch  report  successfully  upon  this  reaction.  Cultures  from  the  blood 
produce  an  organism  which  grows  on  ordinary  media  ;  does  not  coagu- 
late milk,  but  ferments  saccharine  fluids. 

Inoculation.  Inoculation  of  dogs  and  monkeys  produces  a  clini- 
cal picture  similar  to  the  original  infection. 

Diagnosis.  Yellow  fever  is  distinguished  from  pernicious  malarial 
fever  by  the  slow  pulse,  the  characteristic  facies,  the  early  transient 
albuminuria,  the  deep  jaundice,  the  absence  of  diarrhoea,  the  occur- 
rence of  black  vomit,  the  tendency  to  hemorrhage,  and  the  clear  mind. 

If  it  is  not  practical  to  make  a  diagnosis  based  upon  an  examination 
of  the  blood,  the  three  important  characteristics  which  Guiteras  laid 
stress  upon  must  be  borne  in  mind  in  addition  to  the  usual  data  secured 
for  the  purpose  of  determining  the  presence  of  an  epidemic  and  conta- 
gious disease.  The  three  diagnostic  points  of  Guiteras  are  the  facies, 
the  albuminuria,  and  the  slowing  of  the  pulse,  with  continuance  or  in- 
creaseof  the  fever.  By  these  means  the  affection  must  be  distinguished 
from  dengue  and  from  various  forms  of  malarial  fever,  especially  the 
; est i  v<  t-autumnal  infections. 

Malta  Fever. 

Malta  fever  is  a  remarkable  infection  which  seems  to  prevail  within 
the  limits  of  the  Mediterranean.     It  is  an  infection  characterized   by 

20 


306 


GENERAL  DIAGNOSIS. 


gradual  onset  and  by  repeated  remissions  of  the  fever.  The  alternating 
febrile  and  afebrile  periods  which  characterize  the  disease  continue 
from  two  months  to  two  years.     The  most  remarkable  feature  is  the 


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Hi"i:;iiH.iiii!^r1'Tf: 


S        3        S         5 


m 


THE  DATA  OBTAINED  BY  OBSERVATION.  307 

peculiar  character  of  the  temperature-range,  which  consists  of  intermit- 
ting waves  or  undulations  of  fever  of  a  distinctly  remittent  type. 
These  periods  of  fever  last  from  one  to  three  weeks,  followed  by  an 
apyretic  period  or  a  period  of  abatement  lasting  from  two  to  ten  days. 
The  daily  temperature-range  may  be  intermittent  or  remittent.  The 
febrile  course  may  continue  six  months  or  more.  During  this  time 
patients  grow  more  and  more  prostrated,  become  anaemic,  and  usually 
suffer  from  constipation.  Profuse  sweats  attend  the  decline  of  the 
daily  range,  and  in  many  instances  we  find  enlargement  of  the  spleen. 
Neuralgias  occur  in  various  parts  of  the  body  ;  the  joints  become  en- 
larged, and  fibrous  tissues  may  be  the  seat  of  inflammation.  Hughes 
— who  describes  the  disease  most  accurately — describes  a  malignant 
type  lasting  a  week  or  ten  days,  and  an  undulatory  type  continuing 
for  weeks  or  months.  Indeed,  the  relapses  are  known  to  occur  over 
a  period  of  two  years.  The  third  is  known  as  the  intermittent  type, 
in  which  there  is  a  daily  rise  of  temperature  without  other  marked 
symptoms.  The  undulatory  type  is  the  most  common  variety.  The 
infectious  micro-organism  is  the  micrococcus  melitensis. 

Diagnosis.  The  occurrence  of  fever  described  above  in  the  coun- 
tries bordering  upon  the  Mediterranean,  whether  epidemic  or  endemic, 
should  always  suggest  Malta  fever.  The  possibility  of  its  occurrence 
in  other  tropical  countries,  as  in  the  islands  of  the  Caribbean  Sea,  must 
not  be  forgotten.  A  positive  diagnosis  is  made  by  exclusion  of  all 
forms  of  malaria  by  an  examination  of  the  blood,  and  of  typhoid  fever 
by  finding  the  bacillus  typhosus  in  the  urine  or  stools  of  the  suspected 
patient.  The  micro-organism  has  not  been  isolated  from  the  blood, 
but  the  serum  reaction  is  a  valuable  means  of  diagnosis.  (See  page  233.) 
This  reaction  is  performed  as  in  cases  of  typhoid  fever.  The  culture 
must  be  carefully  selected.  With  a  1  to  10  or  1  to  50  dilution  aggluti- 
nation takes  place  when  the  serum  of  a  patient  with  Malta  fever  is 
used.  The  serum  of  such  a  patient  does  not  have  any  effect  upon 
the  typhoid  bacillus  nor  upon  other  organisms.  Aldrich  states  that 
the  first  reaction  occurs  about  the  fifth  day. 

Gonorrhceal  Infection. 

Although  the  infection  is  usually  limited  to  the  genito-urinary  tract, 
it  is  well  known  that  the  gonococcus  may  enter  the  blood  and  infect 
tissues  elsewhere,  causing  a  local  inflammation.  We  therefore  see 
symptoms  due  to  the  primary  infection  ;  symptoms  due  to  the  infection 
of  the  genito-urinary  organs  by  direct  continuity,  and  systemic  infection. 
The  primary  infection  involves  the  adnexre  of  the  genital  organs  in  the 
male  and  the  female.  Salpingitis,  metritis,  and  ovaritis  in  females, 
with  the  occurrence  occasionally  of  peritonitis,  arise  from  spreading  by 
continuity.  In  both  sexes  cystitis,  ureteritis,  and  pyelitis  occur.  The 
infection  is  usually  mixed. 

When  the  gonococcus  invades  the  blood,  symptoms  of  septicaemia  or 
pyaemia  arise.  The  infection  may  be  rapid  and  fatal,  and  may  termi- 
nate ten  days  after  the  primary  lesion.  The  occurrence  of  such  general 
infection  is  suspected  when  the  history  of  the  primary  infection  can  be 


308  GENERAL  DIAGNOSIS. 

secured,  and  in  addition  the  micro-organism  can  be  recovered  from  the 
blood,  as  was  successfully  done  by  Thayer. 

In  other  infections  the  joints  become  involved  and  we  have  the 
phenomena  of  gonorrheal  rheumatism  (see  Joints),  the  course  and 
symptoms  of  winch  are  discussed  elsewhere.  Endocarditis  may  result 
from  gonorrhoeal  infection,  and  can  only  be  distinguished  from  other 
forms  of  endocarditis  by  the  history  and  the  finding  of  micro-organ- 
isms in  the  blood.  Myocarditis  (Councilman)  and  pericarditis  may 
also  occur. 

Diagnosis.  Thayer  and  Blumer  and  Thayer  and  Lazear  have  suc- 
ceeded in  recovering  the  gonococcus  from  the  blood  in  this  form  of 
septicaemia.  The  blood  is  withdrawn  from  the  median  basilic  vein  by 
a  sterilized  syringe.  A  large  quantity  is  secured.  It  is  mixed  with 
melted  agar  and  immediately  plated.  The  medium  should  contam 
at  least  one-third  blood.  This  is  practically  the  medium  which  Wer- 
theim  recommends.  After  forty-eight  hours  colonies  appear  half  the 
size  of  a  pin-head,  granular,  but  with  irregular  borders.  Cover-slip 
preparations  of  the  colonies,  if  the  case  is  gonorrhoea,  will  show  the  tinc- 
torial and  morphological  characteristics  of  the  gonococcus.  (See  Plate 
III.,  Fig.  3,  B.  The  diagnosis  is  further  established  by  finding  the 
gonococcus  in  any  purulent  discharge,  as  of  the  urethra  or  vagina.  (See 
Chapter  XXI. — Exudations,  etc.) 


CHAPTER    XX. 

THE  DATA  OBTAINED  BY  OBSERVATION— (Contin ued). 

FEVER.     THE    INFECTIOUS   DISEASES. 

Infections  Recognized  by  the   Examination  of   Excretions  and 
Secretions  or  by  the  Products  of  the  Infectious  Inflammation. 

The  following  infections  are  disclosed  by  the  examination  of  the 
products  of  the  infection  found  in  the  inflammatory  areas  (pus) ;  in 
the  excretions  and  secretions  of  the  body  ;  in  the  sputa  ;  in  the  voni- 
itus  ;  in  the  fseces  or  in  the  urine.  The  reader  should  refer  to  the 
sections  describing  the  method  of  the  examination  of  pus,  sputum, 
and  secretions  bacteriologically.  They  are  as  follows :  Erysipelas, 
pneumonia,  tuberculosis,  influenza,  cerebrospinal  meningitis,  diphtheria, 
septico-pycemia,  glanders,  cholera  Asiatica,  dysentery,  bubonic  plague, 
leprosy,  actinomycosis,  tetanus,  trichinosis. 

Erysipelas. 

The  fever  of  this  infection,  particularly  in  a  first  attack,  is  very 
marked.  It  rises  suddenly  to  a  considerable  height  and  may  antedate 
the  eruption.     It  resembles  the  course  of  a  pneumococcus  infection. 

It  is  an  acute,  specific,  contagious,  and  infectious  disease,  character- 
ized by  a  sudden  onset,  with  a  bright-red  eruption,  which  usually  begins 
on  the  face  near  the  nose  or  mouth  and  spreads  over  the  entire  face 
and  scalp.  It  is  attended  with  burning  heat  of  the  skin  and  great  dis- 
figurement from  swelling. 

The  specific  cause  of  erysipelas  is  the  streptococcus  erysipelatosus. 
It  is  carried  to  a  slight  extent  by  the  air,  and  still  more  in  the  dis- 
charges, especially  those  of  the  nose.  Repeated  attacks  occur  in  per- 
sons with  chronic  nasopharyngeal  catarrh,  carious  teeth,  or  a  sinus.  It 
is  apt  to  attack  persons  with  open  wounds  (surgical  erysipelas),  and 
puerperal  women,  producing  in  these  cases  sloughing  and  septicaemia. 

One  attack  does  not  protect  against  another  ;  on  the  contrary,  if  there 
is  any  focus  in  which  the  streptococci  linger,  one  attack  actually  pre- 
disposes to  another. 

The  period  of  incubation  is  usually  from  three  days  to  a  week.  On 
close  inquiry  a  history  of  sore-throat  and  some  enlargement  of  the 
cervical  lymphatics  is  usually  found  to  precede  an  attack  of  facial 
erysipelas.  The  invasion  is  sudden  and  is  marked  by  chill.  The  tem- 
perature rises  to  104°  or  105°,  and  in  the  next  two  or  three  days  may 
rise  still  higher. 

Coincident  ly  with  the  rise  in  temperature  the  portion  of  the  shin  to 
be  affected  burns,  tingles,  is  tender  to  the  touch,  and  may  be  seen  to  be 


310  GENERAL  DIAGNOSIS. 

reddened.  The  redness  increases  in  intensity  and  extent,  while  the 
skin  is  swollen  and  slightly  cedematous.  The  part  of  the  face  to  be 
affected  is  usually  the  cheek  in  close  proximity  to  the  nose,  less  fre- 
quently near  the  mouth  and  ear.  Vesicles  and  blebs  often  form  when 
the  inflammation  is  very  intense.  The  redness  disappears  upon  press- 
ure, but  quickly  returns  ;  sometimes  it  has  a  dusky,  purplish  hue. 

A  marked  characteristic  of  the  disease  is  its  tendency  to  spread.  In 
ordinary  cases  it  involves  one  cheek,  eyelid,  and  ear,  and  travels  across 
the  bridge  of  the  nose  to  the  other  side.  The  inflammation  is  most 
intense  when  it  is  spreading ;  the  advancing  margin  is  raised,  tense, 
and  brawny  ;  the  line  is  thus  sharply  drawn  between  healthy  and  in- 
flamed tissue.  The  loose  tissue  about  the  eyes  swells  enormously,  both 
eyes  are  closed,  the  entire  face  swollen,  red,  and  disfigured  with  vesi- 
cles and  blebs  here  and  there.  Curiously  the  chin  escapes.  The  red- 
ness and  swelling  begin  to  subside  in  the  part  first  attacked,  before  the 
process  has  reached  its  height  on  the  opposite  side.  As  a  rule,  facial 
erysipelas  does  not  extend  beyond  the  face,  the  scalp  and  neck  being 
spared.  The  scalp,  however,  is  more  frequently  affected  than  the 
neck ;  occasionally  erysipelas  leads  to  extensive  cellulitis  of  the  scalp, 
with  the  production  of  a  septic  constitutional  condition  and  much 
local  sloughing.  The  submaxillary  glands  are  more  or  less  enlarged, 
sometimes  so  much  so  as  to  prevent  the  taking  of  solid  food. 

When  on  the  body  the  eruption  spreads  over  a  greater  extent  than 
when  primary  on  the  face,  hence  its  name,  "  the  red  runner."  It  may 
pass  from  the  heel  to  the  thigh,  and  over  the  trunk,  lasting  for  weeks. 

"While  the  erysipelas  is  extending  the  fever  continues,  and  is  some- 
times alarmingly  high.  The  pulse  is  frequent  and  soft.  Leucocytosis 
is  present.  Xocturnal  delirium  is  not  uncommon  in  severe  cases,  and 
sometimes  nausea  and  vomiting  are  frequent.  The  bowels  are  usually 
constipated.  The  urine  is  high-colored,  frequently  contains  a  small 
amount  of  albumin,  and  actual  nephritis  sometimes  occurs. 

In  favorable  cases  of  facial  erysipelas  the  process  is  at  an  end  in 
a  week  or  less.  It  may  be  prolonged  to  two  weeks,  subsiding  by  crisis 
or  lysis,  and  convalescence  is  usually  rapid.  The  vesicles  or  bulla?  dry 
up  into  yellowish  crusts  and  the  epiderm  is  shed  in  large  or  small 
pieces  according  to  the  intensity  of  the  process. 

Pneumonia  and  nephritis  are  the  most  frequent  complications.  Men- 
ingitis, pericarditis,  and  endocarditis  also  occur.  Erysipelas  may  extend 
inward  and  involve  the  fauces,  pharynx,  and  larynx,  producing  oedeina 
and  death  from  suffocation. 

Sequelae.  If  the  scalp  has  been  involved  the  hair  falls  out.  The 
cervical  adenitis  may  result  in  abscess  ;  chronic  nephritis  may  result. 
Otitis  media  occurs  occasionally,  and  so  do  keratitis  and  abscess  of  the 
eyelids. 

*  On  the  other  hand,  erysipelas  is  credited  with  causing  the  disappear- 
ance of  lupus,  chronic  eczema,  and  sarcomata. 

Diagnosis.  Bacteeiological  Diagnosis.  Examination  of  pus 
or  discharge  from  the  nose  or  thorax  will  disclose  the  presence  of  the 
streptococcus.     (See  Plate  TIL,  Fig.  1.  and  Chapter  XXI.) 

Herpes  zoster  of  the  face  and  forehead  is  distinguished  from  erysipelas 


THE  DATA  OBTAINED  BY  OBSERVATION.  31 1 

by  the  fact  that  vesicles  appear  first,  followed  by  erythematous  redness, 
and  that  they  are  limited  by  the  median  line,  and  are  preceded  and 
accompanied  by  sharp  neuralgic  pain,  whereas  erysipelas  affects  both 
sides  of  the  face,  and  vesicles  appear  at  the  height  of  the  disease  ;  the 
pain  is  much  less  in  erysipelas.  It  is  distinguished  from  dermatitis  of 
various  kinds  mainly  by  the  sharper  febrile  reaction,  the  raised  border 
of  the  eruption,  which  begins  on  one  side  and  spreads  to  the  other. 
Erysipelas  is  rarely  equally  intense  upon  the  two  sides.  Dermatitis 
frequently  is.  The  latter  often  exhibits  a  rough  surface,  whereas,  until 
vesicles  appear,  erysipelas  is  smooth  and  shiny. 

Chronic  erythematous  eczema  occurs  in  the  middle-aged  and  old  per- 
sons, is  afebrile,  accompanied  by  little  swelling  but  a  great  deal  of 
itching,  and  runs  a  slow  course. 

Lobar  Pneumonia. 

The  Pneumococeus  Infections.  In  typical  cases  of  the  infection  we 
are  about  to  consider  the  course  of  the  fever  is  of  great  diagnostic  sig- 
nificance. Its  sudden  rise  to  a  great  height,  preceded  by  a  rigor,  is  of 
itself  suggestive.  During  the  succeeding  days  of  the  disease  the  morn- 
ing and  evening  temperature  varies  but  little.  When  associated  with 
hurried  respiration  and  the  intoxication  symptoms  attending  this  infec- 
tion, even  though  no  physical  signs  are  present  in  the  lungs,  pneumonia 
can  reasonably  be  suspected.  The  termination  of  the  febrile  course  is 
characteristic  of  the  infection.  The  sudden  fall  to  normal  or  a  subnor- 
mal temperature — known  as  the  crisis — brings  to  an  abrupt  end  the 
usually  alarming  symptoms. 

Acute  pneumonia,  croupous  or  lobar  pneumonia,  is  an  infectious 
inflammatory  disease  excited  by  the  micrococcus  lanceolatus  (diplococ- 
cus  pneumonia?,  pneumococeus)  involving  the  vesicular  structure  of  the 
lungs,  and  followed  by  choking  of  the  alveoli  with  the  products  of 
inflammation  ;  it  is  attended  by  severe  constitutional  symptoms  due  to 
the  toxines  of  the  infecting  organism. 

Symptoms.  Mode  of  Onset.  The  invasion  of  pneumonia  is  usually 
sudden,  and  is  marked  by  a  chill.  The  temperature  rises  rapidly,  and 
may  reach  104°  or  105°  in  the  first  twelve  hours  after  the  chill.  With 
the  fever,  the  patient  complains  of  severe  headache  and  pain  in  the 
side,  and  has  a  short,  quick  cough  and  sometimes  vomiting.  The  pulse 
is  moderately  accelerated,  and  the  respiration  either  is  or  soon  becomes 
very  frequent.  The  face  is  apt  to  be  flushed,  and  there  may  be  a  circum- 
scribed red  spot  on  the  cheek.  The  skin  is  hot  and  dry.  On  physical 
examination,  within  the  first  twenty-four  hours,  a  small  patch  of  con- 
solidation is  detected,  which  may  subsequently  extend  over  a  large 
area. 

While  this  i>  the  picture  of  an  ordinary  pneumonia  in  its  early  stage, 
all  cases  are  by  no  means  so  clear.  In  some  the  course  resembles  that 
of  a  general  fever  in  which  the  pulmonary  disease  is  a  local  manifesta- 
tion. In  such  cases  there  may  be  prodromata,  consisting  of  headache, 
general  malaise,  a  slight  bronchitis,  and  digestive  disturbance.  Then 
follows  the  chill.      Central  'pneumonia.     The  fever  may   he  high  for 


312  GENERAL  DIAGNOSIS. 

several  days  before  there  is  any  discoverable  consolidation  of  the  lungs, 
and  during  this  time  cough  may  be  wholly,  or  almost  wholly,  absent. 
The  respirations  increase  gradually  in  frequency,  and  finally  a  well- 
marked  pneumonia  can  be  made  out.  It  is  customary  to  account  for 
these  cases  by  the  supposition  that  pneumonia  developed  in  the  interior 
of  the  lung  and  consolidation  gradually  extended  to  the  surface.  In 
some  cases  the  patient  presents  no  more  definite  symptoms  for  three 
or  four  days  than  high  fever,  intense  headache,  and  moderately  accel- 
erated respiration. 

Later  Stages.  At  the  end  of  forty-eight  hours,  or,  at  the  most, 
of  four  days,  the  patient  is  found  lying  in  bed  in  the  dorsal  position, 
or  on  the  affected  side.  The  face  is  flushed,  and  countenance  anxious, 
the  respiration  hurried,  the  alse  nasi  play  vigorously.  The  tempera- 
ture varies  little  from  the  first  day's  rise  ;  the  chest  pain  has  subsided, 
and  the  short,  dry  cough  is  now  attended  by  viscid  expectoration.  The 
respiration  continues  hurried,  the  pulse  full  and  bounding.  During 
this  time  the  physical  signs  of  consolidation  continue  and  increase. 

After  a  period  of  five  to  ten  days  the  termination  takes  place  by 
crisis,  the  pain  in  the  chest  abates,  the  cough  becomes  looser,  and  the 
expectoration  more  free,  but  the  other  symptoms  persist.  In  addition, 
in  some  cases,  delirium  occurs,  the  pulse  softens  and  becomes  dicrotic, 
the  urine  becomes  albuminous. 

Respiratory  Symptoms.  Chest-pain,  cough,  hurried  respiration 
of  a  peculiar  type,  and  expectoration  are  characteristic.  The  chest- 
pain  is  sharp  and  stabbing  or  lancinating.  It  is  increased  by  breath- 
ing. It  is  seated  about  the  nipple  or  in  the  axillary  region,  at  the 
angle  of  the  scapula  or  below  the  diaphragm.  Its  seat  always  indicates 
the  side  affected.  Cough  is  short  and  dry,  smothered  and  painful ; 
it  soon  becomes  softer  and  painless  as  the  expectoration  becomes  free. 
It  may  be  absent  in  the  feeble,  in  the  aged,  in  alcoholic  subjects,  or  in 
persons  with  brain  disease,  including  insanity. 

Characteristic  symptoms  of  pneumonia  are  the  increased  frequency 
and  the  type  of  the  respiration.  The  rate  in  adults  reaches  40,  50,  or 
even  60  per  minute,  and  in  children  80  and  100  are  not  very  un- 
common. 

The  pulse,  on  the  contrary,  does  not  increase  in  frequency  in  the 
same  proportion  ;  hence,  the  normal  ratio  of  respiration  to  pulse  of  1 
to  4  ceases,  and  becomes  1  to  3  or  1  to  2. 

Inspiration  is  short,  expiration  quick  and  often  attended  by  an  expi- 
ratory noise  or  grunt.  The  long  pause  may  take  place  after  inspira- 
tion instead  of  expiration.  In  children  both  are  so  short  that  unless 
the  epigastrium  is  inspected  it  may  be  difficult  to  distinguish  the  two. 

In  ordinary  cases  which  run  a  normal  course  the  cough  is  followed 
by  expectoration,  which  is  at  first  viscid  mucus,  but  gradually  becomes 
reddish-brown  from  admixture  of  blood — the  rusty  sputum  of  pneu- 
monia. This  sputum  is  characteristic,  almost  pathognomonic.  It  is 
expelled  with  difficulty  from  the  mouth,  clinging  to  the  lips  or  to  the 
mustache.  It  cannot  be  removed  from  the  spit-cup  by  turning  it 
upside  down.  It  continues  to  be  rusty,  and  as  the  crisis  approaches 
becomes  purulent  and  is  discharged  with  ease.     In  typhoid  pneumonia 


THE  DATA  OBTAINED  BY  OBSERVATION. 


313 


it  looks  like  prune-juice  (See  Sputum.)  It  contains  blood,  alveolar 
epithelium,  the  specific  micrococcus,  and  later  pus  and  small  fibrinous 
casts. 

Fig.  74. 


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314  GENERAL  DIAGNOSIS. 

The  Fever.  The  chill  that  precedes  the  fever  is  pronounced  and 
is  always  a  warning  to  look  for  a  pulmonic  inflammation.  In  children 
a  convulsion  is  rarely  absent  in  frank  pneumonias.  During  its  occur- 
rence the  body-temperature  rises.  In  twelve  hours  it  reaches  104°  to 
105°.  (See  Figs.  74  and  75.)  It  remains  at  this  point,  obeying  the 
laws  of  diurnal  variation.  The  hot,  dry  skin,  the  parched  lips,  the  dry 
tongue,  the  thirst,  the  anorexia,  the  hurried  breathing,  the  occasional 
delirium,  the  loaded  urine  attest  its  presence.  At  the  end  of  the  third, 
or  more  frequently  the  fifth,  seventh,  or  ninth  day,  crisis  takes  place ; 
the  fall  is  abrupt,  and  the  normal  or  a  subnormal  temperature  may 
be  reached  in  from  five  to  fifteen  hours.  Pseudo-crisis,  as  the  accom- 
panying chart  indicates,  may  precede  the  true  crisis  by  twenty-four  or 
forty-eight  hours.  The  decline  may  take  place  by  lysis,  however.  Pro- 
tracted fever  indicates  delayed  resolution  or  the  occurrence  of  a  compli- 
cation. 

Cerebral  Symptoms.  In  some  cases,  especially  in  children,  the 
onset  of  the  disease  may  be  marked  by  a  convulsion.  This  is  said  to 
occur  more  frequently  in  apical  pneumonias  than  in  pneumonias  of  the 
base.  Headache  and  delirium  are  so  pronounced  in  some  cases  as  to 
simulate  meningitis.  This  is  most  likely  to  be  the  case  in  severe  apical 
pneumonia  in  children,  and  in  double  pneumonia  either  in  children  or 
in  adults. 

Delirium  may  occur  during  the  height  of  the  fever,  and  occasionally 
is  maniacal.  Xocturnal  delirium  may  be  a  constant  symptom  in  very 
grave  cases.  In  drunkards  it  may  simulate  delirium  tremens,  and 
may  be  pronounced,  without  much  fever.  In  the  later  stages  of  grave 
or  fatal  cases  a  low  form  of  delirium,  with  a  tendency  to  coma,  is 
common. 

The  Heart  and  Pulse.  The  pulse  is  small  at  the  time  of  the  chill, 
but  becomes  full  and  bounding  during  the  fever  ;  later  it  may  become 
dicrotic.  The  pulse-respiration  ratio  has  been  referred  to.  The  pulse 
varies  in  frequency  and  in  character  with  the  type  of  the  disease.  In 
healthy  adults  it  is  rarely  over  110.  In  the  debilitated  it  may  be  very 
frequent,  small,  and  feeble  ;  in  the  aged,  frequent  and  dicrotic.  Exten- 
sive consolidations  reduce  the  amount  of  blood  in  the  general  circula- 
tion, cause  rapid  action  of  the  heart  and  a  small  pulse,  and  favor  death 
with  the  heart  in  asystole. 

The  heart-sounds  are  clear.  A  murmur  low  in  pitch  is  often  heard 
in  the  mitral  and  pulmonary  areas.  The  left  ventricle  acts  forcibly. 
The  pulmonary  second  sound  is  accentuated.  If  dilatation  and  failure 
of  the  right  heart  takes  place,  the  area  of  dulness  may  extend  beyond 
the  right  edge  of  the  sternum,  an  epigastric  impulse  be  noted,  tur- 
gescence  of  the  veins  in  the  neck  become  marked,  but,  above  all,  the 
previously  accentuated  pulmonic  second  sound  may  become  weak  or 
disappear. 

Gastro-intestinal  Symptoms.  Vomiting  frequently  occurs  in  chil- 
dren at  the  onset,  and  both  in  them  and  in  adults  may  persist  and  mask 
pulmonary  symptoms.  The  appetite  is  lost.  The  tongue  is  furred. 
It  may  become  dry  and  brown.  The  bowels  are  constipated  except 
when  complications  occur.     The  spleen  is  enlarged.     The  vomiting  and 


THE  DA  TA  OBTAINED  B  Y  OB  SEE  VA  TIOX.  31 5 

epigastric  pain  may  be  so  pronounced  as  to  mask  the  pulmonary  symp- 
toms. The  occasional  presence  of  jaundice  has  caused  it  to  be  mistaken 
for  hepatitis,  congestion  of  the  liver,  and  even  for  gallstones.  I  saw 
a  case  of  pneumonia,  said  to  be  appendicitis  and  peritonitis  because  of 
the  characteristic  pain,  colic,  and  vomiting,  followed  by  great  abdomi- 
nal tenderness  hi  the  upper  abdomen. 

The  Blood.  Leucocytosis  is  a  marked  accompaniment  of  pneumonia, 
especially  in  cases  ending  favorably.  The  white  cells  mav  be  increased 
from  12,000  to  40,000.  They  fall  with  the  crisis,  or  probably  a  day 
after  the  termination  of  the  fever.  In  malignant  forms  there  may  be 
no  leucocvtosis.  Increase  in  the  fibrin  network  causing  the  "  buffv 
coat "  of  older  writers  is  commonly  seen. 

Cutaneous  Symptoms.  Herpes  on  the  lips,  the  nose,  or  the  geni- 
tals is  of  common  occurrence.  Sweating  occurs  with  the  crisis,  or  if 
heart  failure  is  imminent. 

The  Urine.  The  urine  is  scanty  and  high-colored,  and  may  contain 
a  small  amount  of  albumin.  In  some  cases  the  chlorides  are  found  to 
be  absent.  This  is  determined  by  acidulating  the  urine  with  a  drop 
or  two  of  nitric  acid,  and  then  adding  one  or  two  drops  of  a  10  per 
cent,  solution  of  silver  nitrate.  If  chlorides  are  present  a  heavy  white 
cloud  of  chloride  of  silver  is  thrown  down.  The  chlorides  are  not 
invariably  absent,  or  even  diminished  in  pneumonia,  hence  their  reap- 
pearance, which  is  said  to  indicate  beginning  convalescence,  loses  its 
value  as  a  prognostic  sign. 

Physical  Signs.  (See  Diseases  of  the  Lungs,  Plate  XIX.)  Con- 
solidation. Diminution  in  the  amount  of  air,  increase  of  solid  con- 
tents. On  inspection,  diminished  movement.  If  extensive  consolidation, 
enlargement  of  the  affected  side.  On  palpation,  inspection  confirmed 
and  increased  vocal  fremitus  discovered.  Both  are  more  marked  at  the 
height  of  consolidation.  Percussion.  In  first  stage,  impaired  resonance 
or  Skodaic  resonance.  In  stage  of  hepatization,  dulness  or  flatness,  but 
without  any  wooden  quality  or  marked  resistance. 

Auscultation.  In  the  early  stage,  that  of  congestion,  the  respira- 
tory murmur  is  suppressed  and  crepitant  rales  are  heard  at  the  end  of 
inspiration.  On  full  inspiration  or  after  cough  a  broncho-vesicular 
respiration  is  brought  out.  When  consolidation  has  taken  place  the 
respiratory  murmur  is  bronchial.  Rales,  if  present,  are  moist  snbcrep- 
itant  rales  from  associated  bronchitis,  or  a  few  crepitant  rales  may  still 
persist,  and  a  friction-sound  be  heard. 

When  resolution  sets  in  the  crepitant  rale  reappears,  quickly  followed 
by  moist  subcrepitant  rales,  heard  both  on  inspiration  and  expiration, 
while  dulness  gradually  yields  to  impaired  resonance.  The  respiration 
loses  its  bronchial  character  and  again  acquires  a  vesicular  element 
before  becoming  completely  normal.  It  may  be  a  week  or  two,  <>r 
many  months,  even  in  uncomplicated  cases,  before  the  percussion-note 
becomes  perfectly  clear,  and  rales  wholly  disappear. 

The  physical  signs  are  modified  by  the  intensity  of  the  inflammation 
in  the  lung  structure  and  by  the  pleural  complications.  In  massive 
pneumonia,  for  instance,  the  auscultatory  signs  are  absent.  On  percus- 
sion, the  lung  is  absolutely  flat.     There  i-  no  fremitus  or  tubular  breath- 


316  GENERAL  DIAGNOSIS. 

ing.  The  physical  signs  resemble  those  of  pleurisy  with  effusion.  In 
the  central  pneumonia  the  physical  signs  may  be  delayed  until  the  third 
or  fourth  day.  A  few  rales  or  febrile  breathing  oyer  a  small  area  inay 
be  the  only  indication  of  a  possible  lung  process.  In  the  aged  the 
physical  signs  are  obscure.  In  patients  with  laryngeal  disease  or  marked 
obstruction  in  the  nasopharynx  the  physical  signs  may  be  indefinite. 
Bronchial  breathing  may  not  be  heard  unless  the  patient  takes  a  full 
breath  or  coughs.  In  this  class  of  cases,  as  well  as  those  with  feeble 
respiratory  moyement,  as  the  aged,  the  Aveak,  and  those  suffering  from 
some  other  disease,  as  tuberculosis,  the  physical  signs  are  not  made  out 
because  of  the  deficiency  of  respiratory  movements.  The  mdefiniteness 
of  the  physical  signs  makes  the  diagnosis  all  the  more  difficult,  because 
it  is  this  class  of  subjects  in  which  the  general  symptoms  of  infection 
are  very  slight.  Increased  respiration  may  be  the  most  suggestive 
sign.  Slight  elevation  of  the  temperature  and  more  or  less  stupor  may 
be  the  only  other  clinical  symptoms. 

Duration  and  Course.  The  duration  of  the  disease  is  from  one  to 
two  weeks.  It  may  subside  by  crisis  on  the  third,  fifth,  seventh,  or 
ninth  day,  or  gradually  by  lysis.  Crisis  is  marked  by  a  critical  sweat, 
a  copious  discharge  of  limpid  urine,  or  sometimes  by  a  few  loose  move- 
ments of  the  bowels,  accompanying  a  fall  of  temperature  to  or  below 
normal. 

Instead  of  clearing  up,  the  pneumonia  may  progress  to  suppuration, 
abscess,  or  gangrene.  These  conditions  can  be  made  out  by  the  char- 
acter and  range  of  temperature,  the  general  condition  of  the  patient, 
the  sputum,  and  the  physical  signs.  Termination  in  abscess  or  gan- 
grene is  rare. 

In  cases  proceeding  to  a  fatal  issue  the  strength  fails,  respiration 
becomes  more  labored,  and  expectoration  increasingly  difficult.  The 
number  of  respirations  often  diminishes,  but  the  pulse  continues  fre- 
quent and  often  becomes  small  and  irregular.  Physical  examination 
shows  diffuse  bronchitis  with  oedema.  The  heart's  action  is  irregular 
and  rapid.  The  sounds  are  weak  and  feeble  ;  the  first  becomes  short 
and  snappy  like  the  second,  and  later  both  are  weak  or  indistinct.  Death 
may  occur  abruptly  from  convulsion,  or  more  frequently  from  asphyxia, 
due  to  oedema  of  the  lungs,  which  in  turn  sets  in  on  account  of  weak- 
ness of  the  heart  or  the  development  of  heart-clot  from  cardiac  asystole. 

Varieties.  Migratory  pneumonia.  Sometimes,  with  the  reappear- 
ance of  abundant  rales  and  increased  expectoration,  the  fever  continues 
high,  or,  if  the  temperature  has  fallen  to  normal,  again  rises,  the 
patient  is  disinclined  to  take  food,  has  a  dry,  brown  tongue,  and  is  often 
delirious.  In  such  cases  the  pneumonia  is  probably  extending  in  the 
lung  already  involved,  or  has  attacked  the  other  lung. 

Typhoid  pneumonia  is  an  unfortunate  name  for  an  adynamic  form  of 
the  disease  with  typhoid  symptoms.  If  it  arises  in  the  course  of  or 
complicates  low  fevers,  it  is  usually  of  the  typhoid  type  ;  but  it  occurs 
also  in  those  much  exhausted,  in  depraved  health,  or  exposed  to  unhy- 
gienic surroundings.  It  is  found  also  in  cases  of  septicaemia,  in  Bright' s 
disease,  in  drunkards,  and  in  the  negroes  in  the  southern  part  of  the 
United  States. 


THE  DATA   OB TA INED  B Y  OBSEB VA TION.  3 1  7 

The  characteristic  features  of  this  form  of  pneumonia  are  the  great 
physical  prostration  and  the  weak  heart-action.  The  fever  is  high,  the 
respiration  and  pulse  frequent,  and  delirium  and  vomiting  are  more 
frequent  than  in  the  ordinary  form.  The  skin  sometimes  has  a  dusky 
hue ;  the  tongue  is  heavily  coated,  or  may  be  dry  and  brown,  and 
sordes  collect  on  the  teeth.  The  sputa  may  be  rusty,  and  sometimes 
pure  blood  is  expectorated.  The  disease  may  prove  fatal  rapidly,  or 
may  linger  for  a  long  time,  the  patient  only  gradually  coming  out  of 
a  low  typhoid  state.     It  is  always  dangerous. 

Bilious  pneumonia  is  the  name  given  to  a  type  of  pneumonia  occur- 
ring in  persons  who  are  already  suffering  from  malarial  poisoning. 
The  initial  chill  lasts  longer,  and  the  pain  in  the  side,  from  coincident 
pleurisy,  is  more  marked  that  in  ordinary  pneumonia.  The  fever  is 
more  remittent,  and  jaundice  and  vomiting  are  present. 

Pneumonia  in  infants  is  characterized  by  nervous  symptoms.  Re- 
peated convulsions  and  active  delirium  may  be  most  pronounced,  fol- 
lowed by  torpor  and  coma.  There  is  no  sputa  and  but  little  cough. 
The  apex  of  the  lung  is  affected. 

Pneumonia  in  the  aged  is  characterized  by  latency  of  symptoms. 
There  is  but  little  cough  and  expectoration.  A  tendency  to  the  typhoid 
state,  however,  is  pronounced.     The  physical  signs  are  obscure. 

Pneumonia  in  alcoholic  subjects  also  develops  insidiously  and  may  be 
masked  by  the  symptoms  of  delirium  tremens.  The  temperature  may 
be  the  only  indication  of  infection,  as  there  is  no  pain,  no  cough,  no 
expectoration,  and  no  dyspnoea. 

Pneumonia  ivith  Other  Infections.  The  staphylococcus  and  strepto- 
coccus pyogenes,  the  colon  bacillus,  and  the  bacillus  pneumonia?  (Fried- 
lander)  are  often  found  with  the  pneumococcus,  and  may  predominate, 
inducing  a  mixed  infection.  The  micro-organisms  which  cause  diph- 
theria, typhoid  fever,  influenza,  and  the  plague  may  cause  a  pneumonia 
which  resembles  that  of  lobar  pneumonia  in  the  extent  of  the  consoli- 
dation. The  micrococcus  lanceolatus  is  found  in  increased  numbers  in 
the  sputum  of  these  cases.  There  is  not  the  same  intensity  of  pulmo- 
nary symptoms,  however.  The  respirations  are  not  so  hurried.  The 
physical  signs,  while  extensive,  are  obscure,  and  indicate  rather  a  heavy 
lung  (congested)  than  one  greatly  consolidated.  There  is  impaired  reso- 
nance, feeble  breathing,  and  a  few  rales  in  a  large  number  of  cases. 

It  is  this  form  of  lobar  pneumonia  which  it  is  difficult  to  distinguish 
from  bronchopneumonia  or  catarrhal  pneumonia — an  infection  which 
usually  begins  in  the  upper  air  passages.  This  form  of  local  infection  is 
considered  in  the  chapter  on  diseases  of  the  lungs. 

Diagnosis.  The  diagnosis  is  based  upon  the  aggregation  of  special 
symptoms.  The  mode  of  onset,  the  chill,  the  course  of  the  fever,  the 
pain  in  the  chest,  the  cough,  the  peculiar  expectoration,  the  dyspnoea, 
the  abnormal  pulse-respiration  ratio,  the  peculiar  character  of  breath- 
ing, the  physical  signs,  and  leucocytosis  are  the  phenomena  of  the  symp- 
tom-complex. It  must  be  remembered  that  in  children,  in  the  aged,  in 
drunkards,  in  cases  of  chronic  disease,  the  type  is  different.  In  drunk- 
ards cerebral  symptoms  are  more  marked.  In  children  the  cerebral 
symptoms  are  more  prominent,  the  expectoration  often  absent.     In  the 


318  GENERAL  DIAGNOSIS. 

aged,  the  cough,  the  expectoration,  and  the  fever  are  not  pronounced ; 
the  former  may  be  absent ;  the  onset  is  insidious.  The  same  onset  and 
course  occur  in  wasting  diseases,  as  cancer,  phthisis,  Bright' s  disease, 
diabetes,  and  organic  heart  disease.  In  this  class  of  cases  a  small  patch 
of  pneumonia,  difficult  to  determine  on  physical  examination,  may  be 
attended  by  the  gravest  general  symptoms.  In  all  of  the  above  cases, 
if  there  is  fever  without  cause,  although  no  pulmonary  symptoms  are 
present,  the  lungs  must  be  examined  repeatedly.  In  many  such  cases 
the  physical  signs  are  obscured  because  respiratory  action  is  enfeebled 
by  the  primary  condition. 

Pneumonia  must  be  distinguished  from  other  acute  inflammatory 
affections  of  the  lung  and  pleura  and  from  acute  tuberculo-pneumonic 
phthisis.  The  evidence  for  each  is  considered  in  the  respective  sections. 
The  presence  of  leucocytosis  serves  to  distinguish  it  from  acute  tubercu- 
losis and  from  typhoid  fever,  meningitis,  and  influenza.  To  distinguish 
pneumonia  from  pleurisy  with  effusion,  the  aspirator  may  be  used. 

Bactebiological,  Diagnosis.  Staining  and  microscopical  exami- 
nation of  the  sputum  reveal  the  characteristic  micro-organism.  Care 
must  be  taken  to  secure  the  sputum  from  the  lung.  By  inoculation  of 
rabbits  with  the  sputum  the  disease  is  readily  reproduced.  The  organ- 
ism is  not  readily  found  in  the  blood.     (See  the  Sputum.) 

Pneumonia  may  be  distinguished  from  cerebrospinal  meningitis  by 
the  results  of  spinal  puncture  alone  ;  from  acute  tuberculous  pneumonia 
by  the  examination  of  the  sputum.  The  diagnosis  in  the  latter  instance 
may  be  postponed,  as  tubercle  bacilli  are  sometimes  not  foimd  until  the 
tenth  or  twelfth  day.  (See  Tuberculosis.)  Typhoid  fever  sometimes 
resembles  pneumonia,  and  must  be  distinguished  after  the  first  week 
by  the  results  of  serum  diagnosis. 

Pneumococcus  Septicaemia.  The  account  Ave  have  just  given  of 
pneumonia  represents  but  one  phase  of  the  pneumococcus  infection. 
This  infection  may  be  attended  by  very  grave  symptoms,  especially 
those  of  a  toxic  nature,  with  but  little  if  any  involvement  of  the  lung 
tissue.  It  is  well  known  that  we  may  see  the  chill,  fever,  rapid  pulse, 
and  hurried  respiration  with  but  little  evidence  of  consolidation  in  the 
lung,  but  with  nervous  symptoms  paramount.  Delirium,  stupor,  coma 
with  the  phenomena  of  the  ataxic  or  the  typhoid  state  may  prevail.  (See 
pages  199  and  200.)  In  the  ataxic  state  the  symptoms  resemble  those 
of  mania.  In  the  typhoid  form  they  are  not  unlike  those  of  uraemia. 
In  either  instance  death  ensues  in  coma  or  from  heart  failure  with  its 
attending  symptoms.  Preceding  the  cardiac  failure  the  urine  is  dimin- 
ished in  amount  and  the  secretions  generally  suppressed. 

In  other  forms  of  this  infection  the  localization  of  the  process  is  in 
the  pleura,  as  in  empyema,  in  the  pericardium,  in  the  endocardium, 
and  in  the  cerebral  meninges.  Pneumococcus  inflammation  of  these 
structures  is  very  common.  It  may  develop  at  the  same  time  that  the 
lungs  are  affected,  independently  of  the  process  in  the  lungs,  or  subse- 
quent to  it.  These  forms  will  be  considered  in  a  discussion  of  the 
various  local  inflammations  just  referred  to. 

It  is  important  to  remember  that  in  pleural,  pericardial,  and  cerebro- 
spinal infections  the  nature  of  the  infection  can  be  determined  by  aspi- 


THE  DATA  OBTAINED  BY  OBSERVATION.  319 

ration  and  bacteriological  examination  of  the  fluid  removed  from  the 
respective  serous  cavity.  The  pneumococeus  infection  can  be  positively 
diagnosticated  in  tins  manner. 

These  complications,  which  occur  in  the  course  of  the  disease,  modify 
the  clinical  picture  and  obscure  the  diagnosis. 

Tuberculosis. 

The  infection  discussed  in  this  section  prevails  to  a  greater  degree 
than  that  of  all  the  others  combined.  In  some  forms,  as  pointed  out 
in  the  clinical  description,  fever  is  one  of  the  gravest  symptoms.  In 
other  forms  the  febrile  process  may  not  be  pronounced.  It  must  be 
remembered  that  the  fever  may  be  due  to  the  specific  micro-organism 
or  its  toxin,  or  it  may  be  due  to  a  mixed  infection.  Staphylococcus 
and  streptococcus  infections  are  common  attendants  upon  the  tubercu- 
lous infection.  This  secondary  infection  may  disappear  or  may  become 
the  most  prominent  infection.  In  many  instances  a  terminal  infection 
ensues,  causing  mortal  symptoms.  Infection  by  the  pneuniococcus  is 
the  most  common  of  these  terminal  infections.     (See  page  228.) 

Tuberculosis  is  an  infectious  disease,  the  course  of  which  may  be 
acute  or  chronic.  It  is  caused  by  the  bacillus  tuberculosis.  This 
micro-organism  sets  up  a  specific  inflammation  characterized  by  the 
development  of  nodules  or  tubercles,  or  by  a  diffuse  growth  of  tuber- 
culous tissue.  Either  anatomical  product  may  undergo  caseation  or 
sclerosis,  and  in  either  instance  ulceration  or  calcareous  degeneration. 

Invasion  of  the  body  by  the  micro-organism  may  give  rise  to  general 
infection,  with  an  eruption  of  miliary  tubercles  in  most  of  the  organs 
and  structures  of  the  body,  or  to  a  local  infection.  General  tubercu- 
losis is  acute  ;  local  tuberculosis  may  be  acute  or  chronic.  In  acute 
tuberculosis  the  serous  membranes,  the  lungs,  liver,  kidneys,  lymphatic 
glands  and  spleen,  the  bone-marrow,  and  choroid  coat  of  the  eye  may 
be  invaded  in  whole  or  in  part.  In  chronic  tuberculosis  the  lymph- 
glands,  the  lungs,  the  serous  membranes,  the  tissues  and  organs  of  the 
alimentary  canal,  the  liver,  the  organs  of  the  genito-urinary  system, 
and  the  brain  and  cord  are  individually  invaded. 

Diagnosis.  The  diagnosis  of  any  form  of  tuberculosis  is  aided  by 
the  determination  of  the  chief  factors  in  its  etiology,  where  this  is 
possible. 

Bacteriological  Diagnosis.  First.  The  discovery  of  the  bacillus 
tuberculosis  in  any  inflammatory  area,  or  any  product  of  inflammation, 
as  serum,  blood,  pus,  or  the  secretion  from  any  gland  or  mucous  mem- 
brane invaded  by  the  disease,  establishes  at  once  the  diagnosis  of  this 
condition.  The  method  of  determining  the  presence  of  this  micro- 
organism is  fully  detailed  in  the  various  descriptions  of  tuberculosis  in 
the  discussion  of  local  diseases,  and  in  the  accounts  of  the  examination 
of  the  sputum  and  of  exudations  and  transudations.  Inoculation  of 
inflammatory  products,  as  of  a  gland  or  of  fluid  which  has  been  sedi- 
mented,  is  a  positive  mode  of  diagnosis.  Guinea-pigs  are  selected  for 
this  purpose. 

Second.  As  tuberculosis  is  an  infection-  disease,  discovery  of  the 
infection  is  an  aid  in  the  diagnosis.     Infection  takes  place  by  means  of 


320  GENERAL  DIAGNOSIS. 

the  inhalation  of  the  sputum  or  other  secretions,  which  when  dry  float 
about  in  the  air.  It  implies  in  a  measure  more  or  less  contact  with 
individuals  previously  infected.  In  rare  cases  such  contact  is  produc- 
tive of  the  disease  by  means  of  direct  contagion.  The  second  source  of 
infection  is  the  food-supply.  This  may  occur  from  the  consumption 
of  milk  secured  from  a  cow  infected  with  tuberculosis.  The  eating  of 
meat  of  tuberculous  animals  may  possibly  lead  to  infection.  Direct 
inoculation  is  another  but  rarer  source  of  infection.  This  usually 
occurs  accidentally  only. 

Third.  It  is  possible  that  tuberculosis  may  be  inherited.  A  more 
prominent  etiological  factor,  which  aids  in  the  diagnosis  of  the  disease, 
is  the  presence  of  a  certain  type  of  structure  which  is  a  marked  heredi- 
tary characteristic  in  families,  on  account  of  which  feeble  resistance  is 
offered  to  the  invasion  of  the  tubercle-bacillus.  The  phthisical  and 
phthisinoid  chest  which  belongs  to  this  type  has  been  described  else- 
where, and  the  tuberculous  and  scrofulous  states  have  been  outlined. 
(See  page  67  and  Part  II.,  Chapter  II.)  These  anatomical  conditions, 
which  are  inherited,  undoubtedly  favor  the  development  of  tuber- 
culosis. 

It  is  a  mistake  to  lay  much  stress  in  the  diagnosis  of  tuberculosis 
upon  the  age  or  the  occupation  of  the  individual.  Tuberculosis  may 
occur  at  any  age.  It  is  true,  however,  that  at  certain  periods  of  life 
the  tubercles  are  distributed  more  commonly  in  one  group  of  organs, 
while  in  other  periods  they  affect  another  group.  Lymphatic,  joint, 
and  meningeal  tuberculosis  is  most  common  in  the  first  decade  of  life. 
The  mesenteric  glands  are  particularly  open  to  invasion  at  this  period. 

The  diagnosis  of  tuberculosis,  whether  local  or  general,  is  further 
aided  by  a  complete  knowledge  of  the  phenomena  that  attend  the 
entrance  of  the  virus  into  the  body  and  the  mode  of  diffusion  through- 
out the  body  after  infection  has  taken  place.  The  phenomena  at  the 
point  of  entrance  of  the  micro-organism  are  nearly  always  distinct. 
The  general  invasion  is  associated  with  symptoms  like  those  of  specific 
fevers.  The  local  secondary  effects  upon  the  tissues  are  always  decided. 
It  must  be  borne  in  mind  that  after  the  exposure,  which  may  lead  to 
infection,  either  an  acute  form  of  tuberculosis  of  a  general  character 
may  be  set  up,  with  or  without  marked  local  symptoms,  or  acute  local 
tuberculosis  alone  may  arise.  In  local  tuberculosis  the  disease  is  con- 
fined to  one  organ  or  to  the  lymphatic  glands  and  the  organs  in  the 
lymphatic  distribution,  as  the  bronchial  glands,  which  are  primarily 
affected,  and  to  the  lungs.  In  these  structures  the  entire  process  of 
nodular  formation,  caseation  or  sclerosis,  ulceration  or  calcification, 
may  take  place.  The  disease  remains  primarily  local.  On  the  other 
hand,  it  may  be  spread  by  continuity  of  structure  through  the  lymph- 
atics throughout  the  remainder  of  the  organ  affected,  leading  to  its 
ultimate  destruction  and  the  death  of  the  patient ;  or  general  infection 
of  the  system  may  take  place  from  the  primary  local  area.  The  pri- 
mary seat  of  infection  may  be  the  lungs,  the  larynx,  the  alimentary 
tract,  or  the  genito-urinary  organs.  Primary  tuberculosis  of  the  serous 
membranes,  of  the  lymph -glands,  of  the  bones  and  joints,  may  take 
place. 


THE  DATA  OBTAINED  BY  OBSERVATION. 


321 


The  symptomatology  and  diagnosis  of  the  various  forms  of  tubercu- 
losis are  detailed  in  the  section  devoted  to  the  special  diseases  of  the 
various  organs  of  the  body. 

The  Tuberculin  Test.  The  physical  signs  and  clinical  symptoms 
may  point  to  an  inflammatory  process  in  one  of  the  many  structures  of 
the  body  which  may  be  invaded  by  tubercle  bacilli.  On  the  other 
hand,  failure  in  health,  loss  of  weight,  ansemia,  and  moderate  fever  may 
alone  occur.  The  nature  of  the  inflammatory  process  may  be  obscure. 
To  determine  more  accurately  whether  the  inflammation  is  tuberculous 
or  not,  or  the  "decline"  due  to  tuberculosis,  we  can  resort  to  the  use  of 
tuberculin.  Since  the  researches  of  Koch,  who  introduced  tuberculin 
as  a  remedy  in  tuberculosis,  he  himself  as  well  as  a  number  of  other 
observers,  has  employed  this  preparation  to  determine  the  presence  of 
tuberculosis  in  the  body.  In  this  country  Trudeau  has  been  the  earliest 
and  most  earnest  exponent  of  this  means  of  diagnosis.  After  the  injection 
of  tuberculin  a  group  of  phenomena  follows,  known  as  the  tuberculin 
reaction,  if  tuberculosis  existed  anywhere  in  the  body.  It  was  thought 
the  occurrence  of  this  reaction  was  necessary  to  bring  about  a  cure. 
As  a  therapeutic  measure  its  value  has  not  been  upheld  by  experience. 
The  invariable  production  of  the  reaction  has  led  it  to  be  used  as  a 
diagnostic  medium. 

Phenomena  of  Reaction.  About  twelve  hours  after  the  injec- 
tion of  tuberculin  the  temperature  rises  rapidly.  In  the  course  of  a 
few  hours  it  has  risen  two  or  three  degrees.     This  elevation  of  tem- 


Fig.  76. 


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Typical  reaction  with  tuberculin. 


perature  is  attended  by  malaise,  pains  in  the  head,  back,  and  legs,  and 
sometimes  nausea  or  vomiting.  The  maximum  temperature  is  main- 
tained for  two  or  three  hours,  and  then  a  gradual  decline  to  the  norm  til 
takes  place.     The  normal  temperature  is  reached  in  from  twenty-four 

21 


322  GENERAL  DIAGNOSIS. 

to  thirty-six  hours.  The  whole  period  of  the  reaction,  from  the  time  of 
the  injection  until  the  termination  of  the  fever,  is  about  forty-eight 
hours.  With  the  fall  of  temperature  to  normal  the  constitutional 
symptoms  subside.  The  accompanying  chart  (Fig.  76)  shows  the 
course  of  the  fever  in  a  typical  reaction. 

Method.  Twenty-four  to  forty-eight  hours  preceding  the  test  the 
patient's  temperature  should  be  taken  every  two  hours  to  determine 
the  range  at  this  period  of  the  disease.  The  injection  should  be  made  at 
a  time  when  the  reaction  could  be  observed — i.  e,,  during  the  period 
of  normal  or  subnormal  temperature.  This,  of  course,  can  only  be 
selected  if  the  temperature  of  the  disease  is  intermittent.  The  hour  of 
day  selected  to  inject  the  tuberculin  should  be  such  that  the  reaction 
may  be  conveniently  observed  during  the  waking  hours  of  the  patient. 
Bedtime  or  the  early  morning  hours  are  the  most  convenient. 

The  site  of  the  injection  is  not  material.  Usually  the  interscapular 
space  is  selected.  The  amount  of  tuberculin  employed  is  of  the  greatest 
importance.  The  initial  dose  should  never  exceed  five  milligrammes, 
and  it  is  better  to  use  less  than  this,  and  an  increasing  quantity  in- 
jected every  second  or  third  day.  The  maximum  dose  should  not  ex- 
ceed ten  milligrammes.  For  children  one-twentieth  to  one-tenth  of  a 
milligramme  may  be  the  initial  dose.  The  crude  tuberculin  should  be 
diluted  at  the  time  it  is  used  with  1  to  2  per  cent,  solution  of  carbolic  acid. 

At  the  point  of  injection  a  little  redness  and  infiltration,  with  tender- 
ness to  the  touch,  is  observed.  This  local  reaction  may  also  be  seen  at 
the  site  of  former  negative  injections  when  the  larger  dose  produces 
reaction.  In  pulmonary  tuberculosis  in  which  physical  signs  are 
obscure  some  auscultatory  phenomena  which  were  previously  absent 
may  be  found  during  the  period  of  a  reaction.  This  test  also  enables 
one  to  detect  tuberculosis  in  the  pleura,  pericardium,  peritoneum, 
genito-urinary  tract,  and  lymphatic  glands,  the  meninges,  bones,  and 
the  skin.     The  test  is  of  special  value  in  cervical  adenitis. 

It  must  be  remembered  that  a  negative  result  with  large  doses  of 
tuberculin  is  of  more  value  than  a  positive  one.  In  the  former  instance 
one  can  affirm  that  tuberculosis  is  absent,  as  well  as  that  there  is  no 
old  focus  in  any  of  these  organs.  It  must  also  be  remembered  that 
the  test  should  only  be  employed  after  all  other  means  have  failed  to 
make  a  positive  diagnosis. 

Acute  m Mary  tuberculosis  has  been  spoken  of  elsewhere.  (See  Part  II., 
Chapter  II.)  Its  course  may  resemble  typhoid  fever,  septicaemia,  or 
malignant  endocarditis.  It  usually  develops  in  the  course  of  tubercu- 
losis in  some  other  organ  of  the  body.  The  typhoid  form  has  been 
described  in  the  section  indicated.  It  must  not  be  forgotten  that  the 
diagnosis  is  rendered  positive  by  the  demonstration  of  the  presence  of 
tubercle-bacilli  in  the  blood,  or  of  the  occurrence  of  choroidal  tubercles 
in  the  eye-ground.  Another  form  is  attended  by  marked  pulmonary 
symptoms.  This  is  the  type  seen  in  the  bronchial  pneumonia  that  occurs 
in  children  following  measles  and  whooping  cough.  (See  Catarrhal  Pneu- 
monia.) Of  the  pulmonary  symptoms  dyspnoea  is  the  most  prominent. 
Cyanosis  is  marked.  The  physical  signs  are  not  prominent,  and  may 
be  those  of  bronchitis  alone.     Although  there  is  impaired  resonance 


THE  DATA  OBTAINED  BY  OBSERVATION. 


323 


at  the  base  of  the  lungs,  areas  of  hyper-resonance  are  observed  above  and 
in  front  of  the  chest.  Collapse  of  the  lung  may  cause  tubular  breathing. 
The  temperature  rises  to  102°  or  103°.     An  inverse  type  may  be  seen. 

The  diagnosis  of  acute  tuberculosis  is  determined  by  the  history  of 
infection  from  extraneous  sources  or  from  local  tuberculosis  in  some 
portion  of  the  body,  and  by  the  presence  of  bacilli. 

The  following  conditions  should  point  to  the  possibility  of  chronic 
tuberculosis  in  some  portion  of  the  body  :  (1)  Emaciation,  not  otherwise 
explained  ;  (2)  chlorosis  or  anaemia  ;  (3)  weakness  without  cause  ;  (4) 
fever — the  temperature  should  be  taken  every  two  hours  during  night 
and  day  ;  (5)  causeless  sweats  ;  (6)  gastro-intestinal  catarrh  ;  (7)  morn- 
ing nausea  ;  (8)  signs  of  local  inflammation  in  some  organ  of  the  body. 

Influenza. 

High  temperature  out  of  proportion  to  the  local  signs  of  inflamma- 
tion in  the  lungs  or  other  structures  characterizes  this  infection.  The 
fever  may  be  continuous,  remittent,  or  intermittent. 


Fig.  77. 


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Temperature  in  influenza— interrupted  crisis.    (Wilson.) 


324 


GENERAL  DIAGNOSIS. 
Fig.  78. 


pr 
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Influenza— remittent  type.    (Wilson.) 


THE  DATA  OBTAINED  BY  OBSERVATION.  325 

Influenza  is  a  specific  contagious  febrile  disease,  occurring  in  wide- 
spread epidemics,  having  a  very  short  period  of  incubation,  and  charac- 
terize! by  great  prostration,  marked  nervous  symptoms,  and  catarrhal 
inflammation  of  the  respiratory  or  gastro-intestinal  tracts,  or  both. 
There  is  great  liability  to  relapse,  and  to  complications,  which  are  gen- 
erally pulmonary  or  nervous. 

The  disease  generally  begins  with  the  ordinary  symptoms  of  coryza  ; 
but  the  headache  over  the  eyes  and  root  of  the  nose  is  more  severe,  and 
may  be  so  agonizing  as  to  mask  all  other  symptoms.  The  lacrymation, 
rhinitis,  and  tormenting  cough  are  all  usually  worse  than  in  ordinary 
coryza.  Physical  weakness,  weariness,  and  depression  of  spirits  are 
almost  invariably  present,  and  they  sometimes  reach  an  extraordinary 
degree.  Fever  is  usually  moderate  (100°  to  102°),  but  may  be  104°  to 
105°  for  several  days,  and  then  gradually  subside.  It  may  terminate 
by  crisis  (Fig.  77),  or  may  assume  an  intermittent  or  remittent  type 
(Figs.  78  and  79).  In  ordinary  cases  the  patient  seeks  relief  first  for 
the  headache,  severe  aching  pain  in  back  and  limbs,  and  extreme 
weakness ;  if  these  are  relieved  he  is  apt  to  complain  most  of  incessant 
racking1  cough,  often  due  more  to  a  tracheitis  than  to  bronchitis. 
Nausea  and  vomiting  are  not  uncommon,  especially  in  the  morning,  at 
which  time  also  the  patient  frequently  feels  worse  than  he  does  later 
in  the  day.  Sleep  is  broken  and  restless,  and  may  be  accompanied  by 
drenching  perspirations.     Severe  neuralgic  pains  are  common. 

In  some  cases  the  disease  attacks  the  stomach  and  bowels  especially, 
and  vomiting  with  diarrhoea  are  the  prominent  symptoms.  In  others 
the  predominant  symptoms  are  nervous,  and  great  pain  with  prostra- 
tion masks  any  catarrhal  symptoms.  Torpor  and  delirium  may  be 
present.  Sometimes  a  prolonged  and  severe  attack  of  asthma  marks 
infection  in  susceptible  persons. 

The  duration  of  the  disease  is  from  a  few  days  to  a  few  weeks. 
Convalescence  is  remarkably  tedious,  and  is  characterized  by  persistent 
weakness.  Sweats  are  often  annoying  during  this  time.  The  heart 
often  continues  for  some  time  to  beat  too  frequently  and  to  be  easily 
excited  by  exertion.     Relapses  are  common. 

Diagnosis.  Bacteriological  Diagnosis.  This  is  possible  when 
the  characteristic  bacilli  are  detected  by  the  means  described  in  the 
section  on  sputum.  Influenza  in  the  great  majority  of  cases  is  easily 
recognized.  In  certain  cases,  however,  it  is  to  be  differentiated  from 
'pneumonia,  typhoid  fever,  and  cerebrospinal  meningitis. 

Cases  in  which  the  disease  sets  in  with  high  fever  and  marked 
chest-symptoms  are  very  apt  to  be  mistaken  for  pneumonia  ;  but  the 
headache  and  prostration  are  more  intense,  while  the  respiration  is  not 
so  frequent.  Sweats  are  common,  and  albumin  and  casts  in  the  urine 
are  by  no  means  rare.  Physical  exploration  shows  that  botli  lungs 
are  involved,  though  often  not  to  the  same  degree.  Resonance  is  .im- 
paired, and  auscultation  shows  moist  crepitant  and  subcrepitant  rales, 
which  seem  to  be  due  to  an  oedematous  condition  of  the  lung-tissue, 
associated  with  a  diffuse  bronchitis.  A  true  lobar  pneumonia  is  rarely 
I ) resent  even  as  a  complication. 

If  diarrhoea  is  one  of  the  symptoms,  typhoid  fever  lass  t<>  be  excluded. 


326  GENERAL  DIAGNOSIS. 

This  is  extremely  difficult  in  the  first  two  or  three  days.  As  a  rule, 
headache,  backache,  nausea,  and  sleeplessness  are  at  this  time  greater 
in  influenza,  the  spleen  is  not  so  much,  if  at  all,  enlarged,  the  diarrhoea 
can  be  checked,  and  tenderness  and  pain  in  the  right  iliac  fossa  are  absent. 

It  can  be  distinguished  from  cerebrospinal  meningitis  by  noting  the 
fact  that  it  begins  with  coryza,  "whereas  cerebro-spinal  meningitis 
often  sets  in  with  chill,  vomiting,  and  faintness  ;  the  headache  in  the 
former  is  usually  frontal,  in  the  latter  occipital,  and  accompanied  by 
stiffness  of  the  back  of  the  neck.  Further,  in  cerebro-spinal  menin- 
gitis there  are  often  swellings  of  the  joints,  delirium  alternating  with 
coma,  and  in  young  subjects  convulsions  are  common. 

Finally,  it  may  be  said  that  the  pronounced  diagnostic  feature  is  the 
preponderance  of  general  symptoms  over  local  inflammations.  The 
occurrence  of  undue  exhaustion,  extreme  general  neuralgias  and  myal- 
gias, high  fever,  and  profuse  sweats,  without  intense  catarrh  or  inflam- 
■mation  to  account  for  or  co-ordinating  with  them,  is  of  the  highest 
diagnostic  significance.  The  presence  of  an  epidemic,  the  contagious 
nature  of  the  affection,  the  sudden  onset,  and  the  bacteriological  diag- 
nosis, all  point  to  influenza. 

Epidemic  Cerebro-spinal  Meningitis. 

In  this  infection  more  than  all  others  the  course  of  the  temperature 
is  without  diagnostic  significance  unless  it  be  that  this  want  of  a  char- 
acteristic course  is  significant.  Its  extraordinary  irregularity  is  most 
striking  when  a  large  number  of  charts  are  examined.  The  fever  may 
have  the  course  and  exacerbation  of  a  typhoid  temperature,  but  it  is 
more  similar  to  that  of  tuberculosis.  It  is  often  of  very  short  dura- 
tion, followed  by  a  prolonged  subnormal  temperature.  It  may  be  high 
from  the  immediate  onset  of  the  disease,  or  remain  below  100°  for 
several  days,  and  then  suddenly  rise  to  a  great  height.  Remissions 
and  exacerbations  may  attend  many  of  the  cases.  The  most  marked 
feature,  apart  from  the  irregularity  of  the  temperature,  is  the  inequality 
between  the  pulse  and  the  temperature.  In  some  instances  the  pulse 
is  rapid,  and  the  temperature  is  normal  or  subnormal,  while  later  in 
the  disease  the  pulse  may  be  slow  when  the  temperature  rises  to  a  con- 
siderable height. 

Concerning  the  temperature,  then,  it  may  be  said  that  it  may  be  in- 
termittent, remittent,  or  continuous  ;  it  may  be  intermittent  at  one 
period,  continuous  at  another  ;  it  may  be  afebrile  ;  it  may  be  afebrile 
at  one  period  and  continuous  at  another. 

Cerebro-spinal  meningitis,  also  known  as  spotted  fever,  is  an  acute, 
specific,  infectious,  and  mildly  contagious  disease,  endemic  and  epi- 
demic, characterized  by  evidences  of  systemic  infection,  and  generally 
also  by  symptoms  depending  upon  inflammation  of  the  cerebral  and 
spinal  meninges — particularly  intense  pain  in  the  back  and  head,  hyper- 
esthesia, retraction  of  head  and  neck,  delirium,  coma,  convulsions,  and 
vomiting. 

It  is  most  common  in  cold  weather,  and  in  children  under  fifteen 
years  of  age.    Xone  of  the  epidemics  show  a  continuous  extension.    The 


THE  DATA  OBTAINED  BY  OBSERVATION. 


327 


period  of  incubation  is  unknown,  but  is  probably  short.  It  is  free 
from  symptoms.  The  invasion  of  the  disease  is  abrupt,  although  in 
some  instances  the  patient  may  complain  of  rheumatoid  pains  in  the 
limbs  or   a   joint,   and    headache   and  weakness.     Usually  the    first 


Fig.  80. 


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Cerebro-spinal  meningitis,  showing  irregularity  of  pulse  and  temperature.    (Councilman.) 

symptom  is  a  severe  chill,  which  may  awaken  the  patient  from  sleep. 
In  other  cases  the  initial  symptom  is  a  convulsion.  Then  quickly 
follow  repeated  vomiting,  intense  headache,  sometimes  accompanied 
by  backache,  retraction  of  the  head,  delirium,  and  extreme  prostration. 

The  rise  in  temperature  is  moderate,  and  the  pulse  is  as  often  slow 
as  frequent.  The  face  is  pale  and  livid,  expressing  suffering,  and  the 
patient  may  toss  from  one  side  of  the  bed  to  the  other,  begging  some 
relief  for  his  headache.  Simple  stiffness  of  the  muscles  of  the  neck 
may  prevail.  The  pain  in  the  head  may  be  occipital  or  frontal.  The 
pain  in  the  back  becomes  more  severe,  and  root-pains  dart  in  all  direc- 
tions, but  especially  into  the  limbs  or  joints,  which  may  be  swollen  and 
tender  to  the  touch  ;  in  fact,  the  whole  skin  is  hypersesthetic  and  the 
reflexes  are  increased.  The  spinal  muscles  become  rigid,  and  the  head 
is  often  retracted.  Less  frequently  the  back  is  arched  and  trismus 
occurs.  Delirium  is  common  at  night.  It  may  develop  very  early  or 
appear  at  a  late  period  of  the  disease.  It  is  sometimes  violent  or  low 
and  muttering.  It  is  often  of  a  sportive  type,  the  patient  making 
absurd  remarks,  cracking  jokes,  or  singing  snatches  of  a  comic  song. 
Delirium  may  alternate  with  tonic  or  clonic  convulsions  and  with 
stupor.  The  appetite  is  poor,  the  bowels  constipated.  A  remission 
may  occur  on  the  third  day,  with  temporary  improvement  of  the 
symptoms. 

As  the  attack  progresses  there  may  be  strabismus,  which  is  usually 
divergent,  inequality  of  the  pupils,  nystagmus,  ptosis,  and  optic  neu- 
ritis.     Vertigo,    tinnitus,    anosmia,    and    photophobia    are    common. 


328  GENERAL  DIAGNOSIS. 

Hyperesthesia  and  delirium  persist.  Facial  paralysis,  a  monoplegia, 
a  hemiplegia,  or  a  paraplegia  may  occur.  The  pulse  becomes  more 
frequent  and  the  fever  continues.  In  favorable  cases  improvement 
now  begins,  the  headache  and  root-pains  abating,  and  delirium  and 
spasms  becoming  less  frequent.  In  unfavorable  cases  the  convulsions 
may  become  more  severe  and  end  in  fatal  coma,  or  the  patient  may 
sink  into  a  typhoid  condition,  with  nephritis  as  a  complication.  Coma 
may  come  on  in  the  beginning  and  continue  until  death. 

The  skin  eruptions,  which  explain  the  name  "  spotted  fever,"  are 
not  always  present  and  exhibit  no  constant  character.  Herpes  and 
petechise  are  the  most  frequent ;  in  other  cases  the  eruption  is  a  pur- 
plish mottling,  or  is  macular,  or  the  eruption  resembles  that  of  measles. 
Herpes  is  most  common  on  the  nose  and  mouth,  then  on  the  cheek, 
forehead,  eyes,  and  ears.  The  blood  shows  a  leukocytosis,  the  increase 
being  due  to  the  polynuclear  leucocytes. 

'  In  the  malignant  (fulminating)  form  of  the  disease  death  occurs  in 
a  few  hours,  or  two  or  three  days.  Such  cases  are  apt  to  arise  early  in 
an  epidemic.  The  patient  has  a  violent  chill ;  delirium  occurs  early  ; 
the  headache  is  less  intense,  or  at  any  rate  gives  way  rapidly  to  stupor 
and  coma.  The  pulse  is  frequent  and  feeble  ;  there  may  be  no  rise  of 
temperature,  the  skin  being  cool,  clammy,  and  cyanotic.  Local  or 
general  convulsions  may  occur.  The  eruption  may  be  purpuric,  and 
eccliymoses  may  even  occur.  The  urine  is  scanty  and  contains  albu- 
min and  casts. 

Mild  cases  usually  occur  late  in  epidemics.  They  are  characterized 
by  severe  aching  in  the  head,  back,  and  limbs,  nausea,  vomiting, 
vertigo,  and  prostration.  They  closely  resemble  the  nervous  type  of 
influenza,  and  would  escape  recognition  except  during  an  epidemic. 

An  abortive  form,  ending  in  recovery  in  two  or  three  days,  and  an 
intermittent  form,  with  exacerbations  on  alternate  days,  have  been 
described. 

The  duration  of  the  disease  is  from  a  few  hours  to  two  or  three 
months.  In  ordinary  favorable  cases  there  is  decided  improvement 
toward  the  end  of  the  first  week,  and  convalescence  is  established  in  two 
weeks.  It  may  become  chronic  and  last  for  weeks,  and,  as  already  stated, 
may  be  fatal  in  a  few  hours.     Relapses  are  common  in  some  epidemics. 

The  most  frequent  complications  are  on  the  part  of  the  lungs  and 
heart,  particularly  pneumonia  and  endocarditis  or  pericarditis.  Pneu- 
monia often  occurs  so  early  that  it  is  difficult  to  decide  whether  it  is 
primary  with  marked  nervous  symptoms,  or  is  only  a  complication  of 
the  cerebro-spinal  fever.     Nephritis  also  occurs. 

The  most  frequent  sequels  are  deafness,  blindness,  headache,  and  local 
palsies. 

Diagnosis.  The  diagnosis  in  the  presence  of  an  epidemic  is  not  diffi- 
cult, although  an  absolute  diagnosis  can  only  be  made  by  lumbar  jmnc- 
ture.  The  fluid  withdrawn  is  more  or  less  cloudy  if  the  patient  has 
meningitis.  If  it  is  the  epidemic  form,  microscopical  examination  of 
stained  cover-slips  and  cultures  will  expose  the  diplococcus.  In  some 
cases  fluid  cannot  be  secured,  either  because  the  spinal  canal  is  filled 
with  membrane  or  the  fluid  is  retained  in  the  lateral  ventricles. 


THE  DATA   OBTAINED  BY  OBSERVATION. 


329 


The  fluid  is  turbid  in  the  early  part  of  the  disease.  In  some  cases 
a  purulent  sediment  forms  in  the  bottom  of  the  test-tube  at  once.  In 
others,  the  fluid  is  simply  turbid,  and  after  standing  contains  consider- 
able fibrin  and  many  cells.  The  fluid  secured  at  the  first  puncture  may 
be  more  turbid  than  that  secured  later,  although  the  symptoms  may  be 
more  severe  than  at  first.  If  the  acute  symptoms  subside  the  fluid  may 
be  clear,  and  no  cells  may  be  found.  In  the  intermittent  cases  the 
fluid  may  be  clear  during  the  interval  that  the  patient  is  without 
symptoms.     In  chronic  cases  there  may  be  no  turbidity. 

The  cells  in  the  spinal  fluid  are  chiefly  polymorphonuclear  leuco- 
cytes— "  pus  corpuscles."  Small  lymphoid  cells  and  large  endothelial 
cells  may  be  present.  The  latter  are  phagocytic,  and  have  large  oval 
or  round  nuclei.  They  may  contain  leucocytes  and  blood-corpuscles. 
In  the  pus  corpuscles  or  leucocytes  the  diplococci  are  found  ;  they  are 
rarely  found  outside  of  the  cells.  Late  in  the  disease  the  pus  corpus- 
cles do  not  stain  sharply  and  are  degenerated.  In  chronic  cases  the 
fluid  contains  a  few  pus  corpuscles  which  are  smaller  than  usual,  and 
like  lymphoid  cells. 

Bacteriological  Diagnosis.  This  disease  is  due  to  the  diplococcus 
intracellular  is.  This  micrococcus  appears  in  diplococcus  form  as  two 
hemispheres  the  size  of  the  ordinary  micrococcus.  It  stains  with  the 
ordinary  stains  for  bacteria.  It  is  decolorized  by  the  Gram  method. 
The  staining  is  sometimes  irregular,  some  being  brightly  stained,  others 
faintly.  There  is  some  variation  in  the  size  of  the  organisms.  Both 
variation  in  size  and  staining  are  apparently  due  to  degeneration.  The 
two  organisms  are  sharply  separated  usually,  though  sometimes  they 
seem  to  be  united.     (Figs.  81  and  82.) 


Fig.  SI. 


Fig.  82. 


Fig.  si.  Pus  cells  containing  diplococci  from  the  meninges.  A  few  diplococci  are  in  the  exudate 
outside  of  the  pus  cells.  Between  the  pus  cells  there  are  delicate  (ibrillae  of  fibrin.  The  drawing 
is  an  accurate  representation  of  a  group  of  cells  in  the  field  of  the  microscope.    (Councilman.) 

Fig.  82.  Pus  cells  from  an  alveolus  of  the  lung  in  a  case  of  diplococcus  pneumonia.  The  cells 
are  swollen  and  contain  immense  numbers  of  diplococci.    Both  figures  from  stained  cover-slips. 


The  organisms  do  not  grow  profusely.  The  blood-serum  mixture 
of  Loftier  as  prepared  by  Mallory  is  the  best  medium.  It  is  often 
difficult  to  make  cultures  unless  a  large  quantity  of  material  is  used. 


330  GENERAL  DIAGNOSIS. 

Transfers  must  be  made  daily  to  keep  cultures  going.  The  growth 
on  the  serum  mixture  forms  round,  white,  shiny  viscid-like  colonies 
with  smooth  outlines.  They  do  not  liquefy  the  blood-serum.  In 
the  tissues  the  diplococcus  is  found  in  the  interior  of  the  polynuclear 
leucocytes. 

Cultures.  Cultures  should  be  made  at  the  time  of  puncture.  In  the 
majority  of  cases  a  growth  of  the  diplococcus  is  found,  although  even 
in  acute  cases  rarely  they  may  not  grow.  In  chronic  cases  a  growth 
is  only  rarely  obtained.     (Plate  VIII.) 

This  form  of  meningitis  must  be  excluded  from  pneumococcus  men- 
ingitis, tuberculous  meningitis,  and  streptococcus  meningitis.  In  the 
pneumococcus  form  the  symptoms  are  comparatively  slight  and  are 
usually  preceded  by  pneumonia.  In  the  streptococcus  form  the  clini- 
cal history  is  like  that  of  ordinary  forms  of  meningitis.  The  evidence 
of  an  infection  elsewhere  is  usually  present.  Tuberculous  meningitis  is 
,  recognized  by  the  methods  employed  to  detect  tuberculosis  elsewhere 
in  a  patient  suffering  from  the  usual  symptoms  of  cerebro-spinal  men- 
ingitis. The  most  positive  method  of  distinction  of  the  various  forms 
is  by  lumbar  puncture.     (See  Chapter  XXI.) 

Keknig-'s  Sign  (Kernig,  1884;  Netter,  1898).  This  sign  is  of 
value  in  the  diagnosis  of  meningitis,  but  is  present  in  any  form.  It  is 
determined  by  placing  the  patient  in  the  dorsal  decubitus,  with  the  legs 
relaxed  and  fully  extended  at  the  knees.  When  the  child  is  raised  in 
a  sitting  posture  the  knees  are  flexed,  and  cannot  be  extended  on 
account  of  contracture  of  the  posterior  muscles  of  the  thigh.  In  adults, 
if  the  patient  is  propped  up,  or  seated  on  the  side  of  the  bed,  and  an 
attempt  made  to  extend  the  leg  on  the  thigh,  there  is  contraction  of  the 
flexures.  The  test  can  be  equally  well  performed  by  flexing  the  thigh 
on  the  abdomen  until  it  makes  a  right  angle.  When  an  attempt  is 
made  to  extend  the  leg  it  will  be  found  that  the  limb  cannot  be  fully 
stretched  out  if  meningitis  is  present. 

Diphtheria. 

In  this  infection  the  temperature-range  is  variable.  The  infection 
may  be  intense,  and  yet  the  temperature  remain  subnormal,  especially 
if  the  fever  is  due  to  the  toxin,  and  not,  as  is  frequently  the  case,  to  a 
mixed  infection. 

Diphtheria  is  an  acute,  specific,  infectious,  and  contagious  disease, 
sporadic  and  epidemic,  occurring  especially  in  children  from  one  to  six 
years  of  age,  and  characterized  by  insidious  or  abrupt  onset,  with  mod- 
erate fever,  and  the  development  upon  the  fauces  or  upon  any  abraded 
surface  of  a  grayish-white  false  membrane,  which  has  a  tendency  to 
extend,  especially  to  the  larynx.  The  subsequent  phenomena  are 
those  of  stenosis  of  the  larynx,  or  toxaemia,  with  or  without  superadded 
ursemia  or  marked  cardiac  weakness ;  it  is  further  characterized  by  the 
liability  to  paralysis  as  a  sequel. 

Diphtheria  is  spread  by  inhaling  the  expired  breath  of  a  diphtheritic 
patient,  or  breathing  air  which  has  been  contaminated  by  the  clothing 
of  the  patient  or  the  discharges  from  his  nose  and  throat.     It  may  also 


PLATE    VIII. 


Fig.  1. 


Fig.  2. 


Cerebro-Spinal  Meningitis.     (Councilman.) 


Fig.  i.     Forty-eight-hour  culture  of  diplococcus  intracellular  on  Loeffler's  blood-serum  mixture. 

Fig.  2.     Abundant  growth  in  twenty-four-hour  culture   on   fresh   blood-serum.     The   colonies   are 
minute,  very  numerous,  and  somewhat  resemble  similar  cultures  of  the  pneumococcus. 


THE  DATA  OBTAINED  BY  OBSERVATION. 


331 


be  transmitted  directly,  as  when  a  fragment  of  membrane  is  ejected  by 
coughing  and  infects  the  mouth  or  eye  of  physician  or  attendant. 
Moreover,  it  is  contained  in  the  sewers  of  large  cities  where  the  dis- 
ease is  endemic,  and  it  persists  in  damp  cellars  if  they  have  once  been 
infected.  Hence  sewer-gas  and  cellar-air  may  carry  the  disease. 
There  is  reason  also  for  believing  that  a  similar  disease  affects  birds, 
fowls,  and  cats  at  times,  and  from  them  may  be  transmitted  to  man. 
These  facts  must  be  borne  in  mind  in  making  the  diagnosis. 

The  specific  poison  is  the  Klebs-Loffler  bacillus  and  its  toxin. 

While  children  from  one  to  six  years  of  age  are  especially  liable  to 
it,  no  age  is  exempt — neither  the  newborn  babe  nor  the  very  aged. 

One  attack  does  not  protect  a  person  completely  against  a  subse- 
quent attack. 

The  period  of  incubation  varies  from  a  few  days  to  two  weeks,  or 
perhaps  longer  in  exceptional  cases.  As  a  rule,  it  is  less  than  a  week. 
It  is  shorter  when  the  poison  is  virulent,  and  when  infection  has  been 
upon  abraded  surfaces. 

The  onset  in  mild  cases  is  deceptively  free  from  positive  symptoms. 
The  child  is  languid,  perhaps  slightly  chilly,  and  has  a  little  fever, 
with  thirst,  impaired  appetite,  and  discomfort  in  swallowing.  Unless 
the  nature  of  the  trouble  is  suspected  the  child  is  not  thought  ill  enough 
to  be  kept  in-doors.  The  throat  is  slightly  inflamed,  especially  about 
the  tonsils.  The  child  may  protest  that  there  is  no  pain  on  swallow- 
ing. In  from  twelve  to  twenty-four  hours  from  the  onset,  sometimes 
later,  a  grayish  pellicle  will  be  found  upon  the  tonsils,  and  the  cervical 
glands  will  be  swollen. 

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Diphtheria. 


In  more  severe  cases  the  disease  begins  with  chill  or  chilliness,  fol- 
lowed by  a  rise  in  the  temperature  to  102°  or  104°,  sore-throat,  and 
sometimes  vomiting,   though  this   is   not   so  common  as  in  scarlatina. 


332  GENERAL  DIAGNOSIS. 

Convulsions  and  delirium  may  occur  if  the  fever  be  high  or  the  case 
malignant,  but  they  are  not  common.  Disgust  for  food  makes  it  diffi- 
cult to  nourish  the  patient.  Headache,  thirst,  and  aching  in  the  back 
and  limbs  may  be  complained  of.  Prostration  is  often  very  pronounced 
from  the  first. 

Objective  Symptoms.  The  characteristic  false  membrane  appears 
first  as  a  grayish  pellicle  upon  one  or  both  tonsils,  and  spreads  thence 
to  the  soft  palate  and  pharynx.  The  membrane  soon  becomes  thicker 
and  whitish  in  color  ;  when  f Lilly  developed  it  appears  like  white  or 
grayish-white  parchment,  not  lying  loosely  upon  the  surface,  but  em- 
bedded in  the  mucous  membrane,  the  inflamed  swollen  edges  of  which 
rise  above  the  false  membrane,  surrounding  it  "  as  the  crystal  of  a  watch 
is  surrounded  by  the  rim  "  (J.  Lewis  Smith1).  As  the  membrane  becomes 
older  it  may  be  brownish,  or  even  blackish  in  color,  if  tincture  of  iron 
has  been  given.  If  it  is  forcibly  torn  from  the  underlying  surface  hem- 
orrhage is  excited  and  the  membrane  is  reformed.  As  the  membrane 
loosens  spontaneously  there  is  often  marked  inflammatory  reaction  at 
the  edges  of  the  surrounding  mucous  membrane,  and  in  the  tonsils 
there  may  be  decided  sloughing,  with  a  dark,  gangrenous  appearance. 

The  temperature  usually  falls  on  the  second  or  third  day,  but  this 
does  not  indicate  either  a  favorable  or  an  unfavorable  end.  A  temper- 
ature but  little  above  normal  is  not  uncommon  in  profound  toxaemia. 

Albumin  is  usually  present  early,  and  often  tube-casts  and  renal  epi- 
thelium also  can  be  found.  The  submaxillary  and  cervical  glands  are 
swollen,  and  it  may  be  difficult  to  open  the  mouth  sufficiently  to  inspect 
the  throat. 

As  pointed  out  by  Buzzard  and  McDonnell,  the  patellar  tendon 
reflexes  are  often  abolished  as  early  as  the  first  day. 

In  favorable  cases  the  membrane  ceases  to  extend  after  three  or  four 
days  ;  there  is  no  extension  to  the  larynx  ;  the  urine  is  free  from  albu- 
min, or  only  slightly  albuminous  ;  and  the  pulse  is  not  more  than  100 
to.  120  and  of  good  force. 

In  unfavorable  cases  the  membrane  shows  a  tendency  to  extend, 
either  upward  into  the  nasal  fossa?,  producing  a  thin,  irritating,  excori- 
ating discharge  from  the  nostrils,  and  rendering  mouth-breathing  neces- 
sary ;  or  it  may  extend  also  to  the  ears  through  the  Eustachian  tube, 
or  into  the  maxillary  sinus  ;  or  the  extension  may  be  downward  into 
the  larynx,  producing  laryngeal  stenosis.  This  is  announced  by  hoarse- 
ness, with  rapidly  increasing  difficulty  in  breathing.  Inspiration  is 
high-pitched,  noisy,  and  difficult  ;  the  patient  brings  all  the  accessory 
muscles  of  respiration  into  play,  the  alas  of  the  nose  play,  the  ribs  are 
sucked  in,  and  still  he  pants  for  breath.  Every  now  and  then  a  parox- 
ysm of  coughing  produces  cyanosis. 

In  other  unfavorable  cases  the  throat-symptoms  are  not  dangerous, 
but  uraemia  develops.  The  urine  is  scanty,  contains  a  large  amount 
of  albumin,  considerable  blood,  and  numerous  blood,  epithelial,  and 
granular  casts.  There  are  oedema  of  the  feet  and  puffiness  of  the  eye- 
lids.    There  is  apt  to  be  repeated  vomiting  ;  convulsions,  followed  by 

1  Keating's  Cyclopaedia  of  Diseases  of  Children,  1889,  vol.  i.  606. 


THE  DATA  OBTAINED  BY  OBSERVATION.  333 

coma,  and  death  may  end  the  scene,  or  the  patient  may  slowly  emerge 
from  the  dark  valley. 

In  still  other  cases  the  diphtheritic  poison  affects  the  heart.  The 
pulse  becomes  feeble  and  very  frequent,  the  first  sound  very  faint ; 
acute  dilatation  of  the  right  heart  may  occur.  There  may  be  faintness 
and  a  tendency  to  cyanosis  on  the  slightest  provocation,  or  attacks  of 
sinking  and  faintness  may  come  without  warning  ;  in  still  other  cases 
sudden  exertion  induces  paralysis  of  the  heart,  and  death. 

In  some  malignant  cases  the  patient  is  overwhelmed  by  a  large  dose 
of  the  poison,  and  dies  in  from  one  to  three  days  in  collapse  from  acute 
toxaemia,  without  any  special  local  symptoms  to  account  for  it.  In 
others  the  false  membrane  extends  rapidly  over  the  fauces,  pharynx, 
and  nasal  cavities  to  the  larynx  ;  death  occurs  from  early  obstruction, 
or,  if  it  is  postponed,  there  is  extensive  sloughing,  with  death  from  sec- 
ondary blood-poisoning  or  septic  pneumonia. 

In  exceptional  cases  the  membrane  is  primary  in  the  nares  or  larynx, 
or  develops  upon  some  abraded  surface,  as  a  burn,  or  in  the  vagina  of 
a  puerperal  woman.  It  may  also  attack  the  mucous  membrane  of  the 
eye  or  the  seat  of  a  recent  operation.  Diphtheria  also  occurs  as  a  com- 
plication of  other  diseases,  particularly  scarlet  fever. 

The  most  frequent  sequelae  are  anaemia,  albuminuria,  and  paralysis. 
The  latter  comes  on  in  from  one  to  two  weeks  after  convalescence  has 
set  in,  but  it  may  appear  much  earlier,  and  in  exceptional  cases  later. 
It  may  be  marked  simply  by  loss  of  the  knee-jerk,  which  has  been 
alluded  to  already  in  the  symptomatology,  or  involve  the  palatal  and 
pharyngeal  muscles,  causing  nasal  voice,  difficulty  in  swallowing,  and 
regurgitation  of  food  through  the  nose,  or  there  may  be  multiple 
peripheral  neuritis. 

Lomer's  or  the  Klebs-Loffler  Bacillus.  This  is  found  in  diph- 
theritic pseudomembranes,  especially  in  the  deeper  portions.  It  is  not 
found  in  the  blood. 

Morphology.  A  bacillus  2  to  3//  long  by  0.5  to  0.8//  broad, 
straight  or  slightly  curved,  with  very  many  irregular  forms.  (See  Fig. 
84.) 

The  tpseudo-diphtheritic  bacillus  resembles  the  genuine  in  all  respects, 
except  that  it  is  not  pathogenic.  It  seems  to  be  an  attenuated  form  of 
the  former. 

Biological  Properties.  It  is  facultative  anaerobic,  non-motile, 
and  does  not  liquefy  gelatin.  It  multiplies  by  fission.  Stains  with 
Lomer's  blue.  Certain  points  are  stained  intensely,  almost  black.  It 
grows  in  nutrient  gelatin,  nutrient  agar,  or  bouillon,  but  best  of  all  in 
Lomer's  blood-serum  mixture  (see  page  243)  at  35°.  (Death-point, 
58°,  ten  minutes'  exposure.)  It  forms  large,  round,  elevated  colonics, 
grayish-white  in  color  and  moist.  There  is  no  visible  growth  on 
potato.     Milk  is  a  good  soil.     (See  Plate  VII.,  Fig.  4.) 

On  inoculation  it  causes  a  diphtheritic  pseudomembranous  inflam- 
mation.    It  generates  a  very  poisonous  toxin. 

Diagnosis.  Diphtheria  is  distinguished  from  ordinary  pharyngitis 
by  the  presence  of  membrane.  From  follicndar  tonsillitis  by  the  pro- 
jecting mouths  of  the  follicles  containing  a  creamy-white  exudate.    Later 


334 


GENERAL  DIAGNOSIS. 


the  exudate  may  cover  the  entire  surface  of  each  tonsil  and  be  difficult 
to  distinguish  from  false  membrane.  The  points  of  distinction  are 
that  in  the  former  the  exudate  lies  upon  the  surface  and  can  be  brushed 


Fig.  84. 


6.  Colonies  of  pseudo-diphtheria  bacilli,  X  160.      c.  Colonies  of  diphtheria  bacilli,  x  249. 


L 

fi 


2*^ 


d.  Diphtheria  bacilli,  x  1000. 


off  without  force  and  without  leaving  a  bleeding  surface  ;  whereas  in 
diphtheria  the  membrane  is  embedded  in  the  mucous  membrane  and 
cannot  be  torn  from  it  without  force.  A  raised,  red  inflammatory 
border  of  mucous  membrane  at  the  junction  of  the  patch  is  strongly 
suggestive  of  diphtheria.  In  tonsillitis  there  is  no  appearance  of  mem- 
brane upon  the  soft  palate  or  pharynx.  Furthermore,  in  tonsillitis  the 
onset  is  attended  with  more  fever  and  pain  in  swallowing  than  is  true 
in  simple  tonsillar  diphtheria.  The  existence  of  albuminuria  and  swell- 
ing of  the  cervical  glands  indicates  diphtheria,  and  the  absence  of  knee- 
jerk  is  an  important  but  not  constant  diagnostic  sign  of  diphtheria. 
The  presence  of  the  Klebs-Loffler  bacilli  in  a  culture  from  a  suspected 
throat  is  proof  of  the  existence  of  diphtheria. 

Septico-pyaemia. 

The  clinical  course  of  this  infection  and  the  bacterial  causes  have 
been  considered  in  Chapter  XVI.  (Class  III.  of  infections).  It  will 
be  recalled  that  the  phenomena  may  attend  a  number  of  the  infections 
described  in  this  and  in  previous  chapters.     When  occurring  in  the 


THE  DATA  OBTAINED  BY  OBSERVATION.  335 

course  of  pneumonia,  diphtheria,  typhoid  fever,  etc.,  its  causal  origin  is 
recognized  by  the  methods  discussed  in  the  chapter  referring  to  these 
infections.  Septico-pysemia  caused  by  pyogenic  organisms,  the  so-called 
"  cryptogenetic  sepsis,"  is  recognized  by  bacteriological  examination  of 
the  blood  ;  by  an  examination  of  the  morbid  secretions,  or  by  an  exam- 
ination of  the  products  of  inflammation.  Bacteriological  examination 
of  the  blood  has  its  limitations.  Usually  only  late  in  the  course  of  the 
disease  and  in  the  more  intense  infections  can  the  bacteria  be  found. 
Examination  of  the  pus  from  foci  of  suppuration  in  the  bones  (osteo- 
myelitis), in  the  joints  (pyaemia),  in  the  serous  cavities  (empyema, 
pericarditis,  peritonitis),  in  the  lungs  (see  Sputum),  in  the  genito-urinary 
tract  (see  Urine),  will  show  the  infective  micro-organism. 

The  causal  micro-organism  is  detected  by  cover-slip  preparations 
and  cultures.     (See  Chapter  XXI.) 

Glanders. 

A  general  febrile  disturbance  which  attends  this  infection  is  similar 
to  that  of  the  infective  granulomata  (Class  IV.  of  infections).  In  severe 
cases  the  symptoms  are  like  those  of  an  acute  septicaemia.  It  is  an 
infectious,  constitutional  disease,  transmitted  from  horses  to  man, 
appearing  in  an  acute  and  chronic  form,  and  characterized  by  an  erup- 
tion, ozaena,  small  tumors,  ulcerations,  cough,  and  death  in  coma  or 
collapse  in  from  one  to  four  weeks  in  the  acute  form,  or  in  three  or 
four  months  in  the  chronic  form,  the  symptoms  in  the  latter  resembling 
at  times  syphilis  and  at  times  tuberculosis. 

The  disease  is  rare  in  man.  It  may  be  acquired  by  direct  inocula- 
tion of  an  open  wound  with  the  pus  from  a  glanderous  ulcer  or  nasal 
mucous  membrane,  or  indirectly  from  infected  straw  or  other  material. 
The  raw  meat  of  a  glaudered  animal  also  has  infective  power. 

In  acute  glanders  the  onset  is  marked  by  headache,  slight  fever,  and 
pains  in  the  limbs.  If  a  wound  has  been  infected  this  becomes  pain- 
ful, swollen,  and  behaves  like  any  poisoned  wound.  Sometimes  a 
diffuse  redness,  resembling  erysipelas,  spreads  from  the  infected  point. 
Fagge  refers  to  a  case  in  which  the  first  complaint  was  of  pain  in  the 
side  and  dyspnoea,  so  that  acute  pleuropneumonia  was  suspected. 

An  eruption,  consisting  first  of  papules,  which  rapidly  become  flat 
vesicles  and  then  pustules  or  bulla?,  appears  in  the  first  day  or  two,  or 
sometimes  not  for  a  week  or  even  longer  (Fagge).  The  bulla?  or  pus- 
tules rupture  and  give  vent  to  a  thin  purulent  discharge. 

There  may  be  hard,  painful  lumps  in  the  muscles,  with  subsequent 
suppuration  (farcy). 

Ozsena  is  not  always  present.  It  appears  in  the  second  or  third 
week  of  the  disease.  It  consists  of  a  mucopurulent,  then  purulent, 
fetid  discharge  from  the  nose.  The  latter  subsequently  swells  and 
becomes  red  and  very  painful.  Ulcers  and  even  necrosis  of  the  sep- 
tum are  the  lesions;  the  same  catarrhal  condition  may  exist  in  the 
throat,  eye,  larynx,  and  month,  accompanied  at  times  by  ulcers  and 
false  membrane.  The  patient  gradually  sink-  into  a  septicemic  condi- 
tion, with  irregular  fever,  dry  brown  tongue,  albuminuria,  delirium, 
coma,  and  collapse. 


336  GENERAL  DIAGNOSIS. 

The  duration  of  the  acute  form  is  from  one  to  four  weeks.  Only 
one  in  thirty-eight  cases  collected  by  Bollinger  ended  in  recovery. 

In  the  chronic  form  there  are  ulcers  upon  the  hand,  face,  forehead, 
or  elsewhere.  In  other  cases  the  lesions  are  abscesses  in  connection 
with  joints  which  are  followed  by  persistent  fistulse.  In  still  other 
cases  there  is  pustular  eruption.  Ozsena  may  or  may  not  exist.  In 
still  other  cases  the  prominent  symptoms  are  cough,  bloody  expectora- 
tion, hoarseness,  fever,  and  emaciation.  Bollinger  reports  seventeen 
recoveries  in  a  total  of  thirty-four  cases  of  chronic  glanders. 

Diagnosis.  Acute  glanders  is  distinguished  from  rheumatism  by 
the  history  of  the  case,  the  occupation  of  the  patient,  the  existence  of 
an  open,  irritable  sore,  and  the  fact  that  while  the  joints  may  be 
painful,  they  are  rarely  red  and  swollen,  as  in  rheumatism.  Subse- 
quently the  appearance  of  pustules,  bulla?,  and  ozsena  makes  the  case 
clear. 

The  same  peculiar  features  serve  to  distinguish  it  from  pyaemia, 
malignant  pustule,  and  other  infectious  diseases. 

In  a  suspected  case  of  chronic  glanders  a  correct  diagnosis  might  be 
arrived  at  by  inoculating  a  mule  or  a  horse  with  the  nasal  mucus  or 
pus  from  a  farcy. 

Bacteriological  Diagnosis.  The  specific  germ  is  the  bacillus 
mallei.  This  is  a  short,  non-motile  micro-organism  resembling  the 
tubercle  bacillus.  It  is  2  to  3//  long,  and  0.3  to  0.4//  broad,  frequently 
having  spores  on  the  ends.  It  stains  readily  with  all  the  basic  aniline 
dyes,  although  taking  up  the  dyes  irregularly. 

The  diagnosis  is  readily  made  by  the  method  of  Strauss.  A  portion 
of  the  suspected  tissue  or  a  culture  from  the  lesions  is  inoculated  into 
the  peritoneal  cavity  of  a  male  guinea-pig.  If  the  case  is  one  of  glan- 
ders the  testicles  begin  to  swell  in  about  thirty  hours,  and  an  orchitis 
with  abscess  develops.  The  diagnostic  sign  is  the  tumefaction  of  the 
testicles. 

The  Mallein  Test.  Mallein  is  the  filtered  products  of  the  growth  of 
the  bacillus  on  fluid  media.  It  is  allied  to  tuberculin.  The  injection 
of  it  in  a  suspected  case  produces  a  reaction  similar  in  its  course  to 
the  tuberculin  reaction  if  the  case  is  one  of  glanders. 

Cholera. 

An  acute,  specific,  infectious  disease,  endemic  in  parts  of  India,  but 
occurring  in  epidemics  elsewhere,  characterized  by  the  outpouring  into 
the  stomach  and  bowels  of  large  quantities  of  a  serous  fluid  resembling 
rice-water,  which  fluid  is  usually  vomited  and  discharged  from  the  in- 
testines. It  is  further  characterized  by  an  algid  state  of  collapse  and 
by  painful  muscular  cramps. 

The  specific  poison  of  cholera  is  believed  to  be  the  comma-bacillus 
of  Koch  and  its  ptomaine. 

The  native  habitat  of  cholera  is  India,  particularly  the  neighborhood 
of  Calcutta  ;  here  it  is  endemic,  and  thence  it  is  liable  to  spread  in  suc- 
cessive epidemic  waves  along  the  lines  of  travel  by  sea  and  land,  over 
the  whole  world.     It  is  scarcely,  if  at  all,  contagious  ;  the  poison  is 


THE  DATA  OBTAINED  BY  OBSERVATION.  337 

contained  in  the  vomit  and  dejections,  which  contaminate  the  drinking- 
water,  food,  and  clothing.  The  cholera-bacillns  preserves  its  vitality 
for  long  periods  of  time  in  water,  especially  if  the  water  is  slightly 
alkaline  and  contains  vegetable  matter,  and  in  moist  clothing,  as  rags. 

The  period  of  incubation  is  probably  short  in  the  majority  of  cases, 
lasting  only  a  few  days.  Occasionally  it  is  two  weeks.  There  are 
usually  no  definite  symptoms  during  this  time,  but;  there  may  be  a 
sense  of  weakness,  with  loss  of  appetite  and  dyspeptic  symptoms. 

First  Stage.  The  first  stage,  that  of  premonitory  diarrhoea,  is 
better  regarded  as  the  beginning  of  true  cholera.  It  is  characterized 
by  profuse  watery  stools  of  a  yellow  or  light-yellow  color,  and  alkaline 
in  reaction.  They  are  accompanied  by  a  rumbling  noise  in  the  bowels, 
but  are  passed  without  pain.  From  six  to  a  dozen  of  these  passages 
occur  in  twenty-four  hours.  The  patient  feels  faint  and  exhausted 
after  them,  and  may  suffer  with  nausea,  but  vomiting  is  not  usual. 
In  severe  cases  there  may  be  cramps  in  the  calves  of  the  legs.  The 
voice  is  faint  and  husky,  thirst  intense,  the  tongue  white  and  moist. 
The  temperature  is  normal  or  slightly  depressed. 

This  stage  may  last  from  two  days  to  a  week,  depending  upon  treat- 
ment. In  some  cases  it  is  wholly  absent,  and  the  patient  is  ushered 
abruptly  into  the  second  stage. 

Second  Stage.  This  usually  comes  on  during  the  night.  The 
patient  is  seized  with  vomiting,  which  is  at  first  bilious,  but  the  fluids 
rapidly  lose  all  color  and  become  like  rice-water.  The  stools  likewise 
resemble  water  in  which  meal  has  been  stirred,  or  in  which  rice  has 
been  soaked — a  semi-transparent  fluid,  with  particles  of  epithelium 
resembling  rice  floating  in  it.  This  fluid  seems  to  well  up  and  re- 
gurgitate rather  than  to  be  vomited  from  the  stomach,  and  to  gush  in 
quantities  of  a  quart  or  two  from  the  anus.  Sometimes  vomiting  and 
diarrhoea  occur  at  once.  The  patient  has  unquenchable  thirst,  and  is 
tortured  with  painful  cramps  of  the  toes,  legs,  belly,  and  diaphragm.  As 
the  discharges  continue  the  patient  becomes  more  and  more  exhausted  ; 
the  nose  is  pinched  and  twisted,  the  eyes  sunken,  the  lips  bluish,  and 
the  whole  body  may  shrink  beyond  recognizable  proportions. 

The  skin  is  cold  and  moist,  the  breath  icy,  and  the  temperature 
under  the  tongue  is  sometimes  as  low  as  78°  to  80°  F.  In  the  vagina 
and  rectum  it  may  be  normal  or  slightly  above  normal.  The  patient, 
however,  often  has  a  sensation  of  heat.  The  urine  is  very  scanty,  con- 
taining albumin  and  sugar,  or  it  may  be  suppressed.  The  pulse  is 
very  small  and  feeble,  100  to  120.  The  mind  is  clear,  but  the  patient 
is  listless,  answering  questions  in  an  extremely  faint  voice  and  with 
manifest  effort. 

Third  Stage.  From  this  collapsed  and  algid  condition  the  patient 
may  slowly  emerge,  the  skin  becoming  less  cold,  the  cramps  less  severe. 

A  return  of  the  secretion  of  urine  is  a  hopeful  sign.  The  reaction, 
however,  may  simply  introduce  a  low  typhoid  condition,  with  fever, 
dry  brown  tongue,  subsultus,  low  muttering  delirium,  and  coma. 

In  some  cases  serum  is  poured  out  into  the  stomach  and  intestines 
and  is  retained  there.  The  patient  may  be  seized  while  walking  with 
dizziness,  faintness,  extreme  prostration,  and  early  collapse. 

22 


338  GENERAL  DIAGNOSIS. 

In  other  cases  the  patient  is  smitten  down  with  profuse  vomiting 
and  purging,  dying  algid  and  collapsed  in  a  few  hours,  no  reaction 
appearing. 

In  favorable  cases  the  vomiting  ceases,  the  stools  become  less  fre- 
quent, and  are  tinged  with  bile  and  have  a  fsecal  odor.  The  urine 
increases  in  volume,  while  the  albumin  diminishes.  Convalescence  is 
very  protracted.  Ansemia,  great  debility,  feeble  digestion,  and  some- 
times obstinate  diarrhoea  delay  complete  recovery.  Relapses  are  fre- 
quent. 

In  other  cases  reaction  brings  improvement  in  the  gastro-intestinal 
symptoms,  but  uraemia  develops,  death  following  in  convulsions  or 
coma. 

The  most  frequent  complications  and  sequelae  are  eruptions,  chiefly 
erythematous,  ulcerations  and  bed-sores,  parotitis,  and  a  painful  tetanic 
spasm  of  the  flexor  muscles  of  the  hands,  forearms,  legs,  and  feet,  occur- 
ring between  the  tenth  and  fifteenth  days  of  convalescence  (Stille). 

Diagnosis.  The  chief  points  in  the  diagnosis  from  other  affections 
are  the  knowledge  of  exposure  to  cholera  ;  the  character  of  the  vomit 
and  dejecta,  which  contain  the  comma-bacillus  (for  its  detection  see 
under  Bacteriology) ;  the  cyanosis  ;  the  rapid  development  of  collapse, 
with  cold  skin,  icy  breath,  torturing  cramps,  and  greatly  shrunken 
visage  and  body. 

Cholera  morbus  differs  in  that  the  stools  remain  turbid  with  bile  or 
f secal  matter,  or  contain  blood  ;  they  never  present  the  rice-water 
appearance.  Moreover,  the  passages  are  frequently  preceded  by  col- 
icky pains.  Cyanosis  and  collapse  are  extremely  rare.  The  stools 
do  not  contain  the  cholera-bacillus. 

Other  forms  of  acute  toxic  gastro-enteritis,  whether  from  ptomaine- 
poisoning  or  from  corrosive  poison,  are  to  be  distinguished  by  the 
history,  the  difference  in  the  character  of  the  stools,  and  the  compara- 
tive absence  of  painful  cramps  in  the  legs,  of  cyanosis,  and  of  collapse. 

Bacteriological  Diagnosis.  Koch  remarks  i1  "As  cholera  resem- 
bles in  clinical  symptoms  cholera  nostras,  infantile  cholera,  certain 
forms  of  peritonitis,  certain  organic  poisons,  and  poisoning  by  arsenic, 
it  is  important  to  attain  some  means  of  making  a  definite  diagnosis." 

Spirillum  Cholera  Asiatics.  The  Comma-bacillus.  The 
comma-bacillus  of  Koch  is  the  specific  causative  agent  of  cholera.  In 
a  disease  so  wide-spread  in  times  of  epidemics,  and  so  fatal,  it  is  of 
great  importance  to  be  able  to  recognize  the  bacterium  that  produces 
it.  Works  on  bacteriology  give  a  fuller  study  than  is  permitted  here, 
and  should  be  consulted.  This  is  more  especially  true  because,  while 
the  bacilli,  as  found  in  the  stools,  can  be  stained  quite  easily,  and  may 
be  recognized  by  expert  microscopists,  in  the  great  majority  of  cases 
their  recognition  is  only  effected  by  bacteriological  examination.  They 
have  no  specific  relation  to  dyes,  as  have  tubercle  bacilli. 

Microscopical  Examination.  The  cholera  bacillus  is  a  short, 
more  or  less  bent  rod,  both  shorter  and  thicker  than  the  tubercle 
bacillus,  and  generally  shaped  like  a  comma.     They  are  often  found 

1  Zeitschrift  fur  Hygiene  und  Infektionskranheiten,  1893,  vol.  xiv.,  No.  2. 


THE  DATA  OBTAINED  BY  OBSERVATION.  339 

placed  end  to  end,  and  thus  form  a  curve  like  a  spiral.  They  are 
always  present  in  the  stools  of  cholera  patients  and  sometimes  in  the 
vomit.  They  are  particularly  abundant  in  the  mucous  floccules  of  the 
rice-water  discharges,  and  can  be  obtained  from  the  linen  soiled  by 
the  same.  Cover-slip  preparations  are  made  from  these  portions  by 
placing  a  uniform  film  on  the  slip,  drying  it  in  the  air,  and  then  pass- 
ing it  through  the  flame  of  a  Bunsen  burner  or  spirit-lamp. 

The  spirillum,  or  so-called  "  comma-bacillus,"  consists  of  a  slightly 
curved  rod,  with  rounded  ends,  0.8  to  2//  long  by  0.3  to  0.4//  broad. 
It   is    usually  slightly  curved  like  a 
comma,  but  may  form  a  half -circle,  or  FlG- 85- 

two  may  be  joined  like  an  S.     Under  /  i 

certain   circumstances  they  grow  out  !  <  I 

into  long  spiral  threads.  By  Lo  filer's  ,i  \!i)~i'  §  ,j£'\i 
method  a  single  flagellum  is  found  on 
the  rods.  It  stains  with  anilines,  but 
slowly.  An  aqueous  solution  of  f  uch- 
sin  (Zeihl's  red)  is  the  best.  (See 
Plate  III.,  Fig.  3,  a  ;  and  Fig.  85). 
In  addition  to  the  cholera-bacilli,  the 
bacillus  coli  communis  and  other  in- 
testinal bacteria  are  found.  The 
cholera-bacilli  lie  in  groups  in  the 
thread-like  strands  of  mucus.  They 
form  in  heaps,  the  bacilli  lying  in  the 
same  direction.  Koch  holds  that  this 
mode  of  grouping  is  characteristic 
and   diagnostic.      He   further    holds     cholera  spirilla  srown  on  moist  linen- 

,i      .    •«   i        .-it        t  •         i  X  600.    (After  Koch.)     Cultivated  from  the 

that  if  bacilli  coli  are  m  close  prox-  auctions  after  two  days. 

imity  to  numerous  scattered  bacteria 

resembling  the  cholera  bacilli  the  case  is  one  of  Asiatic  cholera. 

The  bacillus  of  cholera  nostras  and  one  found  in  cheese  by  Deneke 
resemble  the  comma-bacillus  in  shape,  though  somewhat  larger,  but 
they  have  bacteriological  peculiarities  by  which  they  can  be  differ- 
entiated. 

Biological  Properties.     Aerobic  (fac.  anaerobic),  motile,  liquefying. 

Cultures.  Growth.  Grows  in  ordinary  media  at  room  tempera- 
ture; faster  in  oven.  Does  not  grow  except  between  14°  to  42°  C. 
Gelatin  plates :  At  the  end  of  twenty-four  hours  small  white  colonies 
appear  deep  in  the  gelatin.  These  grow  toward  the  surface  and  liquefy 
the  gelatin  in  a  funnel-form,  which  gradually  deepens,  and  at  the 
bottom  of  the  colony  is  seen  as  a  small  white  mass.  Under  Low  power 
the  colony  is  white  or  pale  yellow,  margins  uneven,  texture  granular, 
surface  looks  as  if  covered  with  bits  of  glass.  When  liquefaction 
begins  a  dim  halo  forms  about  the  colony,  which  by  transmitted  light 
is  roseate  in  hue. 

Stab-culture  in  Nutrient  Gelatin.  Develops  all  along  the  puncture, 
liquefaction  beginning  near  the  surface,  forming  a  funnel  which  en- 
larges, and  finally  the  gelatin  almost  entirely  liquefies.  (See  Fig.  XT.) 
On  potato  a  thin,  transparent  grayish-brown    layer.     Milk,  bouillon, 


340 


GENERAL  DIAGNOSIS. 


blood-serum,  are  all  favorable.  In  media  with  other  bacteria  it  soon 
dies.  Death-point,  52°  5'.  In  moisture  it  retains  vitality  for  months, 
but  is  killed  by  drying. 


Fig.  87. 


Cholera  spirilla.    Tube-cultivations. 

(Flugge.) 
a,  after  two  days ;  b,  after  tour  days. 


Finkler  and  Prior's  comma-bacillus. 

Cultivation  in  gelatin. 

c,  two  days  ;  d,  four  days  old. 


Peptone-cultivation.  A  small  quantity  of  the  dejection  of  some 
flake  of  mucus  is  inserted  with  a  platinum  loop  into  a  sterilized  1  per 
cent,  peptone  solution.  The  solution  is  maintained  at  37°  C.  The 
cholera  bacteria  are  aerobic,  and  develop  on  the  surface  of  the  peptone, 
while  the  fsecal  bacteria  remain  in  the  deeper  layers.  As  soon  as  the 
peptone  is  cloudy  a  drop  from  the  surface  is  examined  microscopically. 
Within  six  hours  the  surface  is  overwhelmed  with  a  pure  culture  of 
cholera  bacilli.  Later  they  are  mixed  with  bacteria  coli.  The  exami- 
nation should  be  made  from  six  to  twelve  hours  after  the  peptone  solu- 
tion is  inoculated.  The  peptone  solution  should  be  strongly  alkaline, 
and  a  1  per  cent,  solution  of  common  salt  should  be  added.  Care  must 
be  taken  to  see  that  the  solution  contains  sufficient  soda.  In  plate 
cultivations  the  cholera-bacilli  are  overwhelmed  by  the  fecal  bacteria. 

Agar-plate  Cultivation.  The  growth  is  not  so  characteristic  as 
it  is  in  gelatin.  The  cholera-bacilli  form  large  colonies  of  light  gray- 
brown  transparent  appearance.  Colonies  of  other  bacteria  are  less 
transparent.  The  colonies  can  be  obtained  in  from  eight  to  ten  hours 
after  exposure  to  a  temperature  of  37°  C.  Microscopical  examination 
of  the  colonies  must  be  made. 

Cholera-red  Reaction.  Cholera-cultivations  contain  indol  and 
nitrous  acid,  and  produce  a  red  purplish  color  if  sulphuric  acid  is  added. 
This  color  is  produced  by  other  bacteria  also,  but  by  none  other  of  the 
bacteria  that  are  curved.  Care  must  be  taken  to  make  the  cultiva- 
tions with  suitable  peptone  and  to  have  the  sulphuric  acid  free  from 
nitrous  acid. 


THE  DATA  OBTAINED  BY  OBSERVATION.  341 

To  determine  its  presence  in  the  shortest  time,  inoculate  diluted 
bouillon.  After  ten  to  twelve  hours  a  wrinkled  film  has  formed. 
Make  another  culture  in  the  same  way  from  this,  then  inoculate  gel- 
atin plates  and  use  color-test  on  these. 

Inoculation.  The  agar-cultivations  are  employed.  They  must  be 
introduced  into  the  abdominal  cavity  of  the  guinea-pig.  The  injection 
must  not  be  made  into  the  intestine,  a  matter  which  requires  considera- 
ble practice.  No  other  spirillum  or  curved  bacillus  produces  the  symp- 
toms of  cholera. 

Acute  Dysentery. 

The  fever  which  attends  this  infection  is,  from  a  clinical  stand-point' 
the  least  characteristic  symptom.  It  varies  in  part  with  the  age  of  the 
patient.  In  the  aged  it  is  subnormal,  normal,  or  moderate.  In  the 
young  it  is  usually  very  high.  It  differs  with  the  character  of  the 
infection.      If  a  mixed  infection  prevails  the  temperature  is  not  unusual. 

The  term  dysentery  is  applied  to  an  inflammation  of  the  intestinal 
tract,  chiefly  the  colon,  which  is  attended  by  the  symptoms  of  intesti- 
nal catarrh  in  intense  degree,  with  mucus  and  bloody  discharges  and 
the  general  symptoms  of  fever  and  prostration,  followed  by  extreme 
exhaustion,  and  at  times  the  occurrence  of  abscesses  in  the  portal  cir- 
culation, or  of  paralysis,  arthritis,  nephritis,  or  profound  anaemia.  It 
was  formerly  thought  to  be  an  epidemic,  mildly  contagious  disease. 
Although  of  frequent  occurrence  sporadically,  it  is  especially  common 
in  jails  and  institutions,  in  camps,  or  where  people  are  crowded  together, 
when  at  the  same  time  hygienic  conditions  are  most  unfavorable.  It 
usually  occurs  in  the  summer  or  fall,  and  is  attributed  to  the  drinking 
of  impure  water.  A  form  most  common  in  the  tropics  is  called  tropi- 
cal dysentery.  Recent  investigations  have  shown  that  catarrhal  dysen- 
tery due  to  the  above-mentioned  circumstances  may  occur,  and  that 
in  addition  "  tropical "  dysentery,  which  is  not  confined  to  the  tropics, 
is  associated  with  inflammation  and  ulceration  of  the  bowel,  attended 
by  the  amoeba  dysenterise  or  A.  coli. 

Catarrhal  Dysentery  may  be  limited  to  simple  inflammation  of  the 
intestine,  or  may  be  followed  by  ulceration.  Its  first  symptoms  are 
those  of  intestinal  catarrh.  There  is  indigestion,  with  loss  of  appetite, 
perhaps  vomiting,  and  slight  diarrhoea.  These  symptoms  may  be  the 
immediate  effect  of  the  diarrhoea.  At  the  end  of  three  or  four  days  a 
chill  may  take  place,  showing  the  setting  in  of  an  infection.  The  diar- 
rhoea is  attended  by  pain,  at  first  seated  around  the  umbilicus  ;  it  then 
becomes  marked  in  the  course  of  the  colon.  The  movements  are  fre- 
quent, preceded  by  constant  desire,  and  attended  by  extreme  tenesmus. 
The  stools,  which' were  first  faecal  and  fluid,  soon  become  scanty,  and 
consist  almost  entirely  of  mucus  and  blood.  The  symptoms  of  local 
proctitis  are  severe;  there  is  a  sensation  of  a  hot  mass  in  the  rectum. 
There  may  be  strangury,  and  prolapse  of  the  anus  may  ensue. 

With  the  continuance  of  acute  pain  and  Erequeni  evacuations  the 
skin  becomes  hot  and  dry  ;  thirst,  nausea,  and  occasionally  vomit  inn- 
occur.  The  temperature  continues  at  about  103°  ;  the  pulse  is  rapid. 
The  patient  is  weak  and  restless  ;  the  tongue  is  red  and  raw. 


342  GENERAL  DIAGNOSIS. 

If  the  disease  is  severe  from  the  start,  or  the  course  is  unfavorable,  the 
stools  may  contain  pure  blood,  or  they  may  be  dark  in  color,  and  con- 
tain shreds  of  membrane.  Pain  and  tenesmus  disappear,  and  the  evac- 
uations become  constant  or  involuntary.  Restlessness  is  aggravated  ;  the 
extremities  become  cold  ;  mild  delirium  sets  in.  The  tossing  and  rest- 
lessness are  quite  characteristic,  and  are  attended  by  sighing  and  some 
dyspnoea.  The  pulse  is  rapid  and  feeble  ;  the  heart-sounds  are  weak- 
ened ;  the  tongue  becomes  dry  and  brown,  the  mouth  is  parched,  and 
thirst  is  intense  ;  ulcers  develop  in  the  mouth  and  sordes  collect  around 
the  teeth.  The  delirium  increases  to  stupor,  and  from  that  to  coma. 
The  urine,  at  first  high-colored  and  scanty,  becomes  bloody,  and  con- 
tains albumin  and  casts.  Although  the  fever  continues  during  this 
stage,  the  extremities  become  cool,  perspiration  breaks  out  over  the 
forehead,  and,  instead  of  typhoid  symptoms,  the  symptoms  of  collapse 
may  ensue.  If  the  disease  is  prolonged  and  the  bowels  are  controlled, 
the  symptoms  of  pyaemia  may  develop. 

The  anaemia  that  ensues  is  extreme,  and  there  is  great  wasting. 
Convalescence  is  slow  and  may  be  attended  by  chronic  diarrhoea. 
Before  it  is  established  ulcers  of  the  skin  may  form  on  various  parts 
of  the  surface  of  the  body.  Arthritis  is  of  common  occurrence,  and 
paralysis  may  occur  during  convalescence  on  account  of  peripheral 
neuritis.  Chronic  dysentery  may  succeed  the  acute.  It  is  thus  seen 
that  the  attacks  may  be  of  moderate  severity  or  extremely  grave  ; 
during  the  course  of  the  latter  gangrene  of  the  lower  bowel  may  take 
place. 

Amoebic  Dysentery ;  Tropical  Dysentery.  This  differs  from 
catarrhal  forms  of  dysentery  in  many  respects.  The  onset  may  be 
abrupt  or  gradual,  as  in  the  previous  form,  with  symptoms  of  intestinal 
catarrh.  In  most  of  the  cases  a  frequent  and  painless  diarrhoea  follows 
a  period  of  slight  ill  health.  The  diarrhoea  alternates  with  short 
periods  of  constipation ;  the  stools  are  watery  and  contain  mucus,  but 
no  blood.  The  course  of  the  disease  is  irregular.  There  may  be  inter- 
missions and  exacerbations  of  the  diarrhoea  without  obvious  cause.  It 
may  rapidly  pass  from  one  grade  to  another,  or  become  chronic.  One 
form  is  the  gangrenous,  which  may  scarcely  be  appreciated  by  the 
symptoms  until  the  autopsy  shows  it  to  have  been  present.  True 
relapses  are  common,  and  the  tendency  to  chronicity  is  very  great. 
The  milder  cases  are  attended  by  weakness,  emaciation,  and  pallor ; 
the  expression  is  dull ;  the  skin  is  dry  and  sallow  ;  the  tongue  pale, 
flabby,  and  moist,  slightly  furred  ;  the  abdomen  is  normal  or  retracted  ; 
the  temperature  does  not  rise  above  100°,  and  the  pulse  ranges  from 
70  to  90.  Sleep  is  disturbed  by  frequent  evacuations  of  the  bowels. 
In  the  grave  form  the  face  is  drawn,  or  cyanosed  or  flushed,  the  ex- 
pression anxious ;  the  mind  is  clear.  Anorexia,  intense  thirst,  and 
sleeplessness  are  present.  The  abdomen  is  greatly  retracted,  and  there 
may  be  free  sweating.  The  temperature  is  normal  or  subnormal,  the 
pulse  small  and  rapid.  Progressive  anaemia  and  loss  of  flesh  are 
prominent  and  dominate  the  intestinal  symptoms.  The  skin  is  dry 
and  harsh,  and  of  a  dull  greenish-yellow  color  if  the  cases  are  pro- 
tracted. 


THE  BAT  A  OBTAINED  BY  OBSERVATION.  343 

The  special  features  of  amoebic  dysentery  are  :  1.  The  anaemia- 
This  is  due  to  diminution  of  the  red  cells  and  the  haemoglobin,  first, 
because  of  the  action  of  the  anicebae  upon  the  red  blood-corpuscles, 
which  they  destroy  ;  second,  the  direct  loss  of  blood  ;  and,  third,  mal- 
nutrition.    The  first  is  the  most  prominent. 

2.  Diarrhoea  may  be  the  only  feature  of  the  disease.  It  is  charac- 
terized by  great  variation  in  character  and  frequency  in  all  grades  and 
during  different  periods  of  the  disease.  Intermissions  and  exacerba- 
tions may  be  observed  at  any  time.  The  latter  begin  suddenly,  and 
subside  in  the  same  manner.  They  last  from  two  to  ten  days.  The 
intermissions  continue  from  one  day  to  three  weeks,  during  which  the 
faeces  are  soft,  but  contain  mucus.  Councilman  and  Lafleur  have  ob- 
served this  periodicity  to  be  most  marked  in  cases  complicated  with 
hepatic  abscess. 

3.  The  Stools.  The  stools  are  extremely  variable  according  to  the 
severity  of  the  ulceration,  and  also  vary  in  number  and  character  from 
day  to  day  in  individual  cases.  In  the  gangrenous  form  they  number 
thirty  or  forty  in  twenty-four  hours  at  first,  then  decline,  so  that 
toward  the  end  of  fatal  cases  but  three  or  four  take  place.  At  first 
the  movements  are  small,  and  consist  of  mucus  with  more  or  less 
bright  blood  and  small  faecal  masses.  As  ulceration  advances  the  stools 
change,  they  become  more  copious  and  watery,  faeces  are  absent,  blood 
is  not  so  frequent.  Shreddy  masses  of  grayish  or  yellow  color,  mixed 
with  mucus,  appear.  If  there  is  sloughing,  they  become  greenish  or 
grayish,  resembling  spinach,  or  reddish-brown  and  very  liquid  or  pul- 
taceous.  The  odor  is  penetrating  and  offensive.  Shreddy  masses  of 
necrotic  tissue  are  discharged.  Gray  liquid  movements,  somewhat 
slimy,  contain  more  pus  than  the  others.  Small  opaque,  or  translu- 
cent, gelatinous  grayish  masses,  one  to  three  cubic  millimetres  in  diam- 
eter, are  found  in  the  stools. 

In  the  more  moderate  types  the  stools  at  the  outset  are  like  those  of 
gangrenous  dysentery  if  the  attack  is  abrupt.  If  gradual,  the  stools 
are  faecal,  liquid,  containing  mucus  and  streaks  of  blood  and  many  of 
the  gelatinous  grayish  masses.  Stools  of  this  character  number  from 
four  to  ten  in  twenty-four  hours  ;  this  may  continue  for  weeks.  During 
the  exacerbations  the  stools  resemble  those  of  the  second  period  of  the 
gangrenous  form.  In  chronic  dysentery  there  is  not  so  much  mucus 
or  blood,  except  in  exacerbations.  The  stools  are  of  the  consistence  of 
thin  gruel  and  have  an  earthy  or  dull-yellow  color.  Mucus  is  persist- 
ently present,  however,  in  the  intermissions,  when  the  stools  are  soft 
and  faecal. 

The  reaction  of  dysenteric  stools  is  generally  alkaline. 

Microscopical  Examination.  In  the  mucoid  and  bloody  stools 
of  the  acute  stage  red  blood-corpuscles,  leucocytes,  and  large,  round, 
or  oval  epithelioid  cells  are  seen.  The  latter  are  often  in  groups  of 
three  or  more.  The  nucleus  is  about  the  size  of  the  red  blood-corpus- 
cle, the  protoplasm  granular.  Their  outline  is  sharp.  They  may  be 
taken  for  amoebae.  They  are  non-motile  and  refract  light  less  strongly. 
Oercomonas  intestinal)*  is  present,  but  bacteria  are  not  abundant.  In 
the  later  periods  the  cell-elements  are  less   Qumerous  ;   shreddy  and 


344  GENERAL  DIAGNOSIS. 

muscular  detritus  and  bacteria  are  observed,  with  elastic-tissue  fibres. 
Charcot's  crystals  and  phosphates  are  seen.  In  chronic  dysentery  the 
cell-elements  are  still  fewer  and  amoebae  are  easily  detected. 

Amceba  Dysenteeje.  Amoebae  are  found  at  all  periods  of  the  dis- 
ease. They  vary  in  different  cases  and  at  different  periods  in  propor- 
tion to  the  severity  of  the  intestinal  ulceration.  (See  section  on  the 
Faeces.) 

They  are  most  abundant  in  the  grayish-yellow  gelatinous  masses, 
next  in  the  particles  of  clear  or  opaque  mucus,  and  least  in  the  fluid 
portions  of  the  stools.  In  chronic  dysentery  they  are  found  in  all 
portions.  In  the  intermission  of  the  diarrhoea  they  may  be  found  in 
the  particles  of  mucus  adherent  to  the  faeces.  They  disappear  as  recov- 
ery proceeds,  although  they  may  be  seen  after  the  evacuations  become 
normal.  They  vary  in  size  and  activity.  They  are  more  common  in 
the  alkaline  and  neutral  stools.  They  are  scarce  and  are  rarely  motile 
in  acid  stools.  In  the  more  active  forms  of  the  disease  red  corpuscles 
are  seen. 

For  the  detection  of  amoebae  the  following  should  be  observed : 
First,  the  stools  should  be  passed  in  a  warm  bed-pan  and  kept  at  a 
temperature  of  30°  to  35°  C.  until  an  examination  is  made.  Second, 
the  stools  must  be  examined  before  they  become  acid.  Third,  the 
gelatinous  masses  in  the  stools  should  be  selected  for  examination. 
They  contain  amoebae  hi  greatest  abundance.  A  magnifying  power  of 
four  hundred  diameters  is  required,  although  they  may  be  seen  with  less. 
A  y^  oil  immersion  lens  is  the  best. 

Description  of  the  Amoebae.  When  inactive  they  are  round  or 
slightly  oblong,  highly  refractive,  and  contain  vacuoles  of  greater  or 

Fig.  88. 


Amoebae  coli.    (Hallopeau.) 

less  size.  The  latter  are  clear,  and  vary  from  small  pomts  to  one-third 
of  the  diameter  of  the  areola.  The  ectosarc  and  endosarc  may  or 
may  not  be  sharply  divided.  If  they  are,  the  outer  is  hyaline  or 
homogeneous,  the  inner  is  more  refractive  and  contains  vacuoles. 
They  are  difficult  to  recognize  in  this  condition,  being  mistaken  for 
swollen  connective-tissue  cells.     The  amoebae  frequently  enclose   red 


THE  DATA  OBTAINED  BY  OBSERVATION.  345 

corpuscles,  pus-cells,  blood-pigment,  bacilli,  and  micrococci.  In  a 
fresh  state  the  nuclei  cannot  be  made  out  because  they  resemble  vacu- 
oles. The  endosarc  is  not  granular,  is  composed  of  a  dense  substance, 
and  is  highly  refracting.  When  active  the  movement  is  characteristic. 
It  may  be  slow  or  rapid,  and  is  of  two  kinds,  a  progressive  movement 
and  one  lhnited  to  the  throwing  out  of  pseudopodia.  The  movements 
appear  to  be  rhythmical  in  some  cases,  occurring  at  regular  intervals. 
The  movement  is  sudden  and  characterized  by  change  in  form  of  the 
pseudopodia.  The  ectosarc  and  endosarc  are  clearly  defined  usually. 
The  pseudopodia  are  hyaline  and  homogeneous,  like  the  ectosarc. 
The  amoeba  changes  its  position  sometimes  by  enlargement  of  the 
pseudopodia,  into  which  the  inner  contents  of  the  older  part  follow. 
The  movements  are  increased  when  the  examinations  are  made  on  the 
warm  stage.    These  amoeba?  may  be  stained  with  various  aniline  dyes. 

In  catarrhal  dysentery  the  stools  are  uniform  in  character,  quantity, 
and  frequency.  The  onset  is  sudden,  and  evacuations  consist  of  bright 
blood  and  viscid,  clear  mucus  mixed  with  faecal  matter.  Soon  they  are 
composed  entirely  of  mucus  and  a  little  blood.  The  mucus  is  viscid. 
In  a  week  or  ten  days  the  mucus  changes  and  becomes  grayish-white 
in  color — is  less  blood-stained  and  brown  ;  pultaceous  or  fluid  fsecal 
matter  appears  in  the  stools.  As  the  blood  and  mucus  disappear 
formed  faeces  return.  In  the  prolonged  cases  there  are  soft,  yellowish- 
brown,  or  greenish  stools  in  addition  to  the  bloody  mucoid  stools. 
The  frequency  is  greatest  at  the  onset,  and  progressively  diminishes 
until  convalescence  is  established.  The  more  frequent  the  evacuations 
the  smaller  the  size  of  the  stools.  The  mucoid  stools  are  small,  pulta- 
ceous, more  bulky.  On  microscopical  examination  red  and  white  cor- 
puscles, cylindrical,  epithelial,  and  oval  epithelioid  cells  are  seen.  The 
latter  are  very  characteristic,  and  occur  singly  or  in  groups.  Bacteria 
are  more  common  as  improvement  sets  in.  In  the  pultaceous  stools 
the  cell-elements  are  scarce.  In  diphtheritic  dysentery  the  stools  are 
watery.  They  resemble  wheat-washings — evacuations  such  as  are  de- 
scribed in  cases  of  gangrenous  dysentery.  They  are  grayish-green  or 
reddish-brown  and  very  offensive.  Mucus  is  present  in  small  amounts. 
At  first  unclotted  blood  is  present,  afterward  minute  dark-red  clots  are 
seen.  Shreddy  and  finely  divided  material,  gray  or  reddish-brown  in 
color,  is  present,  but  there  are  no  sloughs.  The  stools  are  not  numer- 
ous at  first,  and  average  from  seven  to  fifteen  daily  during  the  course 
of  the  illness.  The  quantity  passed  is  small.  Cylindrical  epithelial 
cells  are  most  abundant  on  microscopical  examination.  Red  blood- 
corpuscles  and  leucocytes  are  observed,  but  fibrin  constitute  the  larger 
portion  of  the  stool.  In  all  the  stools  bacteria  are  present  in  great 
numbers. 

Other  Symptoms  of  Amoebic  Dysentery.  Abdominal  pain  is 
constant ;  it  occurs  in  the  early  stages  of  both  forms  and  in  acute 
exacerbations.  As  the  movements  diminish  the  pain  decreases.  In 
the  gangrenous  form  pain  also  disappears,  although  the  intensity  of 
the  process  is  increasing.  In  chronic  cases  the  colic  is  complained  of 
during  the  exacerbations  ;  during  the  intervals  a  dull,  aching,  or  burn- 
ing pain  is  complaineol  of  in  the  upper  quadrants.      In  all   cases  the 


346  GENERAL  DIAGNOSIS. 

pain  is  cramp-like,  boring  or  burning  in  character,  and  usually  pre- 
cedes and  accompanies  movements  of  the  bowels.  When  severe  it  is 
general ;  but  it  is  usually  localized  in  the  lower  abdominal  zone. 
Moderate  tenderness  on  pressure  is  present  in  most  cases  along  some 
part  of  the  course  of  the  large  bowel.  In  catarrhal  dysentery  tenesmus 
is  common  ;  in  the  amoebic  form  it  is  infrequent.  A  burning  sensa- 
tion in  the  rectum  and  at  the  anus  during  and  after  the  passage  of 
fasces  is  generally  complained  of.  Nausea  and  vomiting  occur  at  the 
outset  or  at  irregular  intervals,  being  caused  by  improper  food,  or  due 
to  complications.     Hiccough  occurs  in  the  terminal  stages. 

Fever.  In  amoebic  dysentery  fever  is  not  a  prominent  feature, 
although  there  is  usually  a  moderate  rise  in  temperature.  In  the 
gangrenous  form  it  is  normal,  or  may  be  subnormal  for  days.  Chronic 
dysentery  is  afebrile.  In  exacerbations  of  diarrhoea  slight  fever  may 
occur.  Complications  cause  a  higher  temperature.  If  fever  is  present 
it  may  be  remittent  or  intermittent  in  character,  or,  if  the  illness  is 
prolonged,  first  continuous,  then  remittent,  and  then  intermittent.  If 
the  latter,  the  usual  morning  fall  is  observed,  although  an  inverse 
temperature  may  be  present.  Rigors  occur  with  the  complications. 
Sweating  is  observed,  with  subnormal  temperature,  in  the  gangrenous 
form.     In  cases  of  abscess  the  fever  is  intermittent  or  remittent. 

In  chronic  dysentery  the  skin  is  excessively  dry.  The  circulation 
and  respiration  are  influenced  by  the  pyrexia.  Anseniia  is  pronounced. 
When  exhaustion  ensues  the  pulse  becomes  more  feeble,  compressible, 
and  rapid.  The  urine  is  albuminous,  and  often  contains  casts.  In  the 
gangrenous  form  there  may  be  retention  of  urine. 

The  complications  of  amoebic  dysentery  are  :  1.  Hepatic  abscess, 
or  hepato-pulmonary  abscess.  2.  Peritonitis.  3.  Hemorrhage  from 
the  bowels. 

Hepatic  Abscess.  This  complication  may  develop  at  any  period 
of  the  disease.  The  time  of  the  disease  when  it  occurs  cannot  be  deter- 
mined definitely.  In  the  subacute  cases  it  is  liable  to  develop  from  the 
fourth  to  the  twelfth  week.  The  abscess  may  develop  on  the  convex 
surface  of  the  right  lobe  of  the  liver  near  the  coronary  ligament.  In 
these  cases  the  lung  also  becomes  involved.  Councilman  and  Lafleur 
suggest  that  infection  takes  place  by  the  peritoneum.  (See  Abscess  of  the 
Liver.)  While  the  symptoms  of  abscess  of  the  liver  will  be  treated 
under  the  section  devoted  to  liver  disease,  it  is  important  to  note  that 
hepatic  symptoms  may  occur  in  cases  in  which,  on  account  of  the  mild- 
ness of  the  disease,  the  local  bowel  trouble  may  be  overlooked  entirely. 
(See  Amoebic  Abscess  of  Liver :  Musser  and  Willard,  Phil.  Co.  Med. 
Soc.)  If  the  association  of  hepatic  pain  with  fever  and  discharge  of 
mucus  from  the  bowels  is  observed,  it  is  barely  possible,  even  if  an 
examination  of  the  faeces  cannot  be  made,  that  a  hepatic  abscess  is 
present.  If,  in  addition,  cough  and  expectoration  occur,  involvement 
of  the  lungs  is  possible. 

Hepato-pulmonary  Abscess.  The  character  of  the  expectoration 
points  conclusively  to  the  nature  of  the  lung  complication.  After  a 
period  of  dry,  hacking  cough,  sudden  expectoration  of  mucopurulent 
or  bloody  sputum  takes  place.     It  is  of  a  dirty-red  or  brownish  color, 


THE  DATA  OBTAINED  BY  OBSERVATION.  347 

not  unlike  anchovy  sauce.  From  this  time  on  this  material  is  expec- 
torated in  varying  quantities  after  a  paroxysm  of  coughing.  The  expec- 
toration is  diffluent,  tenacious,  and  frothy.  It  varies  in  color  from 
bright  red  to  russet-brown  ;  it  may  be  bile-stained.  The  sputa  are 
alkaline  ;  the  odor  is  not  putrid.  At  a  later  period  they  become  more 
purulent,  and  contain  less  blood.  The  sputum  separates  into  three 
layers  :  an  upper  frothy  layer,  a  middle  layer  of  turbid  fluid,  a  thin 
layer  of  mucopus  below.  Large  amounts  may  be  coughed  up  in 
twenty-four  hours ;  the  sputa  contain,  on  examination,  blood-cor- 
puscles, leucocytes,  round  alveolar  epithelial  cells  and  polyhedral,  fatty 
degenerated  cells,  which  look  like  liver-cells.  Elastic-tissue  fibres  from 
the  lungs  are  found  with  crystals  of  heematoidin  and  tyrosin,  and  Char- 
cot's crystals.  Bacteria  are  present.  Amoebae  are  constantly  present. 
They  vary  in  size  and  activity,  but  are  larger  than  those  seen  in  the 
stools.  The  sputum  should  be  kept  warm  and  examined  as  soon  as 
possible. 

Peritonitis.  Peritonitis  from  perforation  is  not  a  common  com- 
plication of  amoebic  dysentery,  but  takes  place  occasionally  in  the  gan- 
grenous form.  Peritonitis  without  perforation  may  occur.  The 
symptoms  do  not  differ  from  peritonitis  under  other  circumstances 
Hemorrhage  from  the  bowel  occurs  and  may  be  sufficiently  profuse  to 
cause  death.  This  accident  may  occur  in  the  course  of  amoebic  ab- 
scess of  the  liver,  as  in  a  case  reported  by  the  author,  in  which  there 
were  no  intestinal  symptoms.  Other  complications  which  have  been 
described  under  catarrhal  and  croupous  dysentery  are  likely  to  occur 
in  this  affection. 

The  Diagnosis.  The  diagnosis  of  amoebic  dysentery  is  made  abso- 
lute by  finding  the  amoeba?  in  the  stools.  The  history  and  the  course 
of  the  illness  must  also  be  taken  into  consideration,  the  characteristics 
of  which  have  been  previously  detailed.  The  irregularity,  and  the 
intermittency  of  the  diarrhoea,  the  infrequency  of  tenesmus,  the  mod- 
erate fever,  the  reaction  of  the  stools,  and  their  comparative  freedom 
from  bacteria,  are  further  corroborative  points. 

The  Plague. 

This  infection  is  seen  in  two  forms  :  One,  pestis  major,  is  character- 
ized by  inflammation  of  the  glands  of  the  body,  known  also  as  malignant 
adenitis.  Another,  pestis  siderans,  is  attended  by  intense  septicemia, 
with  or  without  hemorrhages.  Unlike  the  first  variety,  the  glands  are 
not  enlarged.  It  is  divided,  in  accordance  with  its  special  features, 
into  septicemic,  pneumonic,  gastro-intestinal,  nephritic,  and  cerebral 
forms. 

It  is  an  acute,  specific,  infectious,  and  contagious  disease,  occurring 
in  epidemics,  characterized  by  high  fever,  sometimes  by  petechia  and 
other  hemorrhages,  and,  in  cases  which  last  long  enough,  by  buboes. 
The  death-rate  is  extremely  high, 

The  plague  is  a  disease  of  the  East,  being  endemic  in  some  parts  of 
India,  but  epidemics  have  occurred  in  Italy,  Russia,  China,  Turkey, 
England,  and  other  parts  of  Europe. 


348 


GENERAL  DIAGNOSIS. 


The  period  of  incubation  is  from  two  to  seven  clays.  The  invasion 
is  marked  by  lassitude,  languor,  headache,  and  dizziness.  The  stupid 
aspect  and  staggering  gait  may  lead  to  the  belief  that  the  patient  is 
drunk.  Chill  or  chilliness  soon  supervenes,  followed  by  fever,  which 
often  rises  to  hyperpyrexia,  and  is  accompanied  by  unquenchable  thirst, 
and  sometimes  nausea  and  vomiting.  Delirium  and  a  typhoid  condi- 
tion follow,  with  a  marked  tendency  to  failure  of  the  circulation  and 
collapse.  If  the  patient  survive  until  the  second  or  third  day,  glandu- 
lar swellings  develop  in  the  groin,  or  axilla,  or  angle  of  the  jaw. 
Often  they  have  to  be  sought  for  to  be  found.  Sometimes  they  are 
prominent  and  are  followed  by  suppuration  and  even  ulceration.  Car- 
buncles are  much  rarer  manifestations  than  buboes.  Petechias,  vibices, 
hemorrhages  into  the  kidney,  and  bloody  vomit,  occur  in  the  worst 
cases. 

Diagnosis.  The  diagnosis  is  based  upon  the  history,  the  clinical 
course,  and  the  results  of  bacteriological  examination.  The  following 
description  from  Abbott  enables  the  diagnosis  to  be  readily  made  : 

Fig.  89. 
A 


'A't  i'*  > 


If 


Bacillus  of  bubonic  plague:  A,  iu  pus  from  suppurating  bubo;  B,  the  bacilli  very  much  enlarged, 
to  show  peculiar  polar  staining.     (Abbott.) 

"  This  organism  is  described  as  a  short,  oval  bacillus,  usually  seen 
single,  sometimes  joined  end  to  end  in  pairs  or  threes,  less  commonly  as 
longer  threads.  It  stains  more  readily  at  its  ends  than  at  its  centre. 
It  is  sometimes  capsulated ;  is  non-spore-forming ;  is  aerobic,  and  is 
non-motile.  It  is  found  in  large  numbers  in  the  suppurating  glands, 
and  in  much  smaller  numbers  in  the  circulating  blood.     (See  Fig.  89.) 

"  It  is  demonstrable  in  cover-slip  preparations  made  from  the  pus 


THE  DATA  OBTAINED  BY  OBSERVATION.  349 

and  in  sections  of  the  glands  by  the  ordinary  staining  methods.  Yersin 
states  that  it  retains  its  color  when  treated  by  the  method  of  Gram, 
while  Kitasato  says  that  it  at  one  time  stains  by  this  method  and  at 
another  it  becomes  decolorized.  Aoyama  observed  that  those  bacilli 
within  the  suppurating  glands  were  decolorized,  while  those  in  the 
blood  retained  the  stain  when  treated  by  Gram's  method." 

The  duration  is  from  six  to  ten  days.  If  there  is  much  suppura- 
tion, convalescence  is  prolonged. 

Leprosy. 

A  chronic,  specific,  infectious  disease,  characterized  by  the  develop- 
ment of  tubercles,  anaesthetic  patches,  and  neuritis,  and  followed  by 
ulceration  and  destruction  of  tissue.  The  disease  occurs  especially 
from  puberty  to  the  thirtieth  year,  and  oftener  in  men  than  in  women. 
It  develops  slowly  and  insidiously.  Sometimes  the  first  skin  lesion  is 
a  crop  of  bullae,  suggestive  of  pemphigus.  More  commonly  there 
appear  reddish  or  violet-colored  patches,  varying  in  size  from  a  quarter 
of  an  inch  to  two  or  three  inches  in  diameter,  and  becoming  of  a  darker 
hue  later.  The  next  step  is  the  formation  of  nodules,  which  are  char- 
acteristic of  the  disease.  These  may  develop  upon  the  patches  already 
described,  or  hi  other  places.  They  vary  in  size  from  a  pea  to  a  bird's 
egg  or  larger.  They  are  most  common  upon  the  face  and  extensor 
surfaces  of  the  arms,  legs,  fingers,  and  toes.  The  tubercles  consist  of 
an  infiltration  into  the  true  skin  ;  they  are  raised,  firm,  relatively  pain- 
less, and  vary  in  color  from  red  to  copper.  The  face  is  characteristi- 
cally distorted  into  a  fierce  expression  (leontiasis).  The  tubercles  may 
become  absorbed  and  leave  atrophic  areas,  but  generally  they  break 
down  into  eroding  ulcers,  which  slowly  burrow  and  increase  in  extent, 
eating  off  a  portion  of  the  nose,  fingers,  hands,  and  feet,  and  exposing 
muscles,  tendons,  nerves,  bloodvessels,  and  bone.  Tubercles  form  also 
upon  nerve-trunks,  and  ulcers  upon  the  mucous  membranes.  (See  the 
Nose  and  Larynx.) 

In  other  cases,  or  in  combination  with  the  tubercles,  especially  upon 
the  limbs  and  trunk,  there  are  anaesthetic  areas.  Ulcers  may  follow 
without  the  previous  occurrence  of  tubercles.  With  the  anaesthetic 
patches  are  associated  crops  of  bullae,  and  neuritis. 

The  further  peculiarities  of  the  disease  are  :  its  long  duration,  its 
slow  progress  interrupted  by  apparent  healing  of  some  of  the  ulcers  ; 
its  afebrile  course  (the  temperature  is  generally  subnormal) ;  its  com- 
parative painlessness,  and  the  slight  impairment  of  the  general  health. 

Death  results  from  gradual  wasting,  or  is  hastened  by  some  intercur- 
rent affection. 

Diagnosis.  The  specific  cause  of  the  disease  is  probably  the  bacillus 
leprae  of  Hansen.  It  is  found  in  the  thin  pus  of  the  ulcers  and  in  the 
lesions  themselves.  It  consists  of  rods  4  to  Q/i  long  and  \fi  broad,  closely 
resembling  tubercle-bacilli.  They  stain  in  alkaline  fluids,  but  do  qo1 
bleach  after  exposure  to  acids.  Staining  cover-slip  preparations  with 
the  Ziehl-Neelsen  fluid  and  decolorizing  in  acid  and  alcohol  bring 
them  out,     They  may  be  distinguished  by  yielding  their  color  more 


350 


GENERAL  DIAGNOSIS. 


readily,  and  by  taking  easily  aniline-dyes  in  simple  watery  solution 
(Yon  Jaksch).     (See  Plate  III.,  Fig.  4,  b.) 

The  diagnosis  from  a  tubercular  syphilide  is  made  by  the  history  of 
the  case,  the  possibility  of  infection,  the  bacteriological  examination, 
the  slow  progress,  and  the  inadequacy  of  specific  treatment.  The  pres- 
ence of  anaesthesia  and  of  neuritis  points  to  leprosy. 


Actinomycosis. 

The  general  symptoms  attending  this  infection  are  like  those  due  to 
suppurative  infections.  The  fever  is  irregular,  often  intermitting. 
It  is  a  specific  infectious  disease  of  cattle,  occurring  occasionally  in 
man,  attacking  especially  the  lower  jaw,  lungs,  and  intestines,  and 
characterized  by  a  long  duration,  by  the  development  of  tumors  and 
metastatic  growths,  and  by  pycemic  symptoms. 

It  is  due  to  the  actinomyces,  or  ray-fungus  (see  Fig.  91),  which  pro- 
duces in  cattle  the  disease  known  as  big  or  lumpy  jaw  and  swelled 
head.  The  fungus  is  conveyed  in  the  food  or  drink,  and  gains  entrance 
to  the  body  through  abrasions  in  the  mouth  or  a  decayed  tooth,  or  is 
inspired  into  the  lungs.  Israel,  Ponfick,  and  Bostrom  have  given  us 
the  greatest  amount  of  information  in  regard  to  this  parasite.  It  was 
discovered  in  1845,  in  human  beings,  by  B.  v.  Langenbeck,  and  in 
1877,  in  cattle,  by  Bollinger. 


Fig. 


Case  of  actinomycosis. 


At  the  seat  of  invasion  a  slowly  growing,  slightly  painful  tumor 
develops.  Bones  are  affected  as  well  as  soft  tissues.  These  become 
swollen  and  suppurate,  the  fungus  being  at  all  times  obtainable.     The 


THE  DATA  OBTAINED  BY  OBSERVATION.  351 

fungous  masses  appear  to  the  unaided  eye  as  particles  of  yellow  sand, 
and  are  greasy  to  the  touch. 

Pulmonic  Form.  Actinomycosis  of  the  lung  may  be  divided  into 
three  stages  :  a  latent  stage,  when  the  lung  proper  is  affected  ;  an  active 
stage,  when  extension  to  the  pleura  and  chest  wall  takes  place ;  and  a 
final  or  chronic  stage,  when  perforation  and  the  formation  of  a  thoracic 
fistula  occur  and  the  adjoining  organs  become  affected.  The  symp- 
toms of  the  first  stage  are  those  of  chronic  bronchial  catarrh,  with 
later  the  occurrence  of  the  physical  signs  of  consolidation,  especially 
in  the  mamillary  and  axillary  regions  of  the  chest,  in  the  middle  zone 
of  the  thorax.  The  apices  and  bases  are  rarely  affected  primarily. 
The  symptoms  of  the  second  stage  are  those  of  pleurisy,  with  adhesions 
and  with  or  without  effusion.  At  this  time  the  disease  may  extend 
downward  to  the  liver  and  peritoneum,  or  the  pericardium  may  become 
infected.  Fever  and  pain  accompany  these  processes.  On  physical 
examination,  in  addition  to  the  signs  of  the  pulmonary  and  pleural 
conditions  above  mentioned,  swelling  of  the  thoracic  wall  will  be  ob- 
served, not  unlike  that  of  an  empyema  which  is  about  to  perforate. 
The  swelling,  which  is  at  first  dense,  and  hard,  and  red,  becomes  softer 
in  small  areas,  and  may  fluctuate.  Fluid,  which  is  mucopurulent  and 
shows  the  parasite,  may  be  removed  by  aspiration.  Repeated  dry  taps 
may  occur  before  the  needle  secures  the  serous  or  sanguino-serous  exu- 
dation in  the  pleura.  The  sputa  at  this  time  may  accidentally  show 
the  parasite,  although  this  is  rare.  The  expectoration  is  mucopuru- 
lent, but  it  is  said  to  never  contain  elastic  fibres.  The  course  of  the 
disease  at  this  time  may  extend  over  many  months,  in  contradistinction 
to  empyema  on  the  one  hand  or  carcinoma  on  the  other.  In  the  final 
stage  ulceration  of  the  swelling  is  seen  in  many  places,  fistula  forms, 
and  the  disease  extends  to  adjacent  structures.  Secondary  infection 
may  occur  and  symptoms  of  pysemia  develop. 

The  masses  which  form  upon  the  intestinal  mucous  membrane  may 
lead  to  suppuration  and  perforation  of  the  intestine.  Metastasis  to  any 
organ  may  occur,  with  resulting  local  symptoms.  The  duration  depends 
upon  the  organs  involved  in  metastases.  If  metastases  do  not  lead  to 
early  death,  that  result  is  brought  about  at  the  end  of  months  or  years  by 
slow  pyaemia,  with  resulting  amyloid  degeneration  and  its  consequences. 

It  is  usually  associated  with  chronic  inflammation  and  the  produc- 
tion of  pus.  The  pus  is  peculiar.  It  is  thin  and  viscid.  Small 
nodules  of  gray  or  yellow  color,  the  size  of  a  poppy-seed,  can  be  seen 
by  the  naked  eye  when  it  is  spread  out  on  a  glass.  With  a  low  power 
these  particles  are  aggregations  of  spherules,  which  with  a,  higher 
power  are  seen  to  be  arranged  in  masses  radiating  from  a  common 
centre.  Each  separate  spherule  is  pear-shaped.  They  have  high  re- 
fractive power.  In  the  centre  of  the  masses  a  network  of  fibres  is 
seen.  If  the  mass  be  broken  up  numerous  club-shaped  forms  in  the 
periphery  are  seen,  while  at  the  centre  a  sort  of  detritus  alone  is  <>!>- 
served.  The  micro-organism  belongs  to  the  class  of  fission-fungi,  and 
the  club-shaped  bodies  are  the  degenerated  forms.     (See  Fig.  91.) 

Gram's  method  of  staining  brings  out  the  threads  of  the  network 
most  distinctly.     The  centre  is  made  up  of  a  network  of  minute  spheri- 


352 


GENERAL  DIAGNOSIS. 


cal  organisms,  with  converging  constituent  threads.  The  whole  is  sur- 
rounded by  a  delicate  envelope.  The  pear-shaped  bodies  may  be 
denned  by  Weigert's  process.  Make  a  solution  of  20  c.c.  of  absolute 
alcohol,  5  c.c.  of  concentrated  acetic  acid,  40  c.c.  of  distilled  water,  and 
sufficient  French  extract  of  litmus  to  color  it  ruby-red  after  repeated 
filtering.  In  this  solution  the  cover-glass  preparations  are  allowed  to 
remain  for  an  hour,  and  then  rinsed  with  alcohol  rapidly  and  placed 


Fig.  91. 


Actinomyces. 

in -a  2  per  cent,  gentian-violet  solution  for  three  minutes.  The  fluid 
should  be  boiled  before  use  and  filtered  after  cooling.  The  fungous 
threads  are  stained  a  ruby-red,  while  the  central  mass  of  actinomyces 
is  colorless. 

Diagnosis.  Simple  microscopical  examination  is  usually  sufficient 
to  determine  the  nature  of  the  fungus.  The  recognition  is  more  posi- 
tive if  we  bear  in  mind  the  peculiar  character  of  the  pus  in  which  the 
nodules  and  the  club-shaped  forms  are  seen.  It  must  not  be  mistaken 
for  the  radiating  leptothrix  threads  found  in  the  mouth.  Pure  cultures 
have  been  obtained  resembling  macroscopically  the  cultivation  of  the 
tubercle  bacillus. 

Tetanus. 

Tetanus  is  an  acute,  infectious  disease  of  the  nervous  system,  the 
essential  characteristic  of  which  is  persistent  tonic  spasm  of  the  muscles 
of  the  jaws  (lockjaw)  and  of  the  spinal  and  trunk  muscles.  The  disease 
begins  with  the  stiffness  of  the  jaw,  which  steadily  increases  until, 
within  a  few  hours,  there  is  complete  tonic  spasm  of  the  jaw.  The 
neck-muscles,  and  then  those  of  the  spine  and  trunk,  become  rigid,  so 
that  the  body  is  arched  backward  and  may  rest  upon  the  heels  and 
head  (opisthotonos).  The  facial  muscles  share  in  the  spasm,  and  by 
their  contraction  produce  a  horrid,  grinning  countenance  (rims  sar- 
donicus).  The  contracted  muscles  become  painful,  and  there  is  also 
epigastric  pain.  The  rigidity  is  persistent,  but  is  interrupted  by  ex- 
acerbations in  which  the  phenomena  already  described  are  exaggerated, 
and,  in  addition,  respiration  is  embarrassed,  the  face  becomes  livid,  the 
skin  bathed  in  sweat,  and  the  patient  is  further  distressed  by  increased 


THE  DATA  OBTAINED  BY  OBSERVATION.  353 

pain  in  the  affected  muscles.  The  body  may  be  bent  forward  (empros- 
thotonos)  or  laterally  (pleurosthotonos).  The  temperature  is  not  con- 
stant. It  may  remain  normal,  be  moderately  elevated,  or  hyperpyrexia 
may  be  present,  especially  toward  and  after  the  end  in  fatal  cases.  The 
spasm  ceases  during  sleep,  but  subsequently  returns. 

The  cause  of  the  disease  is  the  bacillus  of  tetanus,  which  produces 
the  convulsive  poison  tetanin.  The  bacillus  is  seen  as  a  delicate,  slen- 
der rod,  with  a  terminal  spore.  It  stains  with  aniline  dyes  and  Grain's 
fluid.  Cultivations  may  be  made  with  the  pus.  It  should  be  smeared 
over  the  surface  of  slanted  agar-agar  or  blood-serum  in  a  sterilized 
tube,  placed  at  37°  C,  for  twenty-four  hours,  then  heated  to  80°  C.  in 
a  water-bath  from  forty-five  to  sixty  minutes.  At  the  end  of  this  time 
gelatin  plates  or  Esmarch  tubes  are  to  be  made  from  the  growth  in  the 
heated  tube  ;  these  are  to  be  kept  in  an  atmosphere  of  pure  hydrogen 
at  20°  to  22°  C.  Growth  is  favored  by  the  addition  to  the  gelatin  of 
2  per  cent,  of  glucose.  If  the  inoculation  be  made  as  a  stab  in  a  tube 
about  three-quarters  filled  with  gelatin,  growth  is  seen  only  to  within 
about  2  cm.  of  the  surface  of  the  media.  Faint  radiating  striae  or 
thorn-like  processes  are  seen.  The  development  is  rapid  in  agar-agar. 
After  an  exposure  of  thirty  hours  to  a  temperature  of  37°  C.  the 
spores  make  their  appearance.  On  gelatin  the  colonies  are  dense  at 
the  centre,  with  a  more  delicate  periphery.  The  preparation  becomes 
fluid,  and  gas  is  evolved.  It  is  strictly  anaerobic.  The  accompanying 
illustration  from  Abbott's  work  on  Bacteriology  shows  its  appearance. 

Fig.  92. 


a 


J 

Tetanus  bacillus,    a.  Vegetative  stage,  from  gelatin  culture,     b.  Spore-stage,  showing 
pin-shape.    (Abbott.) 

Tetanus  frequently  follows  an  injury.  Trismus  neonatorum  and 
puerperal  tetanus  are  names  given  to  special  varieties  which  occur  in 
new-born  children  and  in  puerperal  women.  Tetanus  is  much  more 
common  in  men  than  in  women,  and  Gowers  states  that  three-fourths 
of  the  cases  occur  between  the  ages  of  ten  and  forty.  It  is  much  more 
common  in  hot  than  in  cold  countries,  though  cold  is  an  exciting  cause. 

In  traumatic  and  puerperal  cases  the  disease  usually  develops  in 
from  a  few  days  to  two  weeks  from  the  time  of  injury  or  childbirth  or 
abortion.  In  new-born  children  it  occurs  usually  during  the  first  week. 
It  lasts  from  two  to  six  weeks,  but  may  be  fatal  much  earlier,  or,  in 
rare  cases,  last  even  longer. 

Tetanus  must  be  distinguished  from  strychnine-poisoning.  In  the 
latter  the  jaw-muscles  are  never  involved  early,  if  at  all,  and  the  nms- 

23 


354  GENERAL  DIAGNOSIS. 

cles  are  relaxed  between  the  paroxysms.  It  is  distinguished  from  tetany 
by  the  history  and  the  distribution  of  the  spasm,  which  in  tetany  is 
confined  to  the  extremities.  Bacteriological  methods  should  be  re- 
sorted to. 

Trichinosis. 

Until  recently  fever  was  not  looked  upon  as  an  attendant  of  the 
gross  parasitic  invasion  which  is  considered  below.  The  study  of  a 
large  number  of  cases  shows  that  fever  is  present  in  various  forms.  In 
not  a  few,  it  is  true,  it  may  be  very  slight  for  a  few  days,  and  then 
fall  to  normal,  and  even,  especially  in  convalescents,  be  strikingly 
subnormal.  In  other  instances  the  temperature  curve  may  be  markedly 
intermittent.  The  chart  from  Osier's  monograph  shows  this  peculi- 
arity. (See  Fig.  93.)  Finally,  the  fever-range  is  not  unlike  that  of 
typhoid  fever  in  many  instances.  Strumpell  observes  that  the  fever  is 
seldom  continuous  for  any  length  of  time,  and  that  its  course  is  inter- 
rupted by  frequent  and  prolonged  intermissions.  Kiemeyer  compares 
the  curve  to  that  of  typhus,  and  Eichhorst  to  that  of  typhoid  fever. 

The  infection  is  acute,  caused  by  absorption  of  trichinae  spiralis,  and 
characterized  by  fever,  gastric  and  intestinal  irritation,  followed  by 
pain  and  stiffness  in  voluntary  muscles,  oedema  of  the  eyelids,  face, 
and  feet,  by  profuse  sweating,  and  by  death  or  tardy  convalescence. 

The  trichinae  are  absorbed  by  human  beings  through  raw  or  imper- 
fectly cooked  food,  often  in  the  form  of  sausage.  The  trichinae  are 
encysted  when  absorbed,  but  within  forty-eight  hours  they  are  liber- 
ated in  the  intestine  and  can  be  found  adherent  to  the  mucous  mem- 
brane. In  the  course  of  six  or  seven  days  each  liberated  female  worm 
produces  about  180  embryos,  which  immediately  penetrate  the  walls 
of  the  intestine  and  travel  or  are  carried  to  all  parts  of  the  body, 
becoming  in  turn  encysted. 

Swallowing  of  trichinous  flesh  does  not  necessarily  produce  symp- 
toms ;  the  trichinae  may  be  destroyed  in  the  stomach,  or,  if  calcified, 
may  pass  through  the  intestine  unchanged.  When  symptoms  result 
the  severity  depends  upon  the  number  of  trichinae  which  become  liber- 
ated. The  symptoms  are  sleeplessness,  lassitude,  anorexia,  nausea, 
vomiting,  tenderness  over  the  abdomen,  and  diarrhoea.  Headache  is 
a  constant  and  marked  symptom  of  invasion.  Colicky  pains  attend 
the  gastro-mtestinal  symptoms.  These  symptoms  may  not  be  marked 
in  the  beginning  of  the  disease ;  or  they  may  be  so  severe  as  to  cause 
death  in  two  or  three  days.  If  the  patient  survive,  toward  the  end  of 
the  week  the  voluntary  muscles  become  stiff,  painful,  and  contracted. 
The  muscles  feel  hard  and  swollen.  The  eyelids,  face,  and  sometimes 
the  feet  become  oedematous.  Depending  upon  the  muscles  involved, 
there  are  interferences  with  the  eye-movements,  contractions  of  the  jaw- 
muscles,  difficulty  in  breathing  or  in  swallowing,  etc.  The  calves  of  the 
legs  are  especially  involved.  Recurrent  oedema  over  the  affected  muscles, 
eyelids,  and  face  is  very  common  and  characteristic.  Profuse  sweating 
also  is  very  common,  and  at  times  there  are  severe  neuralgic  pains. 

The  fever  is  usually  moderate,  but  it  may  be  high.  It  follows  the 
types  described  above.     It  is  accompanied  by  malaise,  with  pains  in 


THE  DATA   OBTAINED  BY  OBSERVATION. 


355 


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356  GENERAL  DIAGNOSIS. 

the  joints  and  muscles,  preceding  the  true  local  muscle  pain.  The  pulse 
is  very  frequent  if  trichinae  reach  the  heart.  The  later  stages  in  fatal 
cases  are  marked  by  insomnia,  delirium,  stupor,  and  coma. 

The  duration  varies  from  a  few  days  to  four  or  five  weeks,  or  even 
longer.  Muscular  pains  may  persist  for  months  after  recovery.  Death 
results  from  exhaustion,  or  from  some  complication,  as  pneumonia  or 
ulceration  of  the  large  intestine. 

The  Blood.  Brown,  in  studying  Dr.  Osier's  cases,  found  an  increase 
in  the  leucocytes,  and  on  a  differential  count  a  great  increase  of  the 
eosinophiles.  The  leucocytes  were  increased  to  17,000  per  c.mm. 
The  eosinophiles  increased  from  2  per  cent.,  the  normal,  to  37  per  cent., 
and  at  one  time  to  68.2  per  cent.  In  subsequent  cases  their  average 
increase  was  as  high  as  48  per  cent. 

Diagnosis.  The  diagnosis  is  based  upon  the  history,  the  peculiar 
muscular  pains  and  swellings,  the  localization  of  the  oedema,  and  the 
leucocy'tosis  and  eosinophilia.  The  muscles  are  swollen  and  hard, 
painful  on  pressure,  and  contracted.  There  is  no  involvement  of  the 
joints,  an  important  point  in  the  diagnosis.  The  oedema  (see  Chapter 
XL)  is  seen  in  the  eyelids  and  over  the  eyebrows.  It  is  of  common 
occurrence  over  the  swollen  and  tender  muscles.  It  is  distinguished 
from  typhoid  fever  by  the  presence  of  vomiting,  and  oedema  of  the  face 
and  eyelids,  the  development  of  muscular  troubles,  by  the  absence  of 
hebetude,  delirium,  and  other  typhoid  symptoms,  and  absence  of  the 
characteristic  eruption  and  enlargement  of  the  spleen. 

Muscular  rheumatism  is  distinguished  by  being  limited  to  one  part, 
as  the  lumbar  region,  arm,  or  chest ;  by  its  appearance  following  ex- 
posure to  draught ;  and  by  the  fact  that  it  is  not  preceded  by  nausea, 
vomiting,  and  diarrhoea,  nor  accompanied  by  oedema. 


CHAPTEE    XXI. 

THE  DATA  OBTAINED  BY  OBSERVATION— {Continued). 

Exploratory  puncture  or  aspiration  for  diagnosis:  Instruments.  Preparation  of  instru- 
ments. Preparation  of  skin.  Point  of  puncture.  —Exudations  (Pus.  Seropus. 
Gangrenous  debris.  Blood.  Serum.  Chyle):  Pus.  Blood-corpuscles  Bac- 
teria. Protozoa.  Vermes.  Crystals. — Chemical  examination:  Seropurulent 
exudations.  Putrid  exudations.  Hemorrhagic  exudations.  Serous  exudations. 
Chylous  exudations.  Pleural  effusions.  Transudations. — The  contents  of  cysts: 
Hydatid,  ovarian,  renal,  pancreatic. 

THE  EXAMINATION  OF   EXUDATIONS,   TRANSUDATIONS, 
AND  CYSTIC  FLUIDS. 

Exploratory  Puncture  or  Aspiration  for  Diagnosis.  The  presence 
or  absence  of  fluids  in  the  natural  cavities  of  the  body,  as  the  peri- 
cardium, the  pleura,  or  the  abdomen,  or  in  the  gall-bladder,  must 
frequently  be  ascertained  by  means  of  puncture  or  aspiration.  The 
fluid  is  secured  at  the  same  time  by  the  puncture  for  examination. 
The  fluid  of  tumors  or  cysts  is  likewise  withdrawn  to  complete  a  diag- 
nosis by  determining  its  chemical,  microscopical,  or  bacteriological 
character.  Certain  rules  of  procedure  are  necessary,  and,  as  the}'  are 
common  to  the  method  in  whatsoever  situation  employed,  may  be  con- 
sidered in  this  section. 

The  Instruments.  If  it  is  the  desire  of  the  observer  to  determine 
the  presence  of  fluid,  an  ordinary  grooved  needle  may  be  used.  If, 
however,  fluid  is  to  be  obtained  for  examination,  a  syringe  or  aspirator 
must  be  used.  An  ordinary  hypodermatic  syringe,  or  the  syringe  of 
Pravaz,  may  be  used  if  the  needles  are  long  enough.  A  special  aspi- 
rator made  for  diagnosis  by  instrument-makers  is  the  best.  The 
needles  are  sufficiently  long,  the  barrel  large  enough  to  hold  sufficient 
fluid  for  any  method  of  examination.  If  the  diagnosis  is  to  be  fol- 
lowed by  treatment  by  aspiration,  the  apparatus  of  Dienlafoy,  or  any 
equally  perfect  apparatus,  may  be  used  at  once. 

Preparation  of  Instruments.  The  instruments  should  be  ster- 
ilized in  a  steam  sterilizer,  or  boiled.  This  does  not  apply  to  the 
needles  alone,  but  every  portion  of  the  instrument  should  be  cleansed, 
because,  for  instance,  the  contents  of  the  barrel  of  the  syringe  pass 
through  the  needle.  After  sterilization  they  should  be  carried  to  the 
patient  in  sterilized  test-tubes  plugged  with  cotton-wool.  When  not 
in  use  the  needles  should  be  kepi  in  absolute  alcohol  and  the  syringe 
in  carbolic  acid  solution,  1  :  20.  Before  using,  the  carbolic  acid  should 
be  washed  from  the  syringe  and  needle  with  boiling  water  ;  they  are 
then  to  be  sterilized  as  described.  Unless  the  carbolic  acid  is  removed 
from  the  syringe  its  presence  may  serve  as  an  antiseptic  or  disinfectant. 


358  GENERAL  DIAGNOSIS. 

and  thus  interfere  with  the  culture-tests,  to  which  the  material  drawn 
is  to  be  subjected. 

Preparation  of  Skin.  The  skin  should  first  be  cleansed  with 
soap  and  water,  then  with  alcohol,  then  with  a  solution  of  carbolic  acid, 
1  :  20,  or  of  the  bichloride  of  mercury,  1  :  1000.  After  thorough 
cleansing  the  parts  should  be  kept  covered  with  a  towel  soaked  in 
bichloride  solution  until  the  time  of  operation.  At  the  time  of  punc- 
ture the  surface  should  be  made  anaesthetic  by  ethylene  chloride,  the 
rhigolene  spray,  by  ice  and  salt,  or,  in  adults,  by  the  Schleich  method 
of  subcutaneous  anaesthesia.  Care  must  be  taken,  if  the  patient  is 
aged  or  poorly  nourished,  or  the  skin  oedematous,  not  to  freeze  the  skin 
too  much,  on  account  of  the  danger  of  local  gangrene. 

The  Point  of  Puncture.  The  points  selected  for  aspiration 
depend  upon  the  cavity  to  be  explored  or  the  situation  of  the  cyst. 

The  Pleura.  To  withdraw  the  fluid  within  the  pleura  it  is  best 
to  select  a  point  for  aspiration  in  one  of  the  lower  interspaces  of  the 
chest,  because  the  fluid  is  more  likely  to  accumulate  in  this  position 
and  because  complete  aspiration  can  there  be  performed  if  necessary. 
The  sixth  or  seventh  interspace  in  the  anterior  axillary  line,  or  the 
eighth  or  ninth  interspace  in  the  posterior  axillary  or  scapular  line, 
may  be  selected.  On  the  right  side  the  upper  interspace  of  the  two 
should  be  chosen  on  account  of  the  position  of  the  liver.  If  the  con- 
tents tend  to  point  or  break  out  at  any  particular  spot  on  the  surface 
of  the  chest  the  puncture  may  be  made  in  this  area.  In  suspected 
loculated  empyema  or  effusions  the  point  of  puncture  should  be  at  the 
site  of  greatest  dulness  and  least  fremitus. 

The  Pericardium.  For  aspiration  of  the  pericardium  three  points 
of  election  have  been  recommended  :  First,  the  usual  position  of  the 
apex-beat,  in  the  fifth  interspace,  inside  of  the  midclavicular  line  ; 
second,  the  space  between  the  ensiform  cartilage  and  the  left  seventh 
cartilage,  the  point  advised  by  Roberts  ;  third,  Rotch  has  tapped  the 
fifth  right  interspace  a  number  of  times  on  the  cadaver,  and  thinks 
that  this  situation  is  a  proper  one  on  the  living  subject.  The  writer 
has  aspirated  the  pericardium  in  several  instances  inside  of  the  normal 
position  of  the  apex.  Care  must  be  taken  to  insert  the  needle  slowly 
and  with  the  point  directed  downward  and  toward  the  left  axilla  when 
this  position  is  selected. 

The  Abdomen.  It  should  be  remembered  that  no  attempts  at 
puncturing  the  abdomen  should  be  made  if  pus  is  suspected,  unless 
preparations  have  been  made  to  perform  laparotomy  at  once.  Indeed, 
this  exploratory  operation  is  performed  with  so  little  detriment  to  the 
patient  by  modern  surgeons  that,  on  the  whole,  it  should  be  advocated 
instead  of  puncture.  There  are  times,  however,  when  the  latter  must 
be  resorted  to.  The  writer  has  performed  it  in  a  number  of  instances 
— always  refusing  to  do  so  in  cases  in  which  pus  was  probably  present 
in  the  peritoneal  cavity,  or  in  tumors,  or  in  organs  the  seat  of  suppura- 
tion— without  any  danger  having  ever  arisen.  Explorations  of  this 
character  are  probably  more  feasible  in  connection  with  diseases  of  the 
liver.  It  does  not  appear  to  be  harmful  to  insert  needles  into  that 
organ,  and  valuable  information  is  often  gained  thereby. 


THE  DATA  OBTAINED  BY  OBSERVATION.  359 

In  aspiration  of  the  abdomen,  to  determine  the  character  of  perito- 
neal contents,  the  median  line  should  be  selected  for  the  puncture.  The 
bladder  must  be  emptied  and  a  point  midway  between  the  umbilicus 
and  pubes  selected. 

The  Vertebral  Canal.  Spinal  or  Lumbar  Puncture.  Proposed 
by  Quincke,  the  procedure  has  been  carried  out  by  many  clinicians  and 
has  proved  to  be  a  means  of  corroborating  and  even  establishing  a  diag- 
nosis. Cerebral  lesions  are  diagnosed  and  intracranial  pressure  relieved 
because  of  the  continuity  of  the  spaces  in  the  brain  and  the  spinal  canal. 
(See  Cerebro-spinal  Meningitis.) 

Method.  The  patient  should  lie  on  the  right  side,  with  the  knees 
drawn  up  and  the  left  shoulder  turned  forward.  The  puncture  is  made 
by  an  antitoxin  needle  or  the  needle  of  a  large  hypodermic  syringe, 
which  may  then  be  used  to  withdraw  the  fluid.  The  syringe  itself 
may  be  removed  and  the  fluid  allowed  to  ooze  through  the  needle  drop 
by  drop.  A  needle  4  cm.  in  length  and  1  mm.  in  diameter  is  suitable 
for  infants  ;  a  longer  needle  for  children  over  ten  and  adults.  The 
point  selected  for  puncture  is  midway  between  the  third  and  fourth  or 
fourth  and  fifth  lumbar  vertebra?,  below  the  spinous  process,  a  little 
to  one  side  of  the  median  line.  The  thumb  of  the  left  hand  of  the 
operator  placed  between  the  spinous  process  may  be  used  as  a  guide. 
If  the  needle  is  inserted  to  the  right  of  the  median  line,  preferably  on 
this  side,  it  should  enter  1  cm.  from  the  median  line,  on  a  level  with 
the  thumb,  and  be  directed  slightly  upward  and  inward.  At  a  depth 
of  3  or  4  cm.  in  children  and  7  or  8  cm.  in  adults  the  canal  is  entered. 
The  fluid  oozes  drop  by  drop,  and  should  be  collected  in  a  sterilized 
test-tube.  It  should  not  run  down  the  sides  of  the  tube.  Five  to 
fifteen  cubic  centimetres  should  be  withdrawn. 

The  fluid  is  examined  chemically,  bacteriologically,  and  microscopi- 
cally. Sugar  has  been  found  in  brain-tumor  and  not  in  meningitis  ; 
albumin  is  said  to  be  less  hi  the  former  than  in  the  latter.  In  tubercu- 
lous meningitis  the  fluid  is  usually  clear  and  limpid  ;  in  other  forms 
cloudy  and  turbid.  Pus  has  been  withdrawn  in  leptomeningitis.  Blood 
may  be  found  in  hemorrhage  into  the  lateral  ventricles.  The  respective 
affection  is  distinguished  by  the  results  of  bacteriological  examination. 

Cover-glass  preparations  are  made  of  the  fluid  and  cultivations  taken 
at  once.  In  purulent  meningitis  streptococci,  staphylococci,  the  pneu- 
mococcus,  and  the  meningococcus  (diplococcus  intercellularis)  may  be 
detected.  In  tubercular  meningitis  tubercle  bacilli  have  been  found, 
especially  after  sedimentation.  After  the  fluid  has  been  twenty-four 
hours  in  a  conical  glass  the  fine  clot  which  forms  should  be  examined 
for  bacilli.  The  absence  of  bacilli  does  not  exclude  tuberculosis.  The 
positive  result,  however,  is  diagnostic. 

Inoculation,  as  in  a  case  by  Lafleur,  will  cause  tuberculosis  in  a 
guinea-pig,  and  is  diagnostic.  A  clear  fluid  does  not  exclude  purulent 
meningitis;  usually,  however,  the  fluid  is  purulent,  turbid,  or  rich  in 
leucocytes. 

Sometimes,  although  the  canal  is  entered,  fluid  is  not  secured,  be- 
cause the  needle  enters  pseudomembrane,  thick  pus,  or  gelatinous  fluid, 
or  because  fluid  is  retained  in  the  lateral  ventricles. 


360  GENERAL  DIAGNOSIS. 

Cysts  or  tumors,  with  fluid  contents,  should  be  punctured  over  the 
point  which  presents  externally,  at  which  place  it  is  evidently  hi  closer 
proximity  to  the  external  wall. 

The  Spleex.  The  spleen  has  been  punctured  for  therapeutic  and 
diagnostic  purposes.  If  the  organ  is  hard,  as  in  chronic  malaria,  it 
may  be  done  without  danger  ;  but  if  it  is  enlarged  and  soft,  as  in  infec- 
tious diseases,  such  as  typhoid  fever,  it  is  hardly  justifiable  to  puncture 
it,  because  of  the  danger  of  subsequent  rupture.  Risks  attend  the 
puncture  of  other  organs,  as  the  kidney.  The  writer  has  seen  a  serious 
hemorrhage  follow  such  puncture,  and,  of  course,  septic  inflammation 
may  arise.  Exploratory  operation  is  more  suitable  for  determining  its 
condition. 

The  Examination  of  Fluids  and  Discharges.  While  the  fluids  to 
be  examined  can  be  obtained  by  the  above-mentioned  method,  it  some- 
times happens  that  they  are  discharged  spontaneously,  as  in  the  case 
of  an  empyema. 

The  following  general  methods  apply  to  the  examination,  in  what- 
ever way  material  is  obtained.  When  derived  from  the  natural  cavi- 
ties they  are  known  as  exudations  or  transudations.  Fluids  are  also 
obtained  from  cysts,  but  do  not  require  different  methods  of  exami- 
nation. 

The  naked-eye  appearances  are  first  noted  ;  then  microscopical  ex- 
amination with  and  without  staining  is  resorted  to.  Chemical  exami- 
nation is  also  required.  Often  culture-preparations  and  inoculations 
must  be  resorted  to,  as  hi  the  case  of  pus  or  of  serous  exudation. 

The  Exudations. 

They  may  be  composed  of  pus,  seropus,  gangrenous  debris,  blood, 
or  pure  serum  or  chyle.  When  pus,  seropus,  or  putrid  fluid  is  with- 
drawn, it  implies  absolutely  an  inflammatory  origin.  Blood  and  serum 
may  be  associated  with  inflammation,  simple  or  infectious ;  but  may 
also  point  to  impediments  in  the  general  or  lymphatic  circulation. 
Blood  or  bloody  serum  is  thought  to  be  of  tuberculous  or  cancerous 
origin.  Its  absence  does  not  imply  the  absence  of  either  disease.  A 
chylous  exudation  is  usually  due  to  obstruction  of  the  lymph-channels. 

Purulent  Exudations. 

Pus  ranges  in  color  from  gray  to  greenish-yellow.  It  is  turbid,  of 
high  specific  gravity,  and  alkaline.  It  varies  in  consistence.  When 
standing  after  removal  it  separates  into  two  layers ;  the  upper  layer  is 
light  yellow  and  transparent,  and  the  lower  opaque.  Pus  may  be 
mixed  with  blood,  and  is  then  reddish-brown.  (See  Abscess  of  the 
Liver.)  When  it  has  undergone  decomposition  it  is  thin,  green,  or 
brownish-red,  of  a  penetrating  odor. 

Microscopical  Examination:  White  Corpuscles.  If  the  speci- 
men is  fresh  the  cells  exhibit  the  movements  that  are  common  in 
leucocytes.  If  a  solution  of  iodine  and  iodide  of  potassium  is  added 
to  them  they  change  to  mahogany  color.     If  the  pus  is  old  and  the 


THE  DATA  OBTAINED  BY  OBSERVATION.  361 

cells  are  dead,  they  are  shrunken  and  granular.  Enormous  giant-cells 
and  cells  loaded  with  fat  are  seen  in  pus. 

Red  Corpuscles.  In  fresh  pus  red  corpuscles  are  also  seen  along 
with  blood-pigment  or  haematoidin-crystals. 

In  addition  to  the  corpuscles  free  fat-globules  and  fat-particles  are 
seen.  Epithelium  is  rarely  seen.  In  the  pus  from  the  pleural  cavity, 
if  cancer  is  present,  the  vacuolated  epithelial  and  endothelial  cells 
sometimes  seen  in  cancer  may  be  observed. 

Bacteria.  Micro-organisms  are  always  detected  with  the  aid  of 
staining-methods.  (See  Chapter  XVII.,  Bacteriological  Diagnosis.) 
The  micro-organisms  are  usually  the  determining  cause  of  the  suppu- 
ration. Suppuration,  however,  may  be  caused  by  chemical  substances, 
although  this  is  at  least  of  rare  clinical  occurrence.  Of  the  various 
fungi  found  the  micrococci  and  bacilli  are  the  most  numerous.  The 
commonest  of  these  are  the  staphylococcus  pyogenes  aureus  and  strep- 
tococcus pyogenes ;  the  amoeba  dysenterica,  in  abscess  of  the  liver  and 
secondary  abscess  of  the  pleura  and  lung.  It  was  found  in  an  abscess 
of  the  jaw  by  Flexner.  For  further  description  of  the  pyogenic  micro- 
organisms, see  below  and  Chapter  XVI.,  The  Infections. 

The  Pyogenic  Bacteria.  1.  Staphylococcus  Pyogenes  Aureus. 
This  micro-organism  is  found  in  acute  abscesses  and  boils,  sometimes 
also  in  infectious  osteomyelitis  and  ulcerative  endocarditis.  In  addi- 
tion to  other  portals  it  may  enter  the  tissue  through  abrasions  or  the 
hair-follicles. 

Morphology.  In  cover-glass  preparations  they  appear  as  small 
round  bodies  scattered  among  the  pus-cells,  rarely  within  them,  single, 
in  pairs  or  in  clusters.  They  stain  readily  with  the  basic  aniline  dyes. 
(See  Fig.  94.) 

Biological  Properties.  It  is  aerobic,  facultative  anaerobic,  grows 
in  milk,  meat-infusions,  gelatin,  or  agar  at  18°  C.     Death-point  is  56° 

Flo.  94. 


(TO 


Pus  with  staphylococcus.    X  800.    (FlOgge.) 

to  58°  C.  after  ten  minutes'  exposure.  Growth.  Make  plate-cultures 
on  agar-agar.  After  twenty-four  hours  in  the  incubator  the  plate  will 
be  studded  with  yellow  or  orange-colored  colonies,  round,  moist,  and 
glistening.  In  a  gelatin  stab-culture  liquefaction  occurs  in  thirty-six 
to  forty-eight  hours  along  the  puncture,  forming  a  funnel.  The  whole 
mass  gradually  liquefies.     At  the  bottom  of  the  funnel   the  microbes 


362  GENERAL  DIAGNOSIS. 

collect  as  an  orange-colored  mass.  On  potato  it  grows  as  a  brilliant, 
orange-colored,  somewhat  lobulated  layer.  The  growth  gives  off  an 
odor  of  sour  paste.    (See  Plate  VII.,  Fig.  3,  and  Plate  III.,  Fig.  2,  6.) 

2.  Staphylococcus  Pyogenes  Albus.  It  is  also  found  in  acute 
abscesses,  but  less  often  than  the  "  aureus,"  and  is  less  virulent. 

It  is  morphologically  identical  with  the  "  aureus,"  but  develops  no 
pigment.  The  surface-cultures  are  milk-white,  and  the  mass  at  the 
bottom  of  the  liquefying  gelatin  is  white. 

3.  Staphylococcus  Epidermidis  Albus  (Welch)  closely  simulates 
the  staphylococcus  pyogenes  albus.  It  is  the  most  common  micro- 
organism on  the  surface  of  the  body,  and  is  often  present  in  parts  of 
the  epidermis  too  deep  for  disinfection,  save  by  heat.  It  is  supposed 
to  be  the  usual  cause  of  "  stitch-abscess." 

4.  Streptococcus  Pyogenes.  It  is  found  in  acute  abscesses,  ery- 
sipelas, otitis  media,  puerperal  metritis,  infectious  endocarditis,  pseudo- 
diphtheria,-  scarlatinal  angina,  and  most  purulent  inflammations  of  a 
phlegmonous  character.  It  is  the  organism  most  commonly  found  in 
inflammations  having  a  spreading  tendency. 

Morphology.  Cover-glass  preparations  show  spherical  cocci  of 
varying  sizes,  which  form  chains  of  four  to  twenty  elements,  the  chains 
often  forming  tangled  masses.  It  is  stained  by  the  basic  anilines  or 
by  Gram's  method.     (See  Fig.  95.) 

Biological  Properties.  Grows  in  most  media  at  a  temperature 
of  16°  to  37°  C.  (best  30°  to  37°),  but  not  on  potato.  It  is  facultative 
anaerobic,  and  does  not  liquefy  gelatin.  On  plates  it  forms  a  flat, 
transparent  disk  of  about  one-half  millimetre  diameter.  In  stab-cul- 
tures it  grows  all  along  the  puncture  and  forms  a  white  opaque  granu- 
lar column.  The  death-point  is  52°  to  54°,  ten  minutes'  exposure. 
(See  Plate  VII.,  Figs.  1  and  2.) 

Fig.  95. 


Streptococcus  pyogenes  in  pus.    X  800.    (FmJgge.) 

Inoculated,  it  causes  erysipelatous  or  phlegmonous  inflammation. 

5.  The  Tubercle  Bacillus.  This  is  seen  at  tunes  in  pus  removed 
from  phthisical  cavities,  and  the  pus  of  abscesses,  particularly  about 
glands.  It  may  be  detected  by  methods  of  staining  adopted  in  the 
examination  of  the  sputum.  Pus  may  be  of  tubercular  origin,  and  the 
micro-organisms  may  not  be  detected  by  the  usual  microscopical 
methods.  Its  absence,  therefore,  does  not  imply  the  absence  of  tuber- 
culosis. Culture-methods  and  inoculation  should  be  resorted  to,  partic- 
ularly the  latter. 


THE  DATA  OBTAINED  BY  OBSERVATION.  363 

6.  The  Bacillus  of  Syphilis.  The  pus  under  these  circumstances  is 
usually  derived  from  ulcers  or  inflammations,  or  from  secretions  about 
the  vulva  or  prepuce.  The  actual  relationship  to  syphilis  has  not  been 
demonstrated. 

Lustgarten's  method  is  as  follows  :  After  immersion  for  twenty-four 
hours  at  the  ordinary  temperature  in  the  gentian-violet  fluid  of  Koch- 
Ehrlich,  the  cover-glass  preparation  is  removed  and  washed  for  a  few 
moments  with  absolute  alcohol.  It  is  then  placed  for  ten  seconds  in 
a  1  per  cent,  or  2  per  cent,  solution  of  permanganate  of  potash  ;  a 
watery  solution  of  pure  sulphurous  acid  is  then  poured  over  it,  after 
which  it  is  washed  in  water.  If  the  preparation  still  shows  its  color, 
it  must  be  reimmersed  for  a  few  seconds  in  the  potash  solution  and 
then  in  the  sulphurous  acid,  and  again  washed  with  water. 

7.  Actinomyces. 

8.  The  Bacillus  of  Glanders. 

9.  The  Bacillus  of  Anthrax. 

10.  The  Bacillus  of  Leprosy. 

11.  The  Bacillus  of  Tetanus. 

12.  The  Bacillus  of  Influenza.     (See  Sputum.) 

13.  The  Micrococcus  Lanceolatus.  The  Pneumococcus.  The 
pneumococcus  is  often  found  in  the  pus  of  empyema  and  pericarditis, 
whether  from  the  pleural  cavity  or  after  it  has  burrowed  from  this 
situation.  It  occurs  in  cerebro-spinal  meningitis.  It  is  easily  detected 
by  the  usual  staining-methods  (for  which  see  Sputum). 

14.  The  Bacillus  Coli  Communis.  The  bacillus  coli  communis  is 
found  more  commonly  in  infections  within  the  abdominal  cavity.  (See 
Fseces.) 

15.  The  Gonococcus.  It  is  constantly  present  in  virulent  gonor- 
rhceal  pus,  usually  within  the  pus-cell  or  attached  to  the  surface  of 
epithelial  cells.  Morphology.  Micrococci,  usually  joined  in  pairs  or 
fours,  flattened  and  separated,  when  stained,  by  an  unstained  intercel- 
lular space.     Stains  easily  with  anilines — not  by  Gram's  method. 

No  other  cocci  are  of  the  same  shape,  and  at  the  same  time  within 
the  cells,  except  one  which,  however,  stains  by  Gram's  method.  (See 
Plate  III.,  Fig.  3,  b.) 

Growth.  Does  not  grow  readily  on  ordinary  media,  but  can  be 
cultivated  on  blood-serum  and  other  special  media,  such  as  urine,  agar, 
etc.  ;  30°  to  40°  C.  is  best,  and  a  moist  atmosphere  is  needed.  Growth 
is  slow  and  often  fails.  Forms  a  thin,  scarcely  visible  layer,  with 
smooth,  shining  surface,  grayish-vellow  bv  reflected  light — is  aerobic. 
(See  page  308.) 

Protozoa  in  the  Pus.  Cercomonads  have  been  observed  in  the  pus 
of  an  empyema,  probably  from  the  lungs.  Flexner  has  found  the  amoeba 
dysenterica  in  the  pus  of  an  abscess  of  the  jaw.  It  is  found  in  abscess 
of  the  liver  and  secondary  abscess  of  the  lung.    (See  Sputum  and  Fieces.) 

Vermes.  Filaria  have  been  found  in  abscess  of  the  liver.  In  the 
suppuration  of  hydatids  the  pus  contains  membrane  and  booklets. 

Crystals.  Crystals  of  cholesterin  are  found  in  the  pus  from  cold 
abscesses,  suppurating  ovarian  cysts,  and  foetid  discharges.  They  are 
similar  to  the  crystals  described  under  sputum. 


364  GENERAL  DIAGNOSIS. 

H^matoidiist-crystals  indicate  a  previous  hemorrhage  ;  they  are 
most  frequent  in  suppurating  hydatid  cysts.  (See  Fig.  96.)  Fatty 
needles  are  found  in  old  pus  and  gangrenous  exudates.  (See  Fig  97.) 
Triple  phosphates  are  frequently  seen  in  pus,  and  are  of  the  same  appear- 
ance as  the  phosphates  hi  the  urine.  The  carbonates  and  phosphates 
are  seen  in  foetid  pus. 

Fig.  96.  Fig.  97. 


Pus  from  putrid  empyema.    (Eye-piece 
Rhombic  crystals  of  bsemin.    (Charles.)  III.,  obj.  8,  A.  Reichert.)    Shrunken  leu- 

cocytes.   Fat-crystals.    (Von  Jaksch.) 

Chemical  Examination  of  Pus.  This  does  not  yield  any  informa- 
tion of  diagnostic  value. 

Serum-albumin,  globulin,  and  peptone  are  detected  by  methods  em- 
ployed in  the  examination  of  urine.  Fresh  pus  contains  sugar.  After 
being  boiled  with  an  equal  weight  of  sulphate  of  soda  and  filtered  the 
filtrate  is  examined  by  the  reagents  used  in  examination  of  urine  for 
sugar.  Pus  also  contains  bile-pigments  and  biliary  acids,  cholesterin 
and  salts  of  sodium  and  the  fatty  acids  in  jaundice.  Von  Jaksch  has 
found  acetone  in  pleural  exudations. 

Seropurulent  Exudations.  They  resemble  purulent  discharges, 
chemically  and  morphologically.  They  point  to  antecedent  inflam- 
mation. 

Putrid  Exudations.  The  exudations  are  brown  or  brownish-green 
in  color.  The  odor  is  penetrating  and  offensive.  They  are  usually 
alkaline  in  reaction.  On  microscopical  examination  old  leucocytes  and 
crystals  of  fat,  cholesterin,  and  hsematoidin  are  seen  ;  fission-fungi  of 
various  forms  are  seen.     (See  Figs.  96  and  97.) 

Hemorrhagic  Exudations.  Hemorrhagic  exudations  contain  red 
blood-corpuscles  and  haemoglobin  in  large  amount.  Fatty  endothelial 
cells  are  found.  Quincke  states  that  when  the  glycogen-reaction  is 
shown,  if  the  fluid  is  from  the  pleura,  carcinoma  is  probably  present. 
A  positive  diagnosis  depends  upon  the  discovery  of  the  epithelial  cells 
(see  page  364),  which  are  seen  in  cases  of  cancer.  Hemorrhagic  exuda- 
tions in  the  pleura  are  due  most  frequently  to  cancer,  to  tubercle,  or  to 
scurvy.  To  determine  its  exact  nature  (as  to  tubercle),  inoculation 
and  cultures  are  sometimes  necessary. 


THE  DATA  OBTAINED  BY  OBSERVATION.  365 

Serous  Exudations. 

The  fluid  is  clear  and  light  yellow  or  straw-colored.  On  standing  a 
white  fibrinous  clot  is  deposited.  On  microscopical  examination,  red 
blood-corpuscles,  leucocytes,  fatty  globules,  and  endothelial  cells  are 
found.  They  may  be  bunched  in  groups  or  scattered  about.  The 
micro-organisms,  if  present,  are  detected  with  difficulty.  If  ulcerating 
tuberculosis  of  the  pleura  is  present  the  bacillus  may  be  found,  but 
tuberculous  pleurisy  may  exist  without  ulceration,  and  hence  the  fluid 
is  clear  of  the  bacillus.  Cholesterin-crystals  are  found  in  old  serum. 
On  chemical  examination  the  fluid  contains  more  than  3  per  cent,  of 
serum-albumin  and  globulin  ;  peptone  is  absent  in  pleural  exudations ; 
sugar  in  small  amount  and  acetone  are  found. 

The  specific  gravity  of  the  fluid  is  above  1018. 

Chylous  Exudations.  True  chyle  is  found  in  fluids  of  low  specific 
gravity.  Such  an  effusion  is  rich  in  fat  and  is  due  to  leakage  of 
lymphatics  into  the  peritoneal  cavity.  It  is  known  as  a  chylous  effu- 
sion. Chyliform  effusion  is  a  term  applied  to  the  second  variety  of 
effusions  mentioned  in  this  section.  The  fluid  has  the  property  of 
chyle.  Sometimes  in  peritoneal  exudation,  particularly  if  the  patient 
has  been  upon  a  milk-diet,  the  fluid  contains  fatty  matter,  which  gives 
it  a  milky  appearance.  The  same  character  of  fluid  is  seen  in  obstruc- 
tion of  the  thoracic  duct. 

Special  Effusions.  Effusions  in  the  Pleura.  It  is  of  the 
greatest  importance  to  distinguish  the  various  forms  of  infection. 
Bacteriological  examination  is  often  necessary.  In  purulent  exuda- 
tion, if  micro-organisms  are  absent  (staphylococcus  and  streptococcus), 
it  is  probably  tuberculous  ;  serofibrinous  exudations  are  usually  free 
from  fungi.  AVhen  the  micrococcus  lanceolatus  is  found  it  is  of  favor- 
able prognostic  omen. 

To  distinguish  the  effusion  of  inflammation  from  that  of  transudation 
(obstruction)  the  specific  gravity  is  of  service.  In  the  inflammatory 
effusions  the  specific  gravity  is  high  ;  they  also  contain  a  large  amount 
of  fibrin  and  more  than  3  per  cent,  of  albumin. 

Transudations. 

This  class  of  fluids  is  serous,  bloody,  or  chylous.  The  specific  grav- 
ity is  lower  than  in  inflammatory  effusion.  The  color  is  light  and  the 
reaction  usually  alkaline.  On  microscopical  examination  but  little  is 
found.  In  pleuritic  effusions  there  may  be  considerable  endothelium, 
which,  if  mixed  with  blood,  may  be  due  to  carcinoma.  Serum  contains 
albumin  and  sugar,  the  former  in  great  excess.  Peptone  is  always 
absent.     The  fluid  coagulates  with  difficulty  on  boiling. 

Runeberg1  lays  stress  upon  the  diagnostic  importance  of  the  amount 

1  Runeberg  (J.  W. ) :  On  the  Diagnostic  [mportance  of  the  Amount  of  Albumin  in 
Pathological  Transudations  and  Exudations.  Berliner  klin.  Wochenschrift,  L897, 
No.  33. 


366 


GENERAL  DIAGNOSIS. 


of  albumin  in  pathological  transudations  and  exudations.     His  experi- 
ence warrants  the  following  statements  : 

1.  Inflammatory  processes,  4  to  6  per  cent,  of  albumin. 

2.  Venous  stasis,  1  to  3  per  cent,  of  albumin. 

3.  Marked  hydremic    conditions,   as    in  amyloid    degeneration   or 
nephritis,  0.1  to  0.3  to  0.5  per  cent. 

4.  Combination  of  two  or  three  of  the  above  causes,  0.2  to  6  per 
cent. 

In  group  two,  even  without  inflammatory  complications,  a  high  per- 
centage may  occur  in  old  transudations. 


Contents  of  Cysts. 

In  aspiration  of  the  abdomen  and  of  the  pleura  cysts  are  sometimes 
evacuated,  the  nature  of  which  is  often  determined  by  an  examination 
of  the  fluid.  It  is  within  the  province  of  this  work  to  discuss  hydatid 
cysts,  pancreatic  cysts,  and  the  cystic  kidney.  As  tumors  of  the  ovary 
so  frequently  resemble  tumors  in  other  situations,  it  is  well  also  to 
discuss  in  this  section  the  nature  of  the  fluid  withdrawn  from  them. 

Hydatid  Cysts.  The  fluid  of  hydatid  cysts  is  clear,  alkaline,  and 
of  a  specific  gravity  of  1010.  It  contains  chloride  of  sodium  in  ex- 
cess, grape-sugar  in  small  amount,  and  very  little,  if  any,  albumin. 

Fig.  98. 


Contents  of  an  ovarian  cyst.  (Eye-piece  III.,  obj.  8,  A.  Reichert.)  a,  squamous  epithelial  cells  ; 
b,  ciliated  epithelial  cells  ;  c,  columnar  epithelial  cells ;  d,  various  forms  of  epithelial  cells  ;  e,  fatty 
squamous  epithelial  cells ;  /,  colloid  bodies ;  g,  cholesterin-crystals.    (Von  Jaksch.) 

On  microscopical  examination  booklets  are  found,  as  in  the  sputum 
from  hydatid  cyst  of  the  lung,  as  well  as  portions  of  membrane.  The 
membrane  is  recognized  by  its  peculiar  transverse  striation  and  the 
granular  appearance  of  its  inner  surface.  The  heads  or  scolices  are 
sometimes  found.     Two  circles  of  booklets  and  four  disks  on  the  ante- 


THE  DATA  OBTAINED  BY  OBSERVATION.  367 

rior  aspect  cross  the  head,  which  is  separated  from  the  hinder  part  by 
an  annular  constriction.  (See  Sputum  and  Faces.)  If  suppuration  has 
taken  place  the  original  nature  of  the  cyst  cannot  be  made  out  unless 
hooklets  are  found.  After  the  fluid  has  been  standing  in  a  conical 
glass  vessel  the  bodies  may  be  found  in  the  sediment. 

Ovarian  Cysts.  The  fluid  from  an  ovarian  cyst  is  of  high  specific 
gravity,  1026,  of  alkaline  reaction,  contains  but  a  small  amount  of 
albumin,  and  does  not  coagulate.  On  microscopical  examination  vari- 
ous forms  of  epithelial  cells  are  seen,  colloid  bodies,  and  cholesterin- 
crystals.  If  hemorrhage  has  taken  place  in  the  cyst  the  color  of  the 
fluid  is  correspondingly  changed,  and  beside  the  squamous,  columnar, 
and  ciliated  varieties,  some  epithelium  in  the  stage  of  fatty  degenera- 
tion and  red  and  white  blood -corpuscles  are  seen.  In  colloid  cysts 
the  usual  concretions  are  found.     (See  Fig.  98.) 

In  dermoid  cysts,  in  addition  to  the  above,  squamous  epithelium, 
hairs,  and  fatty-,  haematoidin-,  and  cholesterin-crystals  are  detected. 
Ovarian  fluid  contains  albumin  and  niethsemoglobin,  or  paralbumin. 
The  latter  is  detected  by  mixing  a  portion  of  the  fluid  with  three  times 
its  bulk  of  alcohol.  It  is  then  allowed  to  stand  for  twenty-four  hours, 
when  it  is  filtered.  The  precipitate  is  removed  and  suspended  hi  water. 
After  filtering  the  filtrate  is  seen  to  be  opalescent,  and  is  tested  as 
follows  : 

1 .  On  boiling  no  precipitate  is  formed,  but  the  fluid  becomes  turbid. 

2.  There  is  no  change  with  acetic  acid  alone. 

3.  The  fluid  becomes  thick  and  of  a  yellowish  tint  when  treated  with 
acetic  acid  and  ferrocyanide  of  potassium. 

4.  There  is  a  change  to  a  violet  color  when  treated  with  concentrated 
sulphuric  and  acetic  acids. 

Some  observers  differ  from  the  above  statement  in  their  description 
of  the  fluid  of  an  ovarian  cyst ;  all  agree  as  to  the  large  number  of  cell- 
elements.  At  one  time  it  was  thought  that  the  fluid  contained  a  special 
cell,  but  this  view  has  been  abandoned.  In  rare  cases  the  specific 
gravity  may  be  lower  than  that  of  the  fluid  of  ordinary  ascites.  A 
fluid  of  low  specific  gravity,  with  a  small  amount  of  albumin,  is  said 
to  be  characteristic  of  a  cyst  of  the  broad  ligament. 

Cystic  Kidney.  The  fluid  from  a  cystic  kidney  can  be  recognized 
by  the  properties  it  derives  from  the  renal  secretion.  Urea  and  uric 
acid  in  large  amounts  point  to  its  true  source.  Renal  epithelium  is  of 
the  greatest  diagnostic  value.  (See  Urine.)  If  epithelium  from  the 
urinary  tubules  can  be  detected  after  the  fluid  has  settled  the  diagnosis 
is  absolute.  (See  Hydronephrosis.)  It  must  not  be  forgotten  that  both 
urea  and  uric  acid  may  be  found  in  other  cysts,  as  in  those  of  the 
ovary,  if  they  communicate  with  the  urinary  tract. 

Pancreatic  Cysts.  The  fluid  from  cysts  of  the  pancreas  is  of  a 
specific  gravity  of  1012,  but  may  be  as  high  as  1028.  It  contains 
cholesterin-crystals  in  abundance,  and  blood  or  pigment.  Seruin- 
albumin  is  present,  but  metalbumin  is  not  found.  Three  diastatic 
ferments  are  present : 

(1)  If  on  examination  for  sugar  the  latter  is  found  to  be  a  maltose, 
its  presence  is  of  diagnostic  significance. 


368  GENERAL  DIAGNOSIS. 

(2)  The  most  pronounced  property  of  the  pancreatic  fluid,  and  that 
by  which  we  are  enabled  to  distinguish  it  from  other  fluids,  is  the 
power  of  digesting  albumin  without  the  presence  of  an  acid. 

Boas  (Deutsche  med.  Wochensehr.,  1890,  Bd.  xvi.  p.  1095)  developed 
the  method  of  examination.  The  fluid  is  to  be  added  to  milk.  After 
the  casein  is  precipitated  the  biuret-test  is  applied,  as  follows  :  Heat 
the  substance  with  caustic  potash  and  add  drop  by  drop  a  10  per  cent, 
solution  of  sulphate  of  copper.  If  digested  albumin  is  present  the  fluid 
assumes  a  reddish-violet  color.  No  other  cystic  fluid  can  dissolve 
albumin  in  alkaline  solution. 

It  is  not  necessary  that  albumin  or  fibrin  should  be  employed  in 
performing  this  test,  as  it  is  sufficient  to  add  milk  to  the  secretion  ; 
when  in  such  cases  the  casein  of  the  milk  is  precipitated,  and  the 
biuret  test  is  applied  to  the  resulting  filtrate,  and  the  test  compared 
with  a  control-milk  from  which  the  casein  has  been  removed  (this  can 
be  done  by  adding  very  dilute  acetic  acid  with  constant  stirring),  the 
digestive  property  of  the  liquid  under  examination  may  be  with  cer- 
tainty determined.  The  peptone  would  not  be  precipitated  with  the 
albumin,  and  as  all  albumins  give  the  same  reaction  as  peptone  with 
the  biuret  test,  the  albumin  should  be  removed  before  applying  the 
test.  It  is  removed  from  the  filtrate  by  a  saturated  solution  of  ammo- 
nium sulphate.  Then  test  the  resulting  filtrate  with  the  .biuret  test. 
Then  compare  with  the  control-test  as  above. 

(3)  The  pancreatic  fluid  also  emulsifies  fats.  In  large  cysts,  however, 
particularly  if  of  long  standing,  the  physiological  properties  of  the 
pancreatic  juice  are  sometimes  wanting.1  In  the  case  referred  to  by 
Boas  and  reported  by  Karewski,  the  old  age  of  the  cyst  modified  the 
character  of  the  fluid,  and  hence  rendered  its  nature  doubtful.  More- 
over, in  the  exploratory  puncture  the  stomach  was  penetrated.  For 
two  reasons  the  author  advises  against  exploratory  puncture.  First, 
the  age  of  the  cyst  is  not  known,  hence  an  analysis  would  be  mislead- 
ing. Second,  the  danger  of  puncturing  other  organs  is  too  great.  Ex- 
ploratory laparotomy  is  preferable. 

1  In  a  case  operated  on  by  Penrose  the  analysis  of  the  fluid  was  as  follows :  Sp.  gr. 
1025;  reaction  slightly  alkaline  ;  serum-albumin;  no  metalbumin;  diastatic  ferment 
absent ;  maltose  absent.  By  Boas'  method,  power  to  digest  albumin  appeared  to  be 
great ;  but  when  the  albumin  remaining  in  the  filtrate  was  removed  from  the  pan- 
creatic fluid,  it  failed  to  show  that  peptone  was  formed.  The  method,  therefore, 
appears  to  be  fallacious  in  this  class  of  cases.  The  cyst  was  old,  and  the  fluid  no  doubt 
lost  its  physiological  properties.  Cholesterin  was  present  in  enormous  amount ;  tyrosin- 
crystals  were  very  scarce. 


CHAPTER    XXII. 

THE  BLOOD. 

The  blood  is  a  tissue,  the  origin,  growth,  and  decay  of  the  elements 
of  which  has  been  the  source  of  the  greatest  interest.  It  was  the  tissue 
held  responsible  in  days  gone  by  for  many  diseases,  the  origin  of  which 
was  not  known,  so  that  skin  eruptions,  scrofula,  and  other  affections 
were  known  as  blood  diseases.  At  present  we  hold  such  affections 
only  blood  diseases  which  show  a  demonstrable  change  in  the  physical 
or  morphological  characteristics  of  the  blood.  There  is  either  diminu- 
tion of  the  red  cells,  increase  or  diminution  of  the  white  cells,  or  dimi- 
nution of  the  haemoglobin.  Strictly  speaking,  most  of  the  blood  dis- 
eases now  so  called  are  really  diseases  of  the  blood-making  organs — the 
lymphatic  glands  or  the  spleen.  It  is  interesting  to  note  that  as  late 
as  1866,  J.  Hughes  Bennett  included  under  diseases  of  the  blood  leu- 
cocythaemia,  chlorosis  and  anaemia,  diabetes,  the  infectious  diseases, 
rheumatism,  gout,  and  scurvy.  The  most  recent  text-book  divides  the 
blood  diseases  into  anaemia,  with  two  subdivisions,  and  leuJccemia.  Of 
course,  no  one  thinks  of  considering  the  infectious  diseases  blood  diseases 
any  more  than  we  think  of  considering  typhoid  fever  an  ulceration  of 
the  intestine. 

Although  the  blood  diseases  are  thus  limited,  it  is  none  the  less  true 
that  the  blood  may  be  the  only  tissue  by  an  examination  of  which  we  can 
determine  the  ailment  from  which  the  patient  suffers.  As  has  been 
previously  related,  many  infections  are  recognized  in  this  manner  only. 

The  symptoms  of  blood  affections  are  due  to  the  physical  change  hi 
the  blood  and  the  effect  of  this  altered  blood  upon  the  function  or  the 
nutrition  of  the  organs.  Many  functional  symptoms  thus  arising  may 
be  the  first  indications  of  blood  disease,  as  dyspnoea  or  palpitation, 
both  very  common  symptoms.  The  symptoms  may  be  subjective  or 
objective,  or  both.  The  recognition  of  the  former  comes  from  the 
history  of  the  disease  and  the  complaints  of  the  patient.  The  latter, 
or  the  objective  symptoms,  are 'determined  by  the  physical  examination 
of  the  patient  and  the  examination  of  the  blood. 

We  recognize  scarcely  any  condition  at  the  present  day  due  t<>  an 
increase  of  the  bulk  of  the  blood  or  of  the  red  cells.  Plethora  is  hardly 
a  clinical  identity.  The  symptoms  of  blood  diseases,  therefore,  are  the 
symptoms  of  ancemia.  In  like  manner,  all  the  data  obtained  by  inquiry 
are  those  which  belong  to  some  form  of  anaemia. 

THE  DATA  OBTAINED  BY  INQUIRY. 

The  Social  History.  Generally  speaking,  women,  patients  of 
early  age,  who  have  been  subjected  to  want  or  had  unusual  care,  or 
faulty  nutrition,  are  those  most  liable  to  anaemia.     No  family  predis- 

24 


370  GENERAL  DIAGNOSIS. 

position  exists  to  a  marked  degree  apparently,  although  it  is  well 
known  that  "  pale  people  "  are  a  family  class.  The  previous  history 
and  the  data  to  be  elicited  in  investigating  it  are  best  appreciated  by 
turning  to  the  classification  of  the  cause  of  anaemia  in  succeeding  pages. 

The  history  of  the  disease  is  usually  that  of  gradual  onset,  although 
sudden  fright  or  any  cause  producing  profound  shock  is  said  to  cause 
acute  anaemia.  But  the  reader  must  again  be  referred  to  the  para- 
graphs just  mentioned. 

The  subjective  symptoms  are  general.  Languor,  debility,  and 
fatigue  are  complained  of.  The  patient  with  anaemia  may  have  one 
group  of  symptoms  preponderate.  Thus  headache,  vertigo,  restless- 
ness, noises  in  the  head,  and  neuralgias  may  be  the  most  prominent 
symptoms.  Agam,  dyspnoea  and  air-hunger  may  be  the  most  dis- 
tressing, or  cardiac  palpitation  may  be  the  earliest  symptom,  with  or 
without  cardialgia.  Then  gastro-intestinal  symptoms  are  suggestive, 
although  not  pathognomonic.  The  peculiar  appetite  of  chlorosis  is 
well  known.  The  causeless  vomiting  of  many  forms  of  anaemia  has 
often  been  described.  The  bowels  may  be  constipated  or  loose,  varying 
more  particularly  because  of  the  difference  in  the  cause  of  the  anaemia. 
Ringing  in  the  ears  has  been  referred  to,  and  flashes  of  light,  spots 
before  the  eyes,  and  other  visual  phenomena  may  be  complained  of,  and 
show  their  origin  in  the  state  of  the  blood.  Other  alteration  of  the 
special  senses  are  not  marked  in  the  course  of  any  of  the  anaemias. 
These  symptoms  may  occur  singly  or  are  combined  in  varying  degrees. 

THE  DATA  OBTAINED  BY  OBSERVATION. 

While  diseases  of  the  blood,  and  especially  forms  of  anaemia,  are 
recognized  by  an  examination  of  the  blood,  much  information  can  be 
secured  by  general  physical  examination.  It  is  true  no  disease  would 
be  pronounced  a  blood  affection  unless  that  tissue  is  examined  by  the 
modern  means  of  research. 

An  examination  of  a  case  of  anaemia  includes  a  study  of  the  appear- 
ance of  the  patient,  the  color  or  hue  of  the  surface,  and  the  occurrence 
of  oedema.  Both  these  subjects  are  carefully  considered  in  the  chapters 
devoted  to  them  respectively.  Examination  of  the  eye-grounds  should 
always  be  made,  when  the  findings  discussed  in  the  Chapter  on  the 
Eye  may  be  present,  if  the  case  is  one  advanced  in  its  course.  No 
•consideration  of  anaemia  can  be  made,  however,  without  an  examination 
of  the  organs  thought  to  be  engaged  in  the  blood  formation,  hence  the 
state  of  the  glands  and  the  size  of  the  spleen  are  inquired  into. 

Finally,  as  evidence  of  the  presence  of  anaemia,  we  observe  frequently 
cardio-vascular  phenomena.  The  murmurs  that  are  heard  in  the  heart 
and  bloodvessels  in  this  disease  are  fully  discussed  in  the  Chapter  on 
Diseases  of  the  Heart,  to  which  the  reader  is  referred. 

Examination  of  the  Blood. 

Normal  Blood.  Before  a  consideration  of  the  examination  of  the 
blood,  it  may  be  well  to  review  the  elements  of  which  the  blood  is 
composed. 


PLATE    IX. 


Fly.    1. 


-      :       - 


Blood  from  Case  of  Pneumonia,  showing  Leucocytes. 


Fig.   2. 


@ 


: 


O 


^0 


© 


(•>/  - 


. 


Normal   Blood,  showing  Rouleaux  and  Leucocytes. 


THE  BLOOD.  371 

The  blood  consists  of  corpuscles  and  serum.  The  corpuscles  are 
four  :  (1)  Red  blood-cells  or  erythrocytes  ;  (2)  nucleated  red  blood-cells  ; 
(3)  blood-plaques  ;  (4)  leucocytes. 

The  ordinary  red  blood-cells  measure  -g-joif  mcn  J  *ne  leucocytes, 
2To"o  mcn-  In  an  adult  man  the  red  cells  number  from  5,000,000  to 
5,500,000  to  the  cubic  millimetre  ;  in  an  adult  woman  the  number  is 
usually  less,  being  from  4,500,000  to  5,000,000.  There  are  8000  to 
10,000  leucocytes  in  a  cubic  millimetre  of  blood,  or  1  to  350-600  red 
blood-cells. 

Varieties  of  Leucocytes.  In  the  normal  blood  there  are  found  the 
following  varieties  of  leucocytes  :  1.  Small  mononuclear  forms,  which 
are  cells  about  the  size  of  a  red  blood-corpuscle,  and  have  a  round, 
large,  deeply  staining  nucleus,  surrounded  by  a  narrow  rim  of  non- 
granular protoplasm.  These  are  known  as  lymphocytes.  2.  Large 
mononuclear  leucocytes  several  times  as  large  as  the  foregoing.  They 
have  a  round  or  oval  nucleus,  with  a  relatively  larger  amount  of  non- 
granulated  protoplasm.  3.  Transitional  forms,  which  resemble  the  last 
named,  except  that  the  nuclei  are  indented  or  S-shaped.  4.  Poly- 
nuclear  leucocytes.  These  are  usually  about  the  size  of  the  foregoing 
variety,  but  they  may  be  somewhat  smaller.  The  nuclei  are  long  and 
irregular  and  stain  deeply.  The  protoplasm  contains  granules  that 
stain  by  a  combination  of  both  basic  and  acid  dyes,  but  by  neither 
alone.  The  cells  are  therefore  called  "  neutrophiles."  5.  Leucocytes 
similar  to  the  last  form,  except  that  their  protoplasm  contains  highly 
refractive  granules  that  are  stained  by  acid  dyes  alone.  For  this 
reason  they  are  usually  called  "eosinophiles."  The  proportion  of  each 
variety  in  the  normal  blood  is  fairly  constant  ;  lymphocytes,  15  to  25 
per  cent.  ;  poly  nuclear,  65  to  80  per  cent.  ;  mononuclear  and  transi- 
tional forms,  6  per  cent. ;  and  eosinophiles,  2  per  cent,  or  less.  (See 
Plate  IX.) 

Physical  Appearance.  For  the  purpose  of  examination  of  the  blood 
a  drop  or  two  is  quite  sufficient.  In  olden  times  much  stress  was  laid 
upon  the  physical  character  of  the  blood  drawn  in  bulk.  The  signifi- 
cance of  the  "  buffy  coat"  was  dwelt  upon  by  all  clinicians,  not  alone 
because  of  its  value  from  a  therapeutic  stand-point,  but  also  because  it 
was  held  to  indicate  the  type  of  the  disease  that  was  present.  At  pres- 
ent, however,  we  rely  very  little  upon  the  results  of  the  naked-eye 
examination.  By  this  examination  we  may  be  able  to  distinguish 
bright-red  arterial  blood  from  darker  venous  blood,  and  also  when 
arterial  blood  has  become  deficient  in  oxygen  from  any  of  the  causes 
of  venous  engorgement  and  cyanosis.  In  chlorosis  and  hydremias  the 
blood  is  pale,  as  though  mixed  with  water,  while  in  severe  leukaemias 
it  has  a  slight  milky  tinge.  On  the  other  hand,  in  carbonic-oxide 
poisoning  the  blood  becomes  of  a  brighter  red,  while  in  poisoning  with 
chlorate  of  potash  and  aniline,  and  in  grave  cases  of  poisoning  with 
nitrobenzol  and  hydrocyanic  aeid,  it  is  brownish-red  or  chocolate- 
colored. 

For  accuracy  in  diagnosis  reliance  must  be  placed  upon  instruments 
of  precision.  These  are  the  microscope,  the  luemoglobinometer,  the 
hsemocytometer.     By  this  examination  we  determine  (1)  the  size  and 


372  GENERAL  DIAGNOSIS. 

shape  of  the  red  cells  ;  (2)  the  morphological  characteristics  of  the 
white  cells  ;  (3)  the  number  of  the  red  cells  ;  (4)  the  number  of  the 
white  cells  ;  (5)  the  presence  of  new  elements  as  nucleated  red  cells 
and  myelocytes  ;  (6)  the  presence  of  parasites  ;  (7)  and  the  amount  of 
haemoglobin. 

Method.  A  drop  of  blood  for  this  examination  may  be  taken  from 
the  lobe  of  the  ear  or  the  finger-tip.  The  surface  should  be  thoroughly 
cleansed  with  alcohol,  and  dried  carefully.  If  the  finger  is  used,  it 
should  not  be  unduly  constricted.  The  puncture  should  be  made 
forcibly  and  quickly,  in  order  that  the  drop  of  blood  may  ooze  freely. 
If  it  is  difficult  to  secure  the  blood,  it  is  well  to  allow  the  first  or 
second  drop  to  escape  before  any  is  collected.  AVlien  the  flow  is  started 
and  the  finger  cleansed  the  succeeding  drops  are  gathered  on  cover- 
slips.  If  the  lobe  of  the  ear  is  selected,  it  should  be  steadied  with  the 
fingers  of  the  left  hand,  which  at  the  same  time  stretches  the  skin.  It 
may  be  necessary  to  puncture  to  the  depth  of  one-eighth  of  an  inch,  or 
even  more  if  the  skin  is  bloodless.  The  puncture  should  be  made  on 
the  lower  surface  or  edge  of  the  lobe.  A  surgical  needle,  a  small  lancet, 
or  the  bayonet-pointed  instrument  devised  for  the  purpose,  should  be 
used.  The  nib  of  a  new  steel  pen,  one-half  of  which  has  been  broken 
off,  answers  fully  as  well. 

It  is  well  to  remember  the  precaution  insisted  upon  by  all  who  ex- 
amine the  blood  frequently,  to  beware  of  "bleeders."  It  sometimes 
becomes  a  very  serious  matter  when  hemorrhage  is  started  hi  a  patient 
who  is  the  subject  of  haemophilia. 

Mode  of  Examination.  As  soon  as  the  blood  flows  freely,  without 
pressure,  the  apex  of  a  drop  may  be  touched  by  the  cover-glass,  which 
has  been  previously  prepared.  The  cover-glass  should  not  touch  the 
skin,  and  as  soon  as  it  is  covered  by  the  blood  it  should  be  placed  face 
downward  upon  the  slide,  or  if  cover-slip  preparations  are  to  be  made, 
upon  a  corresponding  cover-glass.  The  precaution  must  be  taken  to 
have  the  slide  and  cover  thoroughly  cleansed.  It  is  well  to  keep  them 
in  alcohol  or  in  a  weak  acid  solution  after  they  have  been  previously 
cleansed  with  soap  and  water,  and  when  removed  from  the  alcohol 
solution  they  should  be  thoroughly  polished  with  a  clean  handkerchief. 
The  blood  will  then  spread  evenly  over  the  surface  with  the  slightest 
pressure  upon  the  cover-glass.  If  the  slide  and  cover  are  warmed 
slightly  before  using,  it  will  not  be  necessary  to  use  the  pressure  just 
referred  to. 

Blood  collected  in  this  way  may  be  examined  fresh  or  be  put  aside 
for  staining  and  future  examination. 

Examination  of  Feesh  Blood.  By  the  examination  of  fresh 
blood  we  learn  of  the  presence  of  parasites  and  of  the  occurrence  of 
rouleaux  formation.  In  a  general  way  we  can  learn  the  number  of 
red  and  white  cells  respectively,  the  degree  of  coloring  of  the  red  cells, 
the  shape  and  size  of  the  red  cells,  and  the  presence  of  blood-plates. 
An  unusual  increase  in  leucocytes  may  be  detected,  and  the  diagnosis 
of  leukaemia  made  without  further  investigation. 

Cover-sKp  preparations.  For  the  purpose  of  future  study,  and 
particularly  in  order  to  determine  the  differential  count  of  the  white 


THE  BLOOD. 


373 


corpuscles,  cover-slip  preparations  are  made.  The  covers  are  cleansed 
and  the  blood  secured  in  the  manner  previously  described.  The  cover- 
glass,  which  has  been  touched  to  the  summit  of  the  drop,  is  let  fall 
upon    another    somewhat    diagonally.      (See    Fig.    100.)      The    drop 


Fig.  99. 


Fig.  100. 


Proper  method  of  holding  a  cover-glass.    (Cabot.) 


Illustrating  the  position  of  cover- 
glass  during  the  spreading  of  hlood 
films    (Cabot.) 


spreads  over  the  adjoining  surfaces  of  the  cover-glass.  As  soon  as  the 
spreading  ceases,  slide  the  glasses  off,  but  do  not  lift  them  apart.  Dr. 
Manson  introduced  the  use  of  tissue  paper  drawn  over  a  slide,  with 
the  object  of  getting  a  more  uniform  thickness  of  film.  Pakes  uses 
this  method  applied  to  cover-glasses,  which  should  be  not  less  than  1^ 
inch  by  f  inch.  The  cover-glasses  are  held  in  a  clip  and  smeared  by 
means  of  cigarette  paper  cut  into  strips  across  the  direction  of  the  rib. 
The  cover-slip  should  be  dried  in  a  gas  or  alcohol  flame  at  once,  by 
means  of  which  the  preparation  is  fixed. 

"  Fixation"  may  also  be  done  by  alcohol  and  ether,  or  by  corrosive 
sublimate  solution.  The  cover-glass  should  be  immersed  for  one-half 
hour  in  equal  parts  of  alcohol  and  ether.  After  such  fixation  malarial 
organisms  and  nucleated  red  corpuscles  are  more  readily  found. 

Fixation  with  formol  is  quickly  secured.  Dilute  one  part  of  formol 
with  nine  times  its  volume  of  water ;  dilute  one  part  of  this  mixture 
with  nine  times  its  value  of  alcohol.  The  resulting  fluid  will  fix  im- 
mersed specimens  in  one  minute. 

Fixation  of  heat  is  best  when  the  white  cells  are  to  be  studied.  By 
this  method  it  is  best  to  put  the  cover-slips  in  a  dry-heat  sterilizer  at 
a  temperature  of  110°  or  115°.  If  this  cannot  be  done,  place  the 
cover-slips  on  the  end  of  a  copper  plate  at  least  a  foot  long,  the  other 
end  of  which  is  heated  by  a  Bunsen  burner  or  a  gas  flame.  The  cover- 
slips  should  be  placed  on  the  plate  at  that  point  on  which  water  boils 
when  dropped  upon  the  surface  of  the  copper.  They  should  be  placed 
face  downward  and  kept  there  from  fifteen  to  twenty  minutes.  When 
they  cool  they  are  ready  for  staining. 

Staining.  The  greatest  care  should  be  taken  to  have  a  perfectly 
clean,  dry  cover-glass,  which  should  be  handled  with  forceps,  to  avoid 
moisture  and  soiling.  (1)  The  prepared  cover-glass,  arranged  as  above, 
should  then  be  immersed  for  a  few  minutes  in  a  solutii f  eosin  : 


374  GENERAL  DIAGNOSIS. 

Eosin 0.5 

Alcohol  (70  per  cent. ) 100.0 

This  solution  should  be  diluted  one-half  before  using.  (2)  The 
cover-glass  should  then  be  dried  and  stained  for  three  or  four  minutes 
in  a  saturated  aqueous  solution  of  methylene  blue,  also  diluted  one-half 
before  using  (Chunzinsky-Plehn's  mixture).  Or,  instead  of  the  latter, 
stain  for  half  an  hour  to  several  hours  in  Delafield's  hematoxylin.  This 
hsematoxylin-stain  is  made  in  the  following  manner  :  To  400  c.c.  of  a 
saturated  solution  of  ammonia  alum  add  4  grammes  of  hsematoxylin- 
crystals  dissolved  in  25  c.c.  of  strong  alcohol.  Leave  this  exposed  to 
the  light  and  air  in  an  unstoppered  bottle  for  three  or  four  days. 
Filter  and  add  100  c.c.  of  glycerin  and  100  c.c.  of  methylic  alcohol. 
Allow  the  solution  to  stand  until  the  color  is  sufficiently  dark.  Then 
filter  and  keep  in  a  tightly  stoppered  bottle.  The  stain  should  ripen 
for  at  least  two  months  before  using.  For  blood-work  the  solution 
is  used  in  its  full  strength.  By  this  double  stain,  a  modification  of 
JEhrlich's  hcemdtoxylin-eosin  mixture,  the  red  corpuscles  are  stained  red, 
the  nuclei  blue,  the  bodies  of  the  leucocytes  light  lilac  and  their  nuclei 
darker,  the  eosinophile  granules  a  brilliant  red. 

Ehrlich' s  Tri-acid  Stain.  The  Ehrlich  tri-staining  mixture  is  the 
best  that  can  be  selected  for  staining.  Thayer  says  the  following  is  a 
satisfactory  modification  of  Ehrlich's  formula  : 

Saturated  aqueous  solution  of  acid  fuchsin      .  .  2 

Water 3 

Saturated  aqueous  solution  of  orange-G.  .         .  6.25 

Saturated  aqueous  solution  of  methyl-green    .         .  6 

To  be  added,  drop  by  drop,  while  shaking  the  solution : 

Water 15 

Alcohol 10 

Glycerin          ........  5 

The  stain  is  spread  over  the  cover-glass  specimen  with  a  glass  rod, 
and  in  from  one  to  five  minutes  washed  off  with  water.  If  the  cover 
glass  has  not  been  heated  very  long  it  will  not  be  necessary  to  keep 
the  stain  long  in  contact  with  the  blood,  although  specimens  which  are 
heated  an  hour  require  at  least  five  minutes  for  the  stain  to  take. 
After  the  specimen  is  stained  and  washed  in  water  it  should  be  dried 
between  layers  of  filter  paper  and  mounted  in  balsam.  It  can  then  be 
examined  at  leisure  with  the  twelfth  oil-immersion  with  diaphragm 
open. 

Specimens  heated  for  one  or  two  hours  stain  better  than  those  which 
have  been  treated  only  a  short  time.  The  red  cells  appear  orange  or 
buff,  the  nuclei  of  the  colorless  corpuscles  green  or  greenish-blue,  the 
neutrophilic  granules  a  violet  or  lilac  color,  the  eosinophilic  granules  a 
deep  red.  The  nuclei  of  nucleated  red  corpuscles,  when  present,  are 
stained  an  intense  deep  green,  almost  black.1 

Another  method  much  used  and  urged  by  Hewes  is  as  follows  : 
The  blood,  after  fixation,  is  subjected  for  four  minutes  to  the  modified 
Ehrlich  stain,  which  is  made  as  follows  : 

1  Thayer,  loc.  cit. 


THE  BLOOD.  375 

Ehrlich-Biondi-Heidenhain  three-color  mixture      .         .       1.7  grammes. 

Acid  fuchsin 0. 05         " 

Absolute  alcohol      .         .         .         .         .         .        ".         .       2  c.c. 

Distilled  water         .         .         .         .         .         .         .         .  18  c.  c. 

After  immersion  wash  the  specimen  in  water  and  then  subject  it 
from  one-half  to  ten  seconds  to  Loffler's  solution  of  methylene-blue. 
Again  wash  the  specimen,  dry,  and  mount  in  balsam. 

L5ffler's  solution  is  saturated  alcoholic  solution  of  methylene-blue, 
30  c.c.  ;  potassic  hydrate  (1  :  10,000  solution),  100  c.c. 

The  Red  Corpuscles  or  Erythrocytes.  In  thickly  spread  blood 
the  cells  are  arranged  in  the  form  of  rouleaux.  If  such  rouleaux  are 
absent  in  a  preparation  thus  poorly  spread  it  is  an  indication  of  great 
reduction  in  the  red  cells. 

In  thinly  spread  films  the  red  cells  are  recognized  by  their  color  and 
shape.  They  vary  from  6  to  9//  in  diameter.  The  lighter  colored 
centre,  due  to  the  biconcavity  of  the  corpuscle,  sometimes  causes  con- 
fusion. It  must  be  remembered,  too,  that  the  corpuscles  readily  become 
crenated,  an  appearance  which  may  be  confounded  with  pigmentation 
or  other  abnormal  change.  In  them,  too,  a  slight  molecular  movement 
is  sometimes  seen,  which  must  not  be  confounded  with  the  amoeboid 
movements  in  dying  cells  or  with  the  rapid  motion  of  malarial  pigment. 

Poikilocytosis.  The  variations  in  size  and  shape  are  indications 
of  disease.  In  forms  of  anaemia  the  red  cells  may  be  larger  than  nor- 
mal ;  they  may  be  irregular  in  shape,  or  they  may  be  smaller  than 
normal.  Large  cells  are  known  as  macrocytes,  small  cells  as  microcytes. 
Cells  that  are  irregular  in  shape  are  known  as  poikilocytes.  They  may 
be  oval,  pointed,  angular,  or  reniform. 

Achromia.  When  the  red  cells  are  stained  the  haemoglobin  takes 
the  orange-G.  of  the  tri-colored  mixture  of  Thayer,  causing  the  red 
cells  to  be  brilliant  yellow  or  pale  orange  in  tint.  An  idea  of  the 
amount  of  haemoglobin  can  thus  be  obtained.  When  the  haemoglobin 
is  diminished  the  centre  is  pallid,  although  in  extreme  poverty  of 
haemoglobin  the  colored  rim  may  be  a  faint  outline  only  (achromic 
forms). 

Nucleated  Red  Cokpuscl.es  or  Blasts.  They  contain  one  or 
more  nuclei.  The  stroma  takes  the  golden  acid  stain  and  the  nucleus 
the  pure  basic  stain.  They  are  divided  in  accordance  with  their  size, 
and  the  depth  of  the  color  of  the  nuclei,  into  three  varieties  : 

(1)  The  normoblast.  It  is  the  size  of  a  normal  red  blood-corpuscle. 
The  stroma  is  golden  in  color  ;  the  one  or  more  nuclei  are  deeply 
bluish-black,  homogeneous.  The  nucleus  occupies  one-fourth  to  three- 
fourths  of  the  whole  corpuscle.  It  is  deeper  in  color  than  the  nuclei 
of  the  white  blood-corpnscle.  It  is  the  parent  cell  of  the  red  blood- 
corpuscle. 

(2)  The  megaloblast.  They  are  larger  than  a  red  blood-corpuscle. 
The  color  of  the  stroma  is  less  intense  than  that  of  the  normoblast,  and 
the  nucleus  is  blue  rather  than  black,  and  not  compact  and  homoge- 
neous. The  nucleus  is  more  compact  and  more  clearly  defined  than  the 
nucleus  of  a  white  blood-corpuscle.  It  is  found  on  the  marrow  of  the 
embryo. 


376 


GENERAL  DIAGNOSIS. 


(3)  The  microblast.  They  are  smaller  than  the  normal.  There  is 
but  little  stroma,  and  the  nucleus  is  deep  black 

Blasts  are  found  in  anaemia.  An  excess  of  normoblasts  indicates 
very  active  regeneration  of  blood. 

Polychromatophiles.  These  are  red  blood-corpuscles  in  which 
the  stroma  takes  not  only  the  normal  acid  staining  elements  but  also 
the  blue  basic  or  purple  neutral  stain.  They  are  degenerate  forms  of 
red  blood-corpuscles. 

Degenerate  Forms.  The  coloring  matter  is  irregularly  distrib- 
uted and  the  stroma  appears  disintegrated. 

When  thus  stained  we  can  readily  find  nucleated  red  cells,  but  the 
fibrin  or  blood-plates,  as  a  rule,  are  destroyed. 

Counting  the  Corpuscles.  It  is  of  the  greatest  clinical  impor- 
tance to  be  able  to  estimate  the  number  of  red  cells  in  a  given  quantity 
of  blood,  in  order  that  approximately  at  least  we  may  know  of  its 
globular  richness.     For  this  purpose  hsemocytonieters  are  used. 

The  hgemocytometers,  or  blood-counters,  most  frequently  used  in 
this  country  are  those  of  Gowers  and  Thoma-Zeiss. 

Gowers'  instrument  (Fig.  101)  consists  (1)  of  a  small  pipette,  A, 
which,  when  filled,  holds  exactly  995  cubic  millimetres  ;  it  is  for  meas- 


FlG.  101. 


Ha?mocvtometer  of  Gowers. 


uring  the  diluting  fluid  ;  (2)  a  capillary  tube,  B,  graduated  for  5  cubic 
millimetres  ;  (3)  a  small  glass  jar,  d,  in  which  the  dilution  is  made  ;  (4) 
a  small  glass  stirrer,  e,  for  mixing  the  blood  and  diluting  fluid  in  the 
jar  ;  (5)  a  small  lancet,  f  ;  ((3)  a  brass  stage-plate,  c,  carrying  a  glass 
slip  on  which  is  a  cell  one-fifth  of  a  millimetre  deep.  The  bottom  of 
the  cell  is  divided  into  one-tenth  millimetre  squares.  On  the  top  of 
the  cell  rests  the  cover-glass,  which  is  kept  in  place  by  the  pressure  of 


THE  BLOOD. 


377 


two  springs  proceeding  from  the  ends  of  the  stage-plate.  995  cubic 
millimetres  of  the  diluting  fluid  are  measured  and  blown  into  the 
mixing-jar ;  then  5  cubic  millimetres  of  blood  are  added  and  the  two 
thoroughly  mixed.  A  small  drop  of  the  mixture  is  then  placed  upon 
the  cell,  the  cover-glass  gently  adjusted  and  held  in  place  by  the  two 
springs.  From  five  to  ten  minutes  should  be  allowed  to  elapse,  so 
that  the  corpuscles  will  have  time  to  settle  to  the  bottom  of  the  cell. 
The  stage-plate  is  then  placed  under  a  microscope,  and  the  number  of 
red  blood-cells  in  ten  squares  counted.  This  number  multiplied  by 
10,000  gives  the  number  in  a  cubic  centimetre  of  pure  blood.  It  is 
better  to  count  a  large  number  of  squares,  take  the  average,  and  multi- 
ply by  100,000.  This  number  is  the  product  of  the  dilution  (200)  by 
the  square  surface  of  the  cells,  100  (10  X  10),  and  again  by  5,  the 
depth  of  the  cell  :  200  X  100  X  5  =  100,000.  To  facilitate  seeing  the 
fine  lines  marking  the  squares,  a  soft  black  lead-pencil  should  be 
gently  rubbed  over  them  before  the  drop  of  diluted  blood  is  placed  on 
the  cell.  Counting  of  the  white  cells  is  made  much  easier  if  the 
diluting  fluid  is  colored  a  pale  violet  with  a  very  small  quantity  of 
gentian-violet.  The  white  cells  then  appear  a  distinct  blue,  while  the 
red  cells  are  unaltered.  As  diluting  fluids,  a  1  per  cent,  solution  of 
common  salt,  or  a  2|  per  cent,  solution  of  bichromate  of  potash,  as 
recommended  by  Daland,  may  be  employed  ;  or  Toison's  fluid  can  be 
used. 

Toison's  Fluid.  It  is  made  up  as  follows  :  Distilled  water,  160  c.c.  ; 
glycerin,  30  c.c.  ;  sulphate  of  soda,  8  c.c.  ;  chloride  of  soda,  1  gramme  ; 
methyl-violet,  .025  gramme. 

Another  hsemocytometer  is  the  Thoma-Zeiss  (Fig.  102).  It  is  pre- 
ferred by  most  clinicians.     It  consists  of  a  heavy  glass  slip  («),  in  the 


Fig.  102. 


0 

lrD             | 

0.100  mm. 

1  fT7%  I 

totj  mm. 

1  ^j 

Thoma-Zeiss  blood-counting  apparatus. 


middle  of  which  is  a  cell  (B)  exactly  T\  millimetre  in  depth.  The  cell 
is  limited  at  the  periphery  by  a  circular  gutter  to  prevent  fluid  placed 
upon  the  cell  from  flowing  beyond  it  between  the  slip  and  cover-glass. 
The  floor  of  the  cell  is  ruled  into  squares  whose  sides  are  ^  nun. 
Double   lines   mark  out  large  squares,  each  containing  sixteen   small 


378 


GENERAL  DIAGNOSIS. 


squares.  Thick,  carefully  ground  cover-glasses  (Z>)  are  provided  in 
the  case.  The  ordinary  Potain  melangeur  (S)  is  used  to  measure  and 
mix  the  blood.  It  consists  of  a  capillary  tube,  the  upper  portion  of 
which  is  blown  into  a  chamber  (E)  holding  100  c.mm.  The  stem  of 
the  tube  is  graduated  at  0.5  and  at  1  c.mm. 

To  use  the  instrument,  a  drop  of  blood  is  obtained  from  the  finger  or 
lobe  of  the  ear,  the  point  of  the  capillary  tube  is  inserted  into  the  drop, 
and  blood  sucked  up  to  the  mark  1  c.mm.  The  point  of  the  tube  is 
then  quickly  wiped  free  from  excess  of  blood  and  inserted  into  the 
diluting  fluid,  which  is  drawn  up  to  the  level  of  the  mark  101.  The 
proportion  of  blood  and  diluting  fluid  is  then  1  to  100  c.mm.  The 
blood  and  diluting  fluid  are  now  thoroughly  mixed.  The  diluting  fluid 
in  the  stem  of  the  melangeur  is  now  blown  out  and  a  drop  of  the 
blood-mixture  placed  on  the  cell.  The  cover-glass  is  adjusted  carefully 
to  avoid  bubbles  and  to  prevent  the  escape  of  the  fluid  between  it  and 
the  slip.  The  cover-glass  is  now  pressed  firmly  down  until  Newton's 
color-rings  appear,  and  then  the  slip  is  allowed  to  stand  for  five  or  ten 
minutes,  until  the  corpuscles  have  settled  to  the  bottom  of  the  cell. 

The  cell  is  ruled  into  400  small  squares,  groups  of  sixteen  squares 
being  separated  by  double  lines.     The  surface  of  a  square  is  T ^  square 

millimetre,  and  the  depth  of  the  cell  be- 
millimetre,   the    space    overlying 


Fig. 

103 

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Appearance  of  blood  in  the  Thoma- 
Zeiss  cells. 


each  square  is  4  qVo"  °^  a  cubic  millimetre. 
In  estimating  the  number  of  corpuscles  in 
a  cubic  millimetre  of  blood,  multiply  the 
number  of  corpuscles  counted  in  all  the 
squares  by  4000  and  the  product  by  the 
dilution,  which  is  1  to  100  or  1  to  200, 
according  as  1  or  0.5  c.mm.  of  blood  has 
been  used.  The  last  product  is  now  to  be 
divided  by  the  number  of  squares  which 
have  been  included  in  the  count,  the  quo- 
tient being  the  number  of  corpuscles  in  a 
cubic  millimetre  of  blood.  The  results 
are  accurate  in  proportion  to  the  care 
exercised  in  the  measurement  of  the  blood  and  diluting  fluid,  and  espe- 
cially in  proportion  to  the  number  of  squares  counted. 

In  the  estimation  of  white  blood-cells  the  pipette  made  by  Zeiss  is 
employed.  In  this  instrument  the  blood  is  diluted  ten  times  by  a 
solution  of  one  part  of  a  J  per  cent,  acetic  acid  solution  to  ten  parts  of 
distilled  water.  By  means  of  this  solution  red  cells  are  dissolved  and 
the  nuclei  of  the  white  cells  are  rendered  distinct  and  easy  of  recogni- 
tion. Toison's  fluid,  mentioned  above,  may  also  be  used.  The  ordi- 
nary Thoma-Zeiss  slide  is  employed,  and  the  average  number  of  white 
cells  in  each  small  square  is  multiplied  by  40,000.  To  obtain  accurate 
results  four  entire  fields  should  be  counted. 

The  hcematokrit  is  an  instrument  devised  for  the  estimation  of  the 
percentage-volume  of  red  corpuscles  by  means  of  centrifugal  force.  In 
Daland's  article  will  be  found  a  full  description  of  the  instrument,  and 
from  the  same  article  the  following:  method  of  using  it  is  abstracted  : 


THE  BLOOD.  379 

' '  The  finger  or  ear  and  apparatus  are  prepared  as  above.  An  incision 
is  made  deep  enough  to  produce  a  good-sized  drop  of  blood.  This  is 
drawn  into  a  hseniatokrit  tube  by  means  of  suction  through  an  attached 
rubber  tube,  one  finger  being  placed  over  the  free  end  when  the  rubber 
tube  is  removed,  to  prevent  the  loss  of  blood.  The  filled  tube  is  then 
placed  in  the  frame  of  the  hsematokrit  and  a  second  prepared  exactly 
as  the  first.  The  larger  wheel  is  then  rapidly  rotated  for  two  minutes 
at  seventy-seven  turns  of  the  handle-crank  per  minute  (giving  alto- 
gether 20,000  rotations  of  the  frame),  and  the  result  read  from  the 
scale  multiplied  by  2  gives  the  percentage-volume.  It  has  been  found 
by  experimenting  that  each  division  upon  the  scale  of  the  haematokrit 
tube  represents  100,000  corpuscles."  This  procedure  is  not  available 
for  the  determination  of  the  volume  of  leucocytes  unless  the  number 
exceeds  20,000,  at  and  above  which  number  an  approximate  estimate 
may  be  readily  determined.  A  distinct  white  band  appearing  between 
the  red  cells  and  the  clear  fluid,  having  the  width  of  one  line,  may 
be  considered  as  representing  from  15,000  to  20,000  leucocytes. 

Number.  The  normal  number  of  red  cells — as  stated  previously — 
is  approximately  5,000,000  per  cubic  millimetre.  They  may  be 
reduced  to  500,000.  A  reduction  below  3,000,000  indicates  grave 
anaemia.  When  the  reduction  is  less  than  1,500,000  the  anaemia  is  said 
to  be  pernicious  or  malignant.  It  must  be  remembered  that  temporarily 
the  red  cells  are  reduced  during  menstruation  and  lactation.  At 
puberty  there  is  also  a  reduction.  On  the  other  hand,  when  the  blood 
is  concentrated  by  profuse  sweating  or  exhaustive  diarrhoea,  the  num- 
ber of  red  cells  is  increased,  while  they  are  lowered  when  the  blood  is 
diluted  by  large  draughts  of  fluid  or  by  subcutaneous  injections  of  fluid. 
A  cold  bath  may  temporarily  concentrate  the  peripheral  blood,  and 
thereby  increase  the  number  of  cells.  Red  cells  are  ahvays  lessened  in 
the  aged,  and  are  reduced  in  number  after  great  exertion.  They  arc 
increased  in  number  after  fasting,  and  diminished  after  a  meal,  particu- 
larly if  much  fluid  is  taken. 

Oligocythemia.  Oligocythemia  is  the  name  applied  to  a  dimi- 
nution in  the  number  of  red  blood-cells,  from  whatever  cause.  It  is 
usually  associated  with  olic/oehromcemia  (deficiency  of  haemoglobin), 
which,  however,  in  idiopathic  anaemia  is  absolute,  not  relative.  Marked 
oligocythemia  can  be  detected  with  the  microscope  alone,  and  can  be 
estimated  accurately  with  the  hsemocytometer  or  hsematokrit.  (See 
Fig.  102.) 

The  White  Corpuscles.  The  white  or  colorless  corpuscles  are 
recognized  by  their  absence  of  color,  by  their  irregular  shape  and  their 
size,  which  is  larger  than  that  of  the  red,  and  by  the  amoeboid  move- 
ments which  they  undergo,  particularly  if  placed  on  a  warm  stage 
They  number  from  8000  to  10,000  per  cubic  millimetre.  They  are 
readily  recognized  by  the  peculiar  affinity  which  they  have  for  various 
aniline  dyes.  They  appear  as  granular  nucleated  cells  in  stained 
specimens.  The  method  of  staining  has  been  described,  and  the  vari- 
eties of  leucocytes  found  in  normal  blood  indicated  on  page  371.  In 
addition  to  determining  the  number  by  counting,  as  described  in  the 
paragraph  which  gives  the  method  of  counting  the  red  cells,  a  so-called 


380  GENERAL  DIAGNOSIS. 

differential  count  is  made.  This  count  enables  us  to  determine  the 
proportion  of  the  many  varieties  of  leucocytes. 

In  counting  the  white  blood-corpuscles,  Phear  advises  the  use  of  the 
camera  lucida.  The  most  convenient  form  is  the  Zeiss- Abbe  drawing 
camera,  used  with  the  stage  of  the  microscope  in  a  horizontal  position. 
The  image  of  the  field  is  projected  on  a  piece  of  paper  or  card- 
board lying  horizontally  on  the  table  immediately  to  the  right  of  the 
microscope  stand.  The  ruled  squares  on  the  floor  of  the  hseniocytoni- 
eter  cell  are  accurately  marked  out  on  the  cardboard.  The  image  of  the 
corpuscles  which  lie  on  the  unruled  part  of  the  cell  floor  is  thrown 
by  means  of  the  camera  on  the  cardboard,  and  the  corpuscles  which 
appear  to  lie  over  each  square  are  enumerated  and  included  in  the 
count.  It  is  convenient  to  use  a  mechanical  stage.  It  is  essential 
that  the  eye-piece,  objective,  and  tube-length  used  during  the  count 
should  be  the  same  as  on  the  occasion  of  marking  out  the  squares  on 
the  cardboard.  For  the  dilution  of  the  blood,  that  recommended 
by  Sherrington,1  consisting  of  distilled  water,  300  cubic  centimetres  ; 
sodium  chloride,  1.2  grammes  ;  neutral  potassium  oxalate,  1.2  grammes, 
and  methylene-blue,  0.1  gramme,  is  excellent.  The  blood-corpuscles 
are  not  stained,  but  their  shape  aud  color  are  preserved.  The  nuclei  of 
the  white  corpuscles  are  in  every  instance  stained,  facilitating  the  dis- 
tinction of  the  white  from  the  red  corpuscles.  For  the  differential 
count  of  the  white  corpuscles  it  is  desirable  to  work  with  an  immer- 
sion lens. 

Differential  Counting.  After  the  specimen  is  carefully  stained  with 
the  triple  solution  it  is  ready  for  differential  counting  of  the  white  cells, 
as  well  as  determining  the  presence  of  nucleated  red  cells.  To  make 
the  differential  count  a  large  number  of  leucocytes  should  be  studied. 
The  best  plan  to  pursue  is  to  begin  at  the  upper  left-hand  corner  of  the 
blood  film  and  count  across  the  film  to  the  right-hand  corner.  Then 
move  the  slide  so  that  an  adjacent  field  comes  into  view,  when  the  pro- 
cess is  to  be  repeated.  In  this  manner  the  entire  field  is  covered.  In 
ordinary  leucocytosis  a  thousand  leucocytes  can  be  seen  in  a  seven- 
eighth  inch  cover-glass  specimen.  We  may  find  an  abnormal  variety 
of  leucocytes ;  an  abnormal  proportion  of  some  one  of  the  normal 
leucocytes  ;  an  abnormal  number  of  all  the  leucocytes. 

Fluid  Preparations.  Dr.  A.  G.  Phear  lays  stress  on  the  advan- 
tages of  fluid  preparations  over  the  cover-slip  method.  In  the  cover- 
slip  method  leucocytes  are  inevitably  flattened  and  distorted  in  the 
process  of  making  and  fixing  the  film  ;  some  are  washed  away  during 
the  staining  ;  others  obscured  by  the  red  corpuscles.  In  the  fluid 
preparation  the  white  cells  are  fixed  and  preserved  as  approximately 
spherical  bodies  ;  camera  lucida  drawings  and  measurements  of  them 
could  be  relied  on  as  accurate.  A  solution  of  methylene-blue  (0.2  per 
cent.)  in  40  per  cent,  alcohol  is  used  for  diluting  the  blood.  The  red 
corpuscles  are  laked  so  that  the  white  cells  alone  remain  conspicuous. 
"  A  small  quantity  of  the  diluting  solution  is  added  to  a  drop  of  blood 
on  a  glass  slide  and  the  two  are  thoroughly  mixed  by  directing  a  cur- 

1  Proceedings  of  the  Koyal  Society,  vol.  lv. 


THE  BLOOD.  381 

rent  of  air  through  a  pipette  on  to  the  surface  of  the  fluid.  The  fluid 
is  allowed  to  spread  as  a  thin  film  under  a  cover-glass  and  the  edges 
then  sealed  with  vaseline."  The  contour  of  the  normal  polymorpho- 
nuclear cells  is  rounded.  Their  diameter  vary  from  9  to  10//.  The 
complex  nucleus  can  be  made  out  by  changing  the  focus,  the  nucleus 
being,  in  fact,  "  an  undivided  elongated  body,  in  places  deeply  con- 
stricted, elsewhere  bulged  into  rounded  lobes."  The  lymphocytes  and 
the  large  hyaline  cells  represent  the  extremes  of  cells,  differing  in  the 
amount  of  protoplasm  around  the  nucleus  ;  all  grades  are  readily 
found.  The  nuclear  diameter  is  fairly  constant  in  these  cells,  varying 
only  between  4.5  and  5.5//.  Large  oval  cells,  as  much  as  14//.  in 
length,  with  the  nucleus  large  and  irregular,  usually  reniform,  are 
seen.  The  protoplasm  becomes  rapidly  and  uniformly  stained  an 
opaque  blue  color  with  methylene-blue.  The  coarsely  granular  or 
eosinophile  cells  (diameter  from  9.5  to  10.5//)  are  at  once  recognized 
in  the  film  prepared  with  methylene-blue  solution,  notwii  hstanding 
the  absence  of  an  acid  dye  ;  the  large  refractile  granules  are  tinged 
with  a  greenish  color.  The  cells  containing  basophile  granules  (diam- 
eter about  8//)  have  a  characteristic  appearance.  The  protoplasm  con- 
tains granules  of  medium  size,  many  of  which  are  aggregated  in  one 
or  more  deeply  stained  clumps  near  the  surface  of  the  cell.  The  non- 
granular part  of  the  protoplasm  is  stained  a  peculiar  mauve  or  purple 
color.  The  nucleus  is  usually  massed  at  the  centre  of  the  cell,  and 
stains  a  slate  or  grayish-blue  color. 

Separate  counts  over  different  areas  of  one  preparation  gave  uniform 
results,  showing  that  the  blood  was  evenly  mingled  with  the  diluting 
fluid.  Not  less  than  500  cells  should  be  enumerated  at  a  time  ;  the 
more  the  better.  It  was  desirable  to  use  a  mechanical  stage  and  to 
work  with  an  immersion  lens.  The  blood  should  always  be  procured, 
if  possible,  before  the  first  meal  of  the  day  is  taken,  since  this  is  the 
time  at  which  the  influence  of  meals  is  least  likely  to  be  evident. 

Leucocytosis.  Leucocytosis  is  a  temporary  increase  in  the  number 
of  white  blood-cells  of  the  same  morphological  varieties  as  in  health, 
with  an  excess  of  the  polynuclear  forms  (neutrophile  leucocytosis). 
Such  increase  may  be  physiological  or  pathological,  as  indicated  in  the 
following  : 

Physiological  Leucocytosis.  (1)  Pregnancy  (14,000  and  up- 
ward) ;  (2)  during  digestion  (from  1000  to  7000  above  normal  ;  more 
in  children)  ;  (3)  new-born  (12,000). 

Pathological  Leucocytosis.  An  excess  of  leucocytes  occurs  in 
the  following  diseases:  (1)  Leukaemia;  (2)  pernicious  anaemia;  (3) 
chlorosis;  (4)  diseases  of  lymphatic  glands;  (5)  disease  accompanied 
by  exudations,  as  pleurisy,  'pericarditis,  meningitis,  polyarthritis,  and 
especially  croupous  pneumonia;  (6)  inflammatory  condition  associated 
with  exudation,  as  appendicitis,  pyonephrosis,  perinephritic  abscess, 
tonsillar  and  retropharyngeal  abscess,  acute  pancreatitis,  cholangitis; 
(7)  many  acute  infectious  diseases,  as  varicella,  variola,  vaccinia,  epi- 
demic cerebrospinal  meningitis ;  cholera,  typhus  fever,  trichinosis,  glan- 
ders, diphtheria,  scarlet  fever,  erysipelas,  pyaemia  and  septicaemia, 
rheumatism,  abscesses,  and  gangrenous  inflammation  ;  (8)  after  bemor- 


382  GENERAL  DIAGNOSIS. 

rhage  and  (9)  just  before  death,  leucocytosis  of  agony.  On  the  other 
hand,  leucocytosis  is  not  found  in  uncomplicated  cases  of  (1)  influenza 
{Boston  Medical  and  Surgical  Journal,  March  22,  1894) ;  (2)  uncom- 
plicated cases  of  typhoid  fever  •  (3)  tuberculosis  when  not  associated 
with  cavity-formation  or  hyperplasia  of  lymphatic  glands  (Stein  and 
Erbman,  JDeutsch.  Archiv.  f.  klin.  Med.,  Bd.  56) ;  (4)  many  forms  of 
carcinoma  and  sarcoma,  gastric  ulcer  and  benign  pyloric  stenosis 
(Schreuger,  Zeitschr.  f.  klin.  Med.,  1895,  27,  475),  although  it  may  be 
present  in  gastric  carcinoma. 

Leucopenia.  Diminution  of  the  number  of  leucocytes  is  seen  (1) 
in  starvation,  as  in  cancer  of  the  oesophagus ;  (2)  the  latter  weeks  of 
typhoid  fever  ;  (3)  leukaemia  complicated  by  infection. 

Diagnostic  Value.  The  value  in  diagnosis  of  determining  the 
presence  of  leucocytosis  is  great.  Its  absence  excludes  the  first  series 
of  cases  ;  its  presence  the  last.  If  leucocytosis  is  present  in  the  course 
of,  or  convalescence  from,  typhoid  fever,  it  pomts  to  a  complication,  as 
thrombosis.  A  post-febrile  rise,  due  to  a  complication,  may  be  distin- 
guished from  a  true  relapse  by  an  increase  of  the  white  cells. 

It  is  best  determined  with  a  hsemocytometer.  Dry  preparations, 
according  to  Ehrlich's  method,  are  necessary  for  a  study  of  the  various 
forms  of  leucocytes.  (See  under  Leucocythaemia,  page  396,  and 
Plate  X.) 

Increase  of  Special  Leucocytes.  Lymphocytosis.  A  relative 
increase  in  the  lymphocytes,  with  or  without  a  total  increase  of  leuco- 
cytes, is  seen  in  infants,  and  is  a  common  accompaniment  to  rickets 
and  hereditary  syphilis.  In  some  forms  of  scurvy  it  is  also  found. 
In  adults  lymphocytosis  occurs  in  chlorosis  and  pernicious  anaemia  and 
in  secondary  ansemia  of  syphilis  and  typhoid  fever.  It  occurs  in  haemo- 
philia, in  adenitis,  and  splenic  tumors.  Cabot  states  that  it  is  also 
found  at  the  end  of  scarlet  fever  and  measles,  in  pneumonia  with  de- 
layed resolution,  and  in  some  forms  of  phthisis.  The  larger  forms  of 
leucocytes  are  seen.  Absolute  lymphocytosis  occurs  in  lymphatic 
leuksernia. 

Eosinophilia.  An  increase  in  the  percentage  of  eosinophiles,  with 
or  without  leucocytosis,  is  seen  in  many  affections  of  the  bones,  in  affec- 
tions of  the  skin,  and  in  diseases  of  the  genital  apparatus  in  females. 
It  is  also  seen  in  certain  disturbances  of  the  sympathetic  nervous 
system,  as  in  cyanosis  and  vasomotor  troubles  associated  with  menstru- 
ation and  pregnancy.  The  bone  diseases  in  which  the  eosinophiles  are 
increased  are  osteomalacia,  sarcoma,  carcinoma,  and  in  those  affections 
of  the  bone  and  marrow  with  which  pernicious  ansemia  and  splenic 
myelogenous  leuksernia  are  seen.  The  skin  diseases  are  urticaria, 
pellagra,  herpetiform,  dermatitis,  and  pemphigus,  in  herpes,  eczema  and 
prurigo,  psoriasis,  lupus,  and  nryxoedema.  In  the  eruption  of  scarlet 
fever  and  syphilis  they  are  increased,  but  not  in  measles  or  smallpox. 
In  various  affections  of  the  uterus  and  ovary,  in  functional  disorders 
connected  with  the  same,  the  eosinophiles  are  increased.  They  are 
also  increased  in  gonorrhoea  and  prostatitis.  They  are  increased  in 
those  infections  in  which  Neusser's  granules  are  found.  Thayer,  in 
Osier's  clinic,  has  found  marked  increase  in  the  eosinophiles  in  trichi- 


PLATE    X. 


FIG.   1. 


*\  <o %     w     o 
Q  I 


90 


5T*& 


% 


°0     ft 


C^ 


T? 


i^ 


Blood  front  Case  of  Secondary  Anaemia. 

1.  Poikilocytes.  3  anc!  6.     Lymphocytes. 

2.  Macrocytes.  4.     Nucleated  red  blood-corpuscle. 

5.     Polynuclear  leucocytes. 
(Oc.  4,  ob.  Tlj  immersion.)       Drawn  by  J.  D.  Z.  Chase. 


FIG.    2. 


A    °    * 


*W 


KSMft 


f  £$S\1$ 


. 


Q 


■sir  ox 


»o 


cr 


Leuksemic  Blood. 

i.     Polynuclear  leucocytes.  3.     Large  n nucleai    li yti 

2.     Eosinophils  cell   (mononuclear),  4.     Small  lymphocyte. 

(Oc.  4,  ob.  ,'.;  immersion.)     Drawn  by    I.  D.Z.Chase. 


THE  BLOOD.  383 

nosis — in  fact,  recognizing  this  condition  by  the  differential  count. 
Diminution  in  the  eosinophiles  takes  place  during  digestion,  and  in 
most  of  the  infectious  disorders  accompanied  by  leukocytosis,  and  in 
typhoid  fever  and  diphtheria.  Malignant  disease  with  hemorrhage 
which  causes  leucocytosis  is,  however,  associated  with  diminution  of 
the  eosinophiles.  Neusser  has  indicated  the  following  diagnostic  points 
of  value  in  eosinophilia.     They  are  given  by  Cabot  as  follows  : 

1.  In  the  diagnosis  between  puerperal  mania  and  puerperal  sepsis, 
eosinophilia  points  to  the  former. 

2.  Between  a  tumor  connected  with  the  genital  system  and  one  not 
so  connected,  eosinophilia  points  to  the  former. 

3.  In  determining  whether  a  given  case  of  hysteria,  neurosis,  or 
psychosis  is  likely  to  be  benefited  by  castration,  the  presence  of  eosino- 
philia favors  the  operation. 

4.  In  malignant  disease  an  eosinophilia  points  to  a  metastasis  in  the 
osseous  system  (tumors  of  the  spleen  are  not  included  in  this  rule). 

5.  In  cases  of  doubtful  syphilis,  eosinophilia  combined  with  lympho- 
cytosis (see  above)  speaks  in  favor  of  syphilis. 

6.  The  diagnosis  of  any  obscure  form  of  "  uric-acid  diathesis"  is 
helped  by  finding  an  increase  of  eosinophiles. 

7.  In  distinguishing  malignant  liver  disease  from  other  liver  disease, 
eosinophilia  points  to  the  latter. 

Pathologic  Leucocytes.  Myelocytes.  The  occurrence  of  myelo- 
cytes in  the  blood  is  pathological.  Their  well-known  occurrence  in 
myelogenous  leukaemia  and  pernicious  anaemia  need  not  be  referred  to. 
They  have  been  found,  however,  in  a  number  of  infections,  but  usually 
only  when  there  is  present  a  grave  form  of  anaemia.  Their  occurrence 
is  not  of  great  diagnostic  value.  They  are  non-amoeboid.  They  are 
large  mononuclear  neutrophils  or  eosinophiles,  with  large,  well- 
defined,  lateral,  spherical  nuclei.  Occasionally  they  are  small  when 
they  are  recognized  by  the  granules  and  the  very  pale  large  nucleus. 
The  "  mast-zellen  "  are  mononuclear,  coarsely  granular  basophiles.  The 
nucleus  is  fragmented  or  three-lobed. 

Neusser's  Granules.  When  making  a  differential  count  we  also 
study  certain  granules  in  the  leucocytes.  Neusser  has  described  peri- 
nuclear basophilic  granulations  in  the  leucocytes,  which  are  demon- 
strated by  staining  the  blood  with  the  following  modification  of  Ehr- 
lich's  triple  stain  : 

Saturated  aqueous  solution  of  acid  fuchsin   .         .         .       50  c.c. 
Saturated  aqueous  solution  of  orange-G.       .         .         .       70   " 
Saturated  aqueous  solution  of  methyl  green  .         .       80  " 

Aquae  dest 150" 

Abs.  alcohol 80  " 

Glycerin       .         .         .         .         .         .         •         ■         .       20  " 

The  granules  in  question  occur  as  separate  bodies  or  as  groups,  lying- 
in  the  protoplasm  immediately  around  the  nucleus.  They  arc  Gael 
with  in  the  mononuclear  forms  in  particular,  and,  according  to  Neusser, 
are  composed  of  some  derivative  of  the  uucleo-albumin  and  indicative 
of  increased  uric-acid  formation.  The  granules  occur  in  gout,  and  also 
in  certain  cases  of  mvelogcnous  leukaemia,  tuberculosis,  diabetes,  and 


384 


GENERAL  DIAGNOSIS. 


other  diseases.  They  are  significant  of  a  uric  acid  diathesis  u  in  the 
clinical  sense."  In  discussing  Neusser's  paper,  Lonit  called  attention 
to  the  fact  that  similar  granules  occur  in  the  leucocytes  of  the  bone- 
marrow  of  rabbits. 

Other  observers  have  found  these  granules  in  a  variety  of  conditions, 
and  incline  to  regard  them  of  less  significance  than  Neusser  is  disposed 
to  admit. 

The  Haemoglobin.  An  estimation  of  haemoglobin  is  made,  in  order 
to  determine  the  richness  of  red  cells  in  this  substance.  For  this  pur- 
pose a  haemoglobinometer  is  used. 

H^moglobinometers.  Gowers'  hsemoglobinometer  (Fig.  104)  con- 
sists of  (1)  a  closed  tube,  D,  containing  coloring-matter  representing 
the  color  human  blood  should  have  normally  if  diluted  one  hundred 
times  ;  (2)  a  corresponding  empty  tube,  c,  graduated  in  an  ascending 
scale  from  10  to  120  ;  (3)  a  capillary  glass  tube,  b,  marked  at  20  cubic 
millimetres  ;  a  small  guarded  lancet,  f,  and  a  small  bottle  with  a  pipette 
stopper,  A,  for  distilled  water.  A  few  drops  of  distilled  water  are 
first  placed  in  the  empty  tube,  c,  to  prevent  the  coagulation  of  the 
blood,  which  would  occur  if  the  blood  were  first  put  in  the  tube.  The 
finger  or  lobe  of  the  ear,  previously  cleansed  with  water  and  ether,  is 
then  deeply  stabbed  with  the  lancet,  so  that  the  blood  will  flow  freely, 
care  being  taken  to  avoid  squeezing  the  punctured  part ;  20  cubic  milli- 
metres of  blood  are  then  quickly  drawn  up  in  the  capillary  tube  and 


Fig.  104. 


Gowers'  bsemoglobinometer. 


at  once  blown  into  the  graduated  tube,  which  is  shaken,  to  allow  the 
blood  to  become  diffused  in  the  water.  The  tubes  containing  the  stand- 
ard coloring-matter  and  the  diluted  blood  are  now  held  up,  side  by 
side,  against  a  sheet  of  paper,  and  more  distilled  water  added,  drop  by 
drop,  with  repeated  shakings,  until  the  colors  in  the  two  tubes  match. 
The  height  to  which  the  column  of  diluted  blood  and  water  has  risen 


THE  BLOOD.  385 

in  the  graduated  tube  represents  the  percentage  of  haemoglobin  con- 
tained hi  the  blood  tested. 

Fleischl's  haemometer  consists  of  a  small  metal  table  with  an  aper- 
ture in  the  middle,  under  which  is  a  reflector  made  of  plaster-of -Paris. 
The  opening  is  occupied  by  a  small  well  having  a  glass  bottom  and 
divided  into  two  equal  compartments.  The  standard  color  of  the  blood 
at  different  dilutions  is  represented  by  a  wedge  of  glass,  colored  with 
Cassius  purple,  which  is,  of  course,  pale  in  color  at  the  extreme  edge 
and  deepens  in  intensity  with  its  thickness.  This  wedge  of  glass  is 
moved  under  the  table  by  a  rack  and  pinion,  and  is  accompanied  by 
a  graduated  scale.  One-half  of  the  well  receives  simply  the  light  from 
the  plaster-of-Paris  reflector,  while  the  other  rests  upon  the  ruby  glass 
and  obtains  light  through  it.  The  light  from  a  candle,  gas-jet,  or  oil-lamp 
must  be  used.  A  small  pipette  and  several  capillary  tubes  about  f 
inch  in  length,  and  mounted  on  slender  metal  handles,  are  employed  to 
obtain  the  necessary  amount  of  blood  ;  each  one  of  them  will  hold 
enough  normal  blood  to  produce,  when  properly  diluted,  a  color  corre- 
sponding to  that  of  the  ruby  glass  at  the  100  mark.  For  use,  one  end 
of  a  capillary  tube  is  carefully  lowered  upon  a  drop  of  blood,  which 
immediately  fills  it ;  the  tube  is  then  at  once  washed  in  one  of  the 
compartments  of  the  well,  which  contains  some  water.  The  compart- 
ments are  now  equally  filled  with  water,  and  the  well  so  placed  that 
the  side  containing  blood  receives  yellow  light,  as  from  a  candle, 
while  the  other  receives  light  through  the  wedge  of  glass.  The  glass 
is  now  moved  by  the  rack  and  pinion  until  the  intensity  of  the  color 
in  the  two  compartments  is  the  same,  and  the  percentage  is  then  read 
off  through  the  small  opening  behind  the  well. 

Both  Gowers'  and  Fleischl's  instruments  are  about  equally  accurate, 
and  both  are  graduated  for  a  higher  percentage  of  haemoglobin  than  is 
the  average  with  Americans,  which  may  be  as  low  as  96  per  cent. 

Color-index.  The  haemoglobin  usually  increases  or  diminishes 
with  increase  and  diminution  of  the  red  cells.  If  there  is  any  variation 
from  this  percentage  the  determination  of  this  variation  is  known  as 
the  color-index.  In  a  healthy  individual  with  5,000,000  red  cells  per 
cm.  the  normal  percentage  of  haemoglobin  should  be  100.  We  then 
say  the  color-index  =  1.  If  the  haemoglobin  is  diminished,  the  color- 
index  is  less  than  1.  The  color-index  is  estimated,  first,  by  reducing 
the  count  of  the  cells  to  a  percentage  ;  second,  by  dividing  this  percent- 
age into  the  haemoglobin  percentage.  Thus  if  the  normal  percentage 
of  red  cells  is  present — that  is  100 — and  the  haemoglobin  is  reduced  to 
50  per  cent.,  the  color-index  is  t5q\,  or  0.5  ;  a  reduction  of  the  red  cells 
to  2,500,000  cells  =  50  per  cent,  of  the  normal.  Now,  if  the  haemo- 
globin is  40  per  cent.,  the  color-index  will  be  f -J},  or  0.8. 

Diminution  in  the  amount  of  haemoglobin  is  seen  in  anaemia,  and 
usually  the  reduction  is  lower  than  the  reduction  of  the  red  cells.  In 
chlorosis  the  reduction  in  haemoglobin  is  very  great,  and  in  consequence 
the  color-index  is  lower  than  in  secondary  anaemias.  The  average 
haemoglobin  per  cent,  in  a  large  number  of  chlorotic  cases,  studied  by 
Cabot  and  by  Thayer  was  about  42  per  cent.  At  the  same  time  in 
most  of  these  cases  the  number  of  red  corpuscles  was  over  4,000,000. 

25 


386  GENERAL  DIAGNOSIS. 

Melanaemia.  Melanaemia  is  a  rare  condition,  in  which  black, 
brown,  or  yellow  grannies  are  seen  floating,  either  free  among  the 
blood-cells,  or,  more  commonly,  enclosed  in  cells  resembling  leuco- 
cytes. They  are  present  in  malarial  fevers,  particularly  the  chronic 
forms,  and  in  relapsing  fever. 

Lipsemia  is  the  presence  in  the  blood  of  fat,  usually  in  the  form  of 
small  droplets,  easily  detected  by  the  microscope.  The  diagnosis  can 
be  confirmed  by  treating  the  fresh  preparation  with  a  1  per  cent,  solu- 
tion of  osmic  acid,  followed  by  a  weak  aqueous  solution  of  eosin.  The 
fat-drops  will  appear  black  among  the  faintly  stained  acid  corpuscles. 
A  saturated  solution  of  Soudan  three  in  96  per  cent,  alcohol  will  stain 
fat  drops  bright  red  or  orange.  Lipsemia  occurs  in  chronic  alcoholism, 
chronic  nephritis,  and  diabetes,  and  after-injuries  to  the  bone-marrow. 

The  Acidity  of  Blood.  The  total  acidity  of  the  blood  is  best 
determined  by  Landois'  titration-method,  as  follows  :  Prepare  a  deci- 
normal  solution  of  tartaric  acid  by  dissolving  7.5  grammes  of  the 
chemically  pure  salt "  in  1  litre  of  distilled  water.  By  diluting  centi- 
normal  and  millinormal  solutions  are  obtained.  Prepare  a  series  of 
solutions  as  follows  : 

I.  contains  0.9  c.c.  centinormal  solution  tartaric  acid  -f-  0.1  c.c.  satu- 
rated potassium  sulphate  solution. 

II.  contains  0.8  c.c.  centinormal  solution  tartaric  acid  -f  0.2  c.c.  sul- 
phate solution. 

IX.  contains  0.1  centinormal  acid  -f  0.9  c.c.  sulphate  solution. 

X.  contains  0.9  c.c.  millinormal  acid  -f-  0.1  c.c.  sulphate  solution. 

XVIII.  contains  0.1  c.c.  millinormal  acid  -j-  0.9  c.c.  sulphate  solution. 

In  each  of  a  series  of  watch-glasses  mix  1  c.c.  fluid  (each  watch- 
glass  containing  a  different  strength,  as  in  the  series  above  given)  with 
0.1  c.c.  of  blood.  This  can  be  done  by  a  graduated  pipette.  The 
pipette  of  a  Thoma-Zeiss  haemocytometer  answers  very  well. 

Test  the  contents  of  each  watch-glass  with  a  strip  of  delicate  litmus- 
paper,  and  note  in  which  solution  the  reaction  is  neutral.  This  opera- 
tion must  be  done  quickly,  the  whole  process  not  taking  more  than  one 
and  a  half  minutes  (V.  Jaksch). 

Suppose  0.4  c.c.  tartaric  acid  neutralizes  1  c.c.  of  blood  ;  now,  0.4 
c.c.  tartaric  acid  neutralizes  0.0016  gramme  caustic  soda.  Therefore 
0.1  c.c.  blood  =  0.0016  sodic  hydrate  and  1  c.c.  =  0.16.  The  normal 
alkalinity  is  1  part  XaOH  to  26  to  30  parts  of  blood,  or  1  c.c.  blood 
=  0.33  to  0.38  gramme  NaOH. 

The  alkalinity  of  the  blood  is  diminished  in  : 

1.  Fevers  and  cachexias. 

2.  Toxic  conditions,  as  uraemia,  diabetes,  and  jaundice.  Or  certain 
poisons,  as  C02  and  phosphorus. 

3.  Pernicious  anaemia,  simple  anaemia,  and  leukaemia. 

4.  Chronic  articular  rheumatism  and  gout  (not  in  acute  articular 
rheumatism).     This  may,  perhaps,  be  due  to  the  accompanying  anaemia. 

It  is  increased,  perhaps,  in  chlorosis,  though  this  is  doubted  by  some 
authorities. 

Uric  Acid.  Garrod's  test.  By  this  test  we  can  determine  the  pres- 
ence or  absence  of  large  amounts  of  uric  acid  in  the  blood.     A  few  c.c. 


THE  BLOOD.  387 

of  blood-serum  or  of  serous  fluid  are  placed  in  a  watch-crystal ;  add  to 
this  6  to  10  drops  of  a  30  per  cent,  solution  of  acetic  acid.  Immerse  a 
thread  of  linen  in  the  fluid,  and  keep  it  at  a  low  temperature  for  from 
twelve  to  twenty-four  hours.  If  uric  acid  is  present  in  large  amounts 
at  the  end  of  twenty-four  hours,  crystals  collect  upon  the  thread.  Their 
true  nature  is  determined  by  the  microscope  (see  Urine)  and  the  murex- 
ide  test.     The  serum  may  be  secured  by  a  blister. 

The  Specific  Gravity.  The  specific  gravity  of  the  blood  is  best 
determined  by  the  following  method  : 

Prepare  a  series  of  solutions  of  water  and  glycerin  in  such  proportions 
that  they  form  a  series  gradually  ascending  in  specific  gravity  from 
1040  to  1080.  Place  from  80  to  100  c.c.  of  each  solution  in  a  series 
of  small  glass  jars  and  bring  a  drop  of  blood  exactly  in  the  middle  of 
each,  as  follows  :  A  hypodermic  syringe  is  connected  by  a  small 
rubber  tube  with  a  right-angled  glass  capillary  tube.  A  drop  of  blood 
is  obtained  from  the  finger  in  the  usual  manner,  and  is  drawn  by  means 
of  the  syringe  into  the  capillary  tube.  By  a  gentle  motion  of  the 
syringe  a  small  drop  is  expelled  into  the  fluid  from  the  point  of  the 
tube.  The  drop  will  remain  stationary  if  the  specific  gravity  of  the 
fluid  equals  that  of  the  blood  ;  it  will  sink  if  the  fluid  be  of  less  specific 
gravity  than  that  of  the  blood,  or  will  rise  if  the  fluid  be  of  greater 
specific  gravity  than  the  blood.  By  repeated  examination  the  specific 
gravity  of  any  specimen  can  be  easily  determined.  The  glycerin  mix- 
ture can  be  preserved  by  the  addition  of  a  small  amount  of  thymol, 
and  may  be  used  a  second  time ;  but  in  this  case  it  is  necessary  to  rede- 
termine its  specific  gravity  before  each  usage.  By  the  specific  gravity 
one  can  estimate  the  amount  of  haemoglobin  because  the  former  runs 
parallel  to  the  percentage  of  the  latter.  Two  methods  are  employed — 
the  water  and  glycerin  method  and  the  method  of  Hammerschlag. 

Hammerschlag's  method  is  as  follows  :  Mix  hi  a  urinometer  glass 
such  quantities  of  chloroform  and  benzol  that  the  specific  gravity  is 
about  1059.  Take  a  drop  of  blood  from  the  punctured  ear  by  a  medi- 
cine dropper  or  a  capillary  tube,  and  blow  it  into  the  chloroform-benzol 
mixture.  The  blood  does  not  mix  but  floats  like  a  red  bead.  Add 
chloroform,  drop  by  drop,  if  the  blood  sinks  to  the  bottom.  Add 
benzol  if  it  rises  to  the  top.  After  each  addition  stir  the  mixture  with 
a  glass  rod.  When  the  drop  remains  stationary  in  the  body  of  the 
fluid  its  specific  gravity  is  the  same  as  that  of  the  fluid  as  a  whole. 
Take  the  specific  gravity  and  you  have  the  specific  gravity  of  the  blood. 
Air  should  not  be  blown  into  the  fluid  with  the  blood  drop.  The  fol- 
lowing table  gives  the  relations  of  the  specific  gravity  to  the  hsemc- 
fidobin,  from  which  an  estimate  of  the  haemoglobin  can  bo  made  : 


Spenfic  gravity. 

Hxmogldbin. 

1033    to 

1035       . 

25 

to 

30 

per  cent. 

1035     " 

1038       . 

30 

n 

35 

" 

1038     " 

1040       . 

35 

ic 

40 

1 1 

1040     " 

1045       . 

.        40 

u 

45 

a 

1045     " 

1048       . 

45 

a 

55 

<( 

1048     " 

1050       . 

55 

it 

65 

i  t 

1050     " 

1053       . 

65 

<  t 

70 

1053     " 

1055       . 

70 

it 

75 

" 

1055     ' ' 

1057       . 

75 

tt 

85 

" 

1057     " 

1060       . 

85 

" 

95 

" 

388 


GENERAL  DIAGNOSIS. 


The  specific  gravity  of  the  blood  is  normally  less  in  women,  and  is 
diminished  in  severe  symptomatic  anaemias,  pernicious  anaemia,  chlo- 
rosis, leukaemia,  and,  according  to  Monti  (Archiv.  f.  Kinderheilk.,  Bd. 
xviii.  S.  161),  in  nephritis.  It  is  increased  in  infancy  and  acute  febrile 
diseases,  as  pneumonia,  pleurisy,  etc.  (Monti,  ibid.),  and  also  in  diph- 
theria (Fibrenthal  and  Bernhard,  ibid.,  Bd.  xvii.  H.  5  u.  6). 

Coagulation  Time.  An  estimate  of  the  time  required  for  the  blood 
to  clot  is  valuable,  particularly  in  prognosis.  In  case  of  jaundice,  for 
instance,  in  which  blood  destruction  is  going  on  rapidly,  it  is  well  to 
know  the  clotting  power  of  the  blood,  as  surgical  interference  should  be 
resorted  to  in  obstructive  forms  whenever  the  coagulation  time  is  very 
rapid.     The  method  devised  by  Wright  is  the  best  at  our  command. 

Parasites  in  the  Blood. 

The  principal  vegetable  parasites  are  those  associated  with  the  infec- 
tions and  described  in  Chapters  XIX  and  XX.  They  are  (1)  spirilla 
of  relapsing  fever  ;  (2)  tubercle-bacilli ;  (3)  anthrax-bacilli ;  (4)  bacilli 
of  glanders  ;  (5)  typhoid  bacilli ;  (6)  streptococci  and  staphylococci ; 
(7)  the  bacilli  of  yellow  fever. 

The  animal  parasites  are  :  (1)  Filaria  sanguinis  hominis  ;  (2)  dis- 
toma  haematobium  ;  (3)  plasmodium  of  malaria. 

Fig.  105. 


Filaria  alive  in  the  blood.    Instantaneous  photomicrograph.    Four  hundred  diameters 
magnification.     Four  millimetres  Zeiss  apochromatic.    (F.  P.  Henry.) 

The  Filaria  Sanguinis  Hominis.  Filaria?  are  found  in  the  blood 
and  lymph  of  persons  who  live  in  the  tropics,  and  in  a  few  instances 
have  been  found  in  native  Americans  (John  Guiteras).  They  have  a 
blunt,  rounded  head  with  a  tongue-like  process  and  a  long,  pointed  tail. 

They  produce  lymphatic  swellings  (particularly  of  the  scrotum), 
chyluria,  and  haematuria. 

Patrick  Manson1  says  the  following  are  the  commonest  mistakes  hi 
the  search  for  filariae  :  (1)  The  use  of  too  high  a  magnify  in  g-power  ; 
(2)  employing  too  strong  illumination  ;  (3)  searching  unmethodically 
and  in  too  small  a  quantity  of  blood  ;  (4)  looking  for  filaria?  in  blood 
drawn  from  the  body  at  a  time  when  the  particular  species  sought  for 
is  normally  absent  from  the  circulation.  He  describes  three  forms  : 
Filaria  sanguinis  hominis  noctuma  (the  ordinary  form) ;  filaria  san- 
guinis hominis  diurna ;  and  perstans.     The  last  appears  to  be  the  one 

1  Trans.  Seventh  International  Congress  of  Hygiene  and  Dermography,  vol.  i.  p.  93. 


THE  BLOOD.  389 

associated  with  the  production  of  the  disease  known  on  the  west  coast 
of  Africa  as  "  deeping  sickness"  He  prefers  dry  preparations  of  the 
blood,  stained  with  a  \  per  cent,  eosin  solution  or  a  weak  solution  of 
fuchsin  (one  drop  of  the  saturated  alcoholic  solution  to  an  ounce  of 
water).  If  a  thin  film  of  blood,  before  it  has  fully  dried,  be  held  over 
acetic  acid  so  as  to  imbibe  the  fumes,  and  be  then  stained  in  a  \  per 
cent,  solution  of  eosin,  the  blood  is  stained,  but  any  filariae  remain 
pearly  white. 

The  filariae  may  have  been  discovered  accidentally,  or  are  sought  for 
because  of  hcemcdo-chyluria,  or  lymph-scrotum,  elephantiasis,  or  varicose 
groin  glands  ("  Demerara  groin").  In  the  former  the  chyluria  is  inter- 
mittent. Microscopically,  the  urine  contains  molecular  fat-globules  or 
granules  and  a  few  red  corpuscles. 

ANEMIA. 

Anaemia  is  a  condition  characterized  by  a  reduction  in  the  number 
of  red  blood-cells,  or  of  their  haemoglobin,  or  of  the  albumin,  or  of  all 
combined. 

The  most  casual  observation  may  be  sufficient  for  the  recognition  of 
anaemia.  The  color  of  the  surface,  the  appearance  of  the  mucous  mem- 
branes, and  the  evident  breathlessness  of  the  patient  are  indications  of 
diminution  in  the  amount  of  blood,  or  of  some  of  its  constituents,  as  the 
red  cells,  or  of  the  coloring  matter  of  these  cells.  On  inquiry  it  would 
be  found  that  the  patient  is  easily  prostrated,  that  there  is  breathless- 
ness on  exertion  (aggravated  on  ascending  any  height),  that  there  is 
palpitation  and  perhaps  cardiac  oppression.  The  patient  will  com- 
plain of  neuralgias  in  various  parts  of  the  body,  and  especially  of  the 
neuralgia  so  often  seen  in  the  inframammary  region  of  the  left  side. 
(See  Pain.)  Headache  will  be  a  more  or  less  constant  symptom,  and 
of  this  peculiarity,  that  it  is  increased  when  the  patient  goes  up  stairs, 
and  is  often  throbbing  or  pulsating.  The- anaemic  subject  lias  usually 
a  poor  appetite  and  suffers  from  gastralgia,  although  it  must  be  re- 
membered that  the  gastric  symptoms  of  anaemia  are  as  often  primary 
as  secondary.-  Many  of  the  train  of  symptoms  which  attend  neuras- 
thenia occur  in  the  course  of  anaemia. 

On  physical  examination  of  the  patient  the  appearances  as  above 
indicated  are  found,  although  grave  anaemias  may  be  present,  and  yet 
the  lips  are  bright  red,  the  color  under  the  nails  fair,  and  the  cheeks 
flushed,  especially  if  the  examination  is  made  in  the  evening.  Refer- 
ence must  be  made  to  the  chapter  on  the  Color  or  Hue  of  the  Surface 
for  a  description  of  the  appearances  of  anaemia. 

A  study  of  the  heart  and  bloodvessels  usually  yields  the  physical 
signs  that  attend  anaemia.  The  vascular  phenomena  are  described  in 
the  section  on  Diseases  of  the  Heart.  Here,  again,  it  must  be  remem- 
bered that  considerable  anaemia  may  be  present  without  any  murmurs 
in  the  bloodvessels. 

The  Blood.  The  final  diagnosis  rests  upon  an  examination  of  the 
blood.  Sometimes  the  most  apparently  anaemic  subjects  yield  normal 
results  in  blood  examination,  while  the  most  plethoric   in  appearance 


390 


GENERAL  DIAGNOSIS. 


may  be  very  anaemic.  The  various  forms  of  anaeinia  give  rise  to  blood 
changes  in  a  measure  peculiar  to  the  respective  variety.  The  primary 
anaemias,  or  hemolytic  varieties,  to  which  pernicious  anaemia  and  chlo- 
rosis belong,  have  characteristics  which  will  be  described  in  the  special 
sections. 

In  anaemia  from  hemorrhage  the  red  corpuscles  may  be  reduced  to 
1,500,000.  The  haemoglobin  is  reduced  to  a  degree  greater  than  that 
of  the  red  cells.  The  leucocytes  are  increased  in  number,  the  polynu- 
clear  forms  being  relatively  much  less  than  the  other  varieties. 

The  red  corpuscles  are  paler  than  normal ;  their  white  centres  are 
increased  in  size.  This  is  known  as  achromia.  There  is  some  poikilo- 
cytosis.  An  excess  of  nucleated  red  corpuscles,  or  blasts,  are  seen  in 
grave  anaemias.  If  the  normoblasts  are  in  excess,  active  regeneration 
is  in  progress  ;  if  the  megaloblasts,  there  is  reversion  to  embryonal  regen- 
eration, a  serious  import  in  an  anaemia.  A  megaloblast  anaemia  is 
associated  with  general  increase  in  size  of  red  cells  and  an  increase  of 
the  macrocytes.  In  fatal  anaemia,  as  in  purpura,  the  red  cells  are  like 
those  in  the  form  just  described,  although  nucleated  red  corpuscles 
are  absent.  The  white  cells  are  also  reduced,  although  the  mono- 
nuclear forms  are  numerous. 

In  the  oligocythaemic  forms  of  anaemia,  other  than  the  hemorrhagic, 
the  occurrence  of  poikilocytosis  is  constant  and  marked.  Nucleated 
red  corpuscles  are  not  common,  but  large  nucleated  cells  in  which 
karyokinetic  figures  occur.  These  corpuscles  have  pale  staining 
nuclei.  Achromic  forms,  polyehromatophiles,  and  degenerate  forms 
are  seen.      There  is  usually  moderate  leucocvtosis. 

For  clinical  purposes  it  is  necessary  to  make  a  number  of  divisions 
of  anaemia,  though  on  etiological  and  pathological  grounds  many  of 
them  will  no  doubt  soon  be  grouped  together. 

The  following  classification  of  anaemias  is  helpful  in  the  study  of 
anaemia.  In  it  both  pernicious  anaemia  and  chlorosis  are  regarded  as 
haemolvtic  in  origin,  the  destructive  agent  probably  being-  absorbed 
from  the  intestine. 


AX-EMIA, 


Xon-cytogenic, 


Haemolytic, 


Oligocythemic, 


f  Pernicious  anaemia. 
J   Other  toxic  anaemias. 
J   Chlorosis. 

I.  Parasitic  anaemia  (some  forms). 

f  Parasitic  anaemia  (some  forms). 
J   Post-hemorrhagic  anaemia. 
I   Ansemia  from  loss  of  albumin. 
I  Anaemia  of  malnutrition. 


(.  Cytogenic. 


r  Spleno-myelogenic. 
Leucocytic,  Leacocytbaemia,  <  Lymphatic. 

I  Medullary  or  myelogenic. 


I.  Xon-leucocytic,         Hodgkin's  disease  (?). 


I.  Toxic  Anaemias.  The  poison  may  be  developed  in  the  body  or 
introduced  from  without.  Toxaemia  is,  sometimes  at  least,  a  factor  in 
the  anaemias  which  develop  in  the  course  of  acute  infectious  diseases  or 
during  convalescence  from  them.  According  to  Hunter,  pernicious 
anaemia  should  be  classed  under  this  head.     The  metallic  poisons,  par- 


THE  BLOOD. 


391 


ticularly  lead,  mercury,  arsenic,  phosphorus,  the  potassium  salts,  espe- 
cially the  chlorate  ;  certain  of  the  antipyretics,  notably  pyrodin  ;  and 
the  aniline-preparations  are  capable  of  producing  anaemia. 

II.  Parasitic  Anaemias.  Anaemia  may  be  parasitic.  1.  To  this 
class  belongs  the  anaemia  of  malaria,  which  is  believed  to  be  due  to 
the  plasmodium  malar  ice  described  by  Laveran. 

2.  Certain  intestinal  worms  are  found  associated  with  marked  anaemias. 
(a)  The  bothriocephalus  latus  sometimes  produces  a  disease  closely  re- 
sembling pernicious  anaemia,  but  whether  by  direct  destruction  of  the 
blood,  or  by  the  development  of  toxic  products,  themselves  destructive, 
is  uncertain  ;  it  may  be  present  in  large  numbers  without  giving  rise 
to  anaemia. 

Fig.  106. 


Severe  anaemia    (Reproduced  from  colored  plate.)    Dry  preparation.    X  300.    Great  poikilocytosis. 
Many  macrocytes  and  microcytes.    To  the  left  above,  a  mononuclear  leucocyte. 


(6)  The  arikylostomwm  duodenale  is  believed  to  be  the  cause  of  the 
anaemia  known  variously  as  Egyptian  or  African  chlorosis,  tropical 
anaemia,  brick-burner's  anaemia,  etc. 

(c)  The  anguillula  intestinalis  is  the  cause  of  "  Cochin-China  diar- 
rhoea "  and  its  associated  anaemia. 

3.  The  filaria  sanguinis  hominis  may  produce  anaemia  by  blocking 
up  the  lymph-channels. 

4.  The  Bilharzia  hasmatobia  may  produce  anaemia  by  inducing  hema- 
turia. 

III.  Anaemia  from  Hemorrhage.  Anaemia  may  be  due  to  hemor- 
rhage. In  addition  to  accidental  and  postpartum  causes,  purpura, 
haemophilia,  menorrhagia,  and  metrorrhagia  are  frequent  causes. 

IV.  Anaemia  from  Constitutional  and  Local  Diseases.  Anaemia 
is  often  a  marked  symptom  of  constitutional  and  local  diseases,  >uch  as 
tuberculosis,  syphilis,  cancer,  rheumatism,  scrofula,  scurvy,  rickets, 
Bright's  disease,  chronic  catarrhal  gastritis,  and  others.  The  anaemia 
here  may  be  due  to  the  malnutrition  and   interference  with   digestion 


392 


GENERAL  DIAGNOSIS. 


brought  about  by  the  disease,  or,  as  iu  the  case  of  Bright's  disease, 
in  part  to  the  direct  loss  of  albumin,  and  in  dyspeptic  conditions  to 
inability  to  take  and  assimilate  food. 

In  many  cases  of  simple  symptomatic  anaemia  the  spleen  may  become 
progressively  enlarged,  probably  secondarily.  In  other  cases  there  is 
an  enlargement  of  the  spleen  in  Hodgkin's  disease.  In  no  case  is 
there  a  primary  splenic  anaemia. 

V.  Anaemia  of  Malnutrition.  Anaemia  may  also  be  the  result  of 
malnutrition  from  deficient  or  improper  food,  or  from  the  poisonous 
influences  of  unsanitary  surroundings. 

Chlorosis. 

Chlorosis,  or  chloro-anaeniia,  is  a  form  of  anaemia  occurring  especially 
in  young  girls  about  the  period  of  puberty,  and  characterized  by  great 
pallor  of  the  skin  and  mucous  membranes,  with  a  greenish  tint  of  the 
skin,  a  pearly  eye,  languor,  weariness,  suppression  or  irregularity  of 

Fig.  107. 


DATE 

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Chlorosis.    Straight  lines,  number  of  red  cells:  small  dots,  percent,  of  haemoglobin;  large  dots, 

number  r>f  white  cells. 

menstruation,  venous  hum  in  the  vessels,  dyspnoea,  palpitation,  dizziness, 
neuralgias,  and  an  unstable  condition  of  the  nervous  system.  In  spite 
of  the  extreme  pallor  there  is  usually  but  little  loss  of  flesh.     The  skin 


PLATE    XI. 


o  *&  .*£•  «%» 

©0 


Blood  from  Case  of  Chlorosis,  showing  slight  Staining  of  the  Red 
Blood-eorpuscles,  and  presence  of  Mononuclear  Leucocytes. 

(Oc.  4.  ob.  J1*  immersion.)     Drawn  by  J.  D.  Z.  Cbase. 


FTG.   2. 


o      ° 


0 


o 


O 


Blood  in  Pernicious  Anaemia,  showing  Macrocytes 
and  Mierocytes. 

(Eosin  stain,  oc.  4.  i>b.  ^  oil  immersion.)     Drawn  by  J.  D.  Z.  Chase. 


THE  BLOOD.  393 

may  be  pigmented,  especially  around  joints.  The  bowels  are  usually 
constipated  ;  the  urine  abundant,  pale,  and  of  low  specific  gravity. 
The  digestion  is  disturbed,  the  appetite  capricious,  and  the  patients 
sometimes  crave  unwholesome  things,  such  as  earth,  slate-pencils, 
vinegar,  and  the  like.  Hyperacidity  of  gastric  juice  is  commonly 
present.  A  systolic  murmur  over  the  base  of  the  heart  is  common. 
Gastralgia  is  more  common  than  in  other  forms  of  anaemia. 

The  changes  in  the  blood  are  very  important.  There  is  always  a 
marked  reduction  in  the  haemoglobin,  the  percentage  falling  sometimes 
to  30  or  25  per  cent,  of  the  normal.  The  red  blood-cells  are  usually 
also  reduced,  but  not  in  the  same  proportion  as  the  haemoglobin.  For 
example,  there  may  be  4,000,000  red  cells,  but  only  30  per  cent,  of 
haemoglobin.  Sometimes  there  is  no  diminution  in  the  number  of  red 
cells  ;  the  latter,  however,  appear  pale  (achromia),  vary  considerably  in 
size,  microcytes  and  occasionally  poikilocytes  are  present,  and,  in  severe 
cases,  nucleated  red  corpuscles  are  found ;  occasionally  macrocytes 
occur,  but  in  general  the  size  of  the  red  cells  is  below  that  which  is 
usually  found.  The  number  of  leucocytes  varies  but  little  from  the 
normal,  but  there  may  be  a  slight  increase.  Occasionally  there  is  a 
rise  of  temperature,  but  it  is  probably  due  to  some  complication. 
(See  Plate  XL,  Fig.  1.) 

The  cause  of  chlorosis  has  not  been  determined  satisfactorily.  Vir- 
chow  has  established  the  existence  of  congenital  narrowing  of  the  blood- 
vessels. Sir  Andrew  Clark  thinks  it  is  due  to  the  absorption  of 
poisonous  matter  from  the  intestine  ;  the  great  benefit  that  follows 
saline  purgatives  in  many  cases  indicates  that  faecal  toxaemia  is  a  factor 
in  these  cases.     Forchheimer1  also  looks  upon  it  as  intestinal  in  origin. 

Sex  and  puberty  are  predisposing  causes ;  but  chlorosis  may  occur 
in  boys,  and  appear  in  girls  before  puberty,  and  in  young  women  con- 
siderably after  that  period.  The  prognosis  is  favorable  ;  it  may,  how- 
ever, be  complicated  with  gastric  ulcer,  chorea,  tuberculosis,  and  endo- 
carditis.    Kecovery  is  often  slow  and  interrupted  by  relapses. 

Pernicious  Anaemia. 

Pernicious  or  idiopathic  anaemia  is  a  form  in  which  the  diminution 
of  red  blood-cells  reaches  an  extreme  degree.  It  occurs  without  ade- 
quate known  cause,  and  runs  a  progressive  course  with  remissions  ;  it 
usually  terminates  in  death. 

The  disease  usually  develops  slowly  and  insidiously,  the  patient  pre- 
senting the  ordinary  symptoms  of  anaemia — pallor,  weakness,  shortness 
of  breath,  palpitation,  venous  murmurs,  loss  of  appetite,  and  impaired 
digestion.  As  the  disease  progresses  the  skin  becomes  of  a  pale  Lemon 
hue,  weakness  and  dyspnoea  increase,  the  patient  has  attacks  of  dizzi- 
ness, faintness,  and  ringing  in  the  ears  ;  there  may  be  slight  (edema, 
and  hemorrhages  from  the  nose,  the  bowels,  and  into  the  retina  occur. 
The  hemorrhages  are  small  and  distinct  in  the  skin  and  mucous  mem- 
branes. The  urine  is  of  low  specific  gravity,  and  usually  contains  an 
increased  amount  of  uric  acid.    According  to  Hunter,  the  mine  should 

1  Trans.  Assoc.  Amer.  Phys.,  1893. 


394 


GENERAL  DIAGNOSIS. 


be  dark  and  contain  a  pathological  amount  of  urobilin,  some  renal 
epithelium,  a  few  casts  containing  blood-pigment,  and  an  increased 
amount  of  iron.     The  bowels  may  be  disturbed  by  diarrhoea. 

A  peculiarity  of  the  disease  is  the  occurrence  of  fever  of  an  irregular 
type.  The  temperature  rarely  rises  higher  than  102°  or  103°  in  the 
evenings,  and  is  followed  by  a  morning  remission.  It  is  not  usually 
present  in  the  early  stages  of  disease,  may  be  absent  for  weeks  at  a 
time  when  the  disease  is  fully  developed,  and  may  cease  entirely  in  the 
later  stages.1 

In  spite  of  extreme  exhaustion,  anaemia,  and  wide-spread  functional 
disturbance,  there  is  no  emaciation  ;  the  patient  appears  well  nourished. 

The  blood  appears  pale  and  watery  to  the  naked  eye  ;  there  is  diffi- 
culty in  obtaining  by  puncture  a  sufficiently  large  drop  for  examina- 
tion. The  specific  gravity  is  lowered,  often  being  1028  instead  of 
1055.     It  has  been  found  deficient  in  fibrin,  iron,  and  nitrogen. 

The  blood-changes  in  idiopathic  anaemia  are  characteristic,  and  are 
essential  to  the  diagnosis  of  the  disease.  In  brief  they  are  :  (1)  Very 
great  reduction  in  the  number  of  red  blood-cells  ;  (2)  an  absolute  dirni- 

Fig.  108. 


85'-' 

DATE 

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2/ 

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Pernicious  anaemia.    Straight  lines,  number  of  red  cells ;  small  dots,  per  cent,  of  haemoglobin ; 
large  dots,  number  of  white  cells. 

nution  in  the  amount  of  haemoglobin,  but  as  compared  with  the  number 
of  red  cells  there  may  be  a  proportionate  increase  ;  (3)  considerable 

-    1  See  "Idiopathic  Anaemia:  A  Report  of  Three  Cases."     Musser,  Phila.  Co.  Med. 
Soc.  Trans.,  1885. 


THE  BLOOD.  395 

variation  in  the  size  of  the  cells,  the  average  size  of  the  cells  probably 
being  larger  ;  (4)  poikilocytosis  ;  (5)  nucleated  red  blood-cells  ;  (6) 
degenerative  cells.     (See  Plate  XI.,  Fig.  2.) 

Redaction  in  the  number  of  red  blood-cells  (oligocythemia)  reaches 
a  more  extreme  degree  in  pernicious  anaemia  than  in  any  other  disease ; 
the  number  often  falls  below  1,000,000,  and  in  one  case  reported  by 
Quincke1  the  number  was  only  143,000  per  cubic  millimetre.  The 
shape  of  many  of  the  cells  is  altered  ;  they  are  oval,  elongated,  bent, 
or  have  projections  of  their  substance  (poikilocytosis).  The  size  of  the 
cells  varies  ;  there  are  microcytes  and  megaloblasts  ;  but  the  occur- 
rence of  a  distinct  proportion  of  large  nucleated  red  blood-cells  (megal- 
oblasts) is  regarded  by  Ehrlich  as  almost  diagnostic.  The  average 
size  of  the  red  cell  seems  to  be  increased,  and  so  is  the  proportionate 
amount  of  haemoglobin  in  each  cell.  The  latter  is  a  very  character- 
istic symptom  (the  only  one,  according  to  Hunter).  There  are  also 
red  corpuscles  which  are  stained  by  methylene-blue  ;  these  are  regarded 
as  degenerative  by  Ehrlich.  The  leucocytes  are  "  usually  diminished 
in  number,  showing  a  relative  increase  in  the  small  mononuclear  ele- 
ments (lymphocytes,  small  transparent  forms),  while  the  multinuclear 
elements  are  relatively  diminished,  sometimes  being  under  50  per 
cent."  2 

The  blood  condition  is  not  constant,  but  is  subject  to  wide  varia- 
tions. Von  Noorden  has  recently  found  that  in  a  very  short  time  a 
change  in  the  form  of  the  blood,  a  ' '  formal "  crisis,  may  occur.  A 
"formal"  overflow  of  the  blood  with  polynuclear  leucocytes  and 
nucleated  red  blood-cells  takes  place  before  a  period  of  improvement. 
Whereas,  before  a  period  in  which  the  blood  becomes  worse  and  before 
the  final  stage,  the  blood  becomes  poor  in  leucocytes  and  nucleated  red 
blood-cells.3 

Secondary  sclerotic  changes  in  the  spinal  cord  cause  late  symptoms 
of  locomotor  ataxia. 

The  etiology  of  the  disease  has  not  been  determined  satisfactorily. 
It  is  more  common  in  Germany  and  Switzerland  than  in  other  parts 
of  Europe  or  in  America.  It  occurs  most  frequently  after  the  twen- 
tieth year,  and  between  that  and  the  age  of  fifty.  Excluding  the 
influence  of  pregnancy  and  parturition,  sex  makes  no  difference.  Pre- 
vious exhausting  disease,  chronic  gastric  and  intestinal  catarrh,  great 
physical  over-exertion,  exposure,  great  shock  or  fright,  precede  in 
certain  cases  the  development  of  the  disease.  It  is  probably  due  to 
faulty  hsematogenesis  and  haemolysis. 

Petrone  and  Halst  regard  the  disease  as  infectious  and  its  genu 
identical  with  that  found  by  Frankenhauser.  Von  Jaksch  supposes 
that  it  is  brought  about  by  a  living  contagium.  Hunter  traces  the 
cause  to  a  poison  produced  by  bacteria  in  the  gastro-intestinal  canal. 

Diagnosis.  The  most  important  diagnostic  features  of  the  disease 
are  extreme  oligocytha?mia,  relatively  high  percentage  of  haemoglobin 
(color-index  high),  great  poikilocytosis,  which  may,  however,  occur  in 

1  Deut.  Arch,  fur  klin.  Med.,  Bd.  xx. 

2  W.  S.  Thayer:  Boston  Med.  and  Surg.  Journ.,  February  16  and  23,  1893. 

3  Quoted  by  Weiss,  Diagnostisches  Lexikon. 


396  GENERAL  DIAGNOSIS. 

any  severe  anaemia,  a  noticeable  number  of  large  nucleated  red  blood- 
cells  (gigantoblasts),  an  average  increase  in  the  size  of  the  cells,  and 
all  this  without  emaciation  or  discoverable  local  disease  which  can  bear 
a  causative  relation  to  the  anaemia.  In  addition,  retinal,  subcutaneous, 
and  submucous  hemorrhages,  a  urine  with  high  specific  gravity,  high 
color,  with  urobilin  in  excess,  alternating  with  urine  of  low  specific 
gravity,  in  the  absence  of  organic  disease,  point  to  pernicious  or  idio- 
pathic anaemia. 

Leucocythsemia. 

Leucocythaemia,  or  leukaemia,  is  a  disease  of  the  blood-making  organs, 
characterized  by  great  and  persistent  increase  in  the  white  blood-cor- 
puscles ;  by  a  diminished  number  of  red  blood-cells,  which  are  altered 
in  shape  and  size,  and  display  nucleated  and  degenerate  forms ;  by  a 
lessened  amount  of  haemoglobin,  and  by  changes  in  the  spleen,  lym- 
phatic glands,  or  medulla  of  bone.  It  is  a  persistent  and  progressive 
cellular  proliferation.  It  resembles  a  tumor  of  solid  tissue  in  its  cel- 
lular overgrowth.  The  disease  occurs  twice  as  frequently  in  men  as  in 
women,  and  two-thirds  of  the  cases  appear  between  the  twentieth  and 
fiftieth  years.  In  women,  pregnancy,  parturition,  and  the  cessation  of 
menstruation  are  causative  factors,  while  in  both  sexes  depressing  influ- 
ences upon  body  or  mind  and  antecedent  disease,  particularly  malarial 
fever,  have  a  distinct  influence. 

The  first  symptom  noted  is  generally  enlargement  of  the  abdomen  ; 
subsequently  the  patient  complains  of  pains  in  the  splenic  region,  weak- 
ness, dyspnoea,  hemorrhage,  oedema,  and  digestive  derangements.  Occa- 
sionally profuse  hemorrhage  from  trifling  cause,  as  the  drawing  of  a 
tooth,  has  been  the  earliest  symptom  noted.  The  increase  of  white 
cells  and  diminution  of  red  cells  is  progressive,  and  soon  makes  itself 
evident  in  the  pallor  of  the  skin  and  mucous  membranes,  and  in 
increasing  weakness  and  dyspnoea.  Pallor  is  not  a  constant  symptom 
of  leukaemia.  A  high  grade  of  color  is  consistent  with  advanced 
leukaemia. 

In  the  so-called  spleno-medullary  form  of  the  disease  the  spleen 
steadily  enlarges,  but  may  attain  considerable  size  before  the  patient 
becomes  aware  of  it.  The  enlargement  is  not  usually  painful,  but  gives 
rise  to  a  feeling  of  distention,  weight,  and  dragging.  There  may  be 
tenderness  on  palpation  and  pressure,  and  sometimes  the  patient  com- 
plains of  sharp,  stabbing  pains,  due  either  to  attacks  of  local  peritonitis 
or  to  sudden  enlargement  of  the  spleen  and  consequent  stretching  of 
the  capsule.  The  splenic  enlargement  is  uniform,  so  that  its  shape  and 
characteristic  notch  are  unchanged.  Moreover,  the  spleen  remains  in 
contact  with  the  abdominal  walls,  lying  in  front  of  the  splenic  flexure 
of  the  colon,  pushing  aside  the  descending  colon  and  small  intestine, 
moving  with  respiration,  and  presenting  the  usual  physical  signs  of  a 
solid  organ.  Not  infrequently  the  enlargement  is  so  great  as  to  fill 
the  left  hypochondriac  and  iliac  regions,  and  reach  beyond  the  middle 
line  toward  the  right  groin.  Sometimes  a  venous  hum  can  be  heard 
over  it.  Pallor,  however,  is  not  a  constant  symptom  ;  more  frequently 
the  cheeks  are  flushed  and  the  lips  red. 


PLATE    XII. 


o.,<N 


i 


! 


^ 


i.     Globiferous  cell. 
3.     Polynuclear  cell. 


Lymph-gland,  Retroperitoneal  Region. 

Hardened  in  Alcohol ;   Rosin's  Stain.     X  1500. 

2.     Globiferous  cell  containing-  polynuclear  and  eosinophile  cells. 

4.     Mononuclear  cell.  5.     Globiferous  cell.  6.     Eosinophile  cell. 


FIG.   2. 


Blood — Leukaemia. 

Haematoxylin  and  Eosin. 

7.     Lymphocyte.  2.     Eosinophile  cell  (mononuclear). 

3.      Polynuclear  leucocyte.  4.     Large  mononuclear  leucocyte  (myelocyte?). 


THE  BLOOD.  397 

As  the  result  of  this  enlargement  the  diaphragm  is  pushed  upward, 
increasing  the  dyspnoea  already  caused  by  anaemia,  and  sometimes  in- 
ducing palpitation.  The  gastric  functions  are  disturbed  from  press- 
ure ;  vomiting  and  other  symptoms  of  dyspepsia  are  common. 

A  rise  in  temperature  is  a  very  common  symptom.  The  fever  is  of 
irregular  type,  usually  with  nocturnal  exacerbations,  the  temperature 
not  often  rising  above  102°.  The  febrile  type  may  be  intermittent  or 
remittent,  and  sometimes  there  are  periods  of  apyrexia. 

The  pyrexia  is  said  to  be  most  marked  toward  the  close  of  the 
disease.  Gowers  states  that  the  cases  in  which  there  is  most  fever 
are  usually  those  of  rapid  course,  considerable  dropsy,  and  extensive 
hemorrhage. 

As  the  disease  progresses  weakness  increases ;  anaemia  becomes  more 
intense  ;  oedema,  ascites,  or  hydrothorax  occurs  ;  hemorrhages  from  the 
nose,  gums,  bowels,  stomach,  lungs,  or  uterus  further  exhaust  the  patient ; 
digestion  is  poor  and  diarrhoea  is  common. 

Headache  and  tinnitus  are  frequent  symptoms,  occasionally  delirium 
and  coma  may  occur,  and  deafness  is  not  uncommon  toward  the  close 
of  the  disease.     The  eyes  may  be  the  seat  of  leukaemic  retinitis. 

The  liver  is  enlarged,  often  to  a  considerable  degree,  but  without 
special  symptoms.  The  same  is  true  of  the  lymphatic  glands  and  other 
adenoid  tissue.  (See  Plate  XII.,  Fig.  1.)  The  marrow  of  the  bones 
becomes  the  seat  of  disease  in  some  cases,  but  it  does  not  usually  give 
rise  to  symptoms  during  life  ;  certain  bones,  however,  may  be  tender.1 

The  Blood.  The  most  characteristic  and  important  changes  from 
a  diagnostic  point  of  view  occur  in  the  blood.  The  blood  when  drawn 
from  the  finger  is  strikingly  pale  and  whitish,  an  appearance  supposed 
at  one  time  by  Bennett  to  be  due  to  admixture  of  pus.  It  coagulates 
slowly,  is  of  lower  specific  gravity  than  normal,  and  its  alkalinity  is 
diminished.  When  placed  under  the  microscope  it  is  at  once  seen 
that  the  number  of  white  cells  is  greatly  increased.  If  a  drop  of 
blood  is  mixed  with  some  distilled  water  containing  a  small  quantity 
of  gentian-violet,  the  white  cells  are  stained  a  decided  blue  and  can  be 
picked  out  with  the  greatest  ease.  Instead  of  there  being  one  white 
cell  to  300  or  500  red,  the  ratio  falls  as  low  as  1  :  5  or  1  :  3,  or  even 
lower.  Authorities  differ  as  to  the  degree  of  increase  necessary  to  dis- 
tinguish leucocythaemia  from  leucocytosis,  some  including  all  in  which 
the  ration  is  1  :  50  or  lower,  and  others  excluding  those  in  which  the 
ratio  is  greater  than  1  :  20  or  1  :  12.  In  leucocytosis  the  increase 
takes  place  solely  in  the  polynuclear  neutrophilic  leucocytes. 

Not  only  the  white  cells  greatly  increase  in  number,  but  they  vary 
considerably  in  size  and  react  differently  to  staining-fiuids. 

Ehrlich  has  described  five  varieties  of  leucocytes.  The 'pathologi- 
cal changes  in  the  normal  leucocytes  in  this  disease  are  :  (1)  The  small 
mononuclear  elements  are  relatively  diminished  ;  (2)  the  great  differ- 
ence in  size  of  the  multinuclear  elements;  (3)  the  presence  of  myelo- 
cytic elements,  in  which  the  protoplasm  is  filled  with  fine  neutrophilic 

1  See  "A  Case  of  Leucocythsemia."  Musser  and  Sailer,  Airier.  Journ.  of  the  Med. 
Sciences,  1896. 


398 


GENERAL  DIAGNOSIS. 


granules  ;  (4)  the  presence  of  a  normal  proportion  of  eosinophiles^in  so 
extensive  an  increase  of  leucocytes.1  (Plate  XII.,  Fig.  2.)  (5)  Large 
mononuclear  elements  with  karyokinetic  figures  (Miiller).  (6)  Mast- 
cells.  Satisfactory  study  of  these  can  be  obtained  only  by  cover-glass 
preparations. 

Fig.  109. 


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Leuktemia.    Straight  line,  red  cells ;  small  dots,  hEemoglobin  ;  large  dots,  white  cells. 


The  essential  points  in  the  diagnosis  of  leucocythsemia  are  :  1.  Such 
an  excess  of  leucocytes  in  the  blood  that  the  ratio  of  white  to  red  falls 
below  1  :  50  or  1  :  20  ;  if  the  ratio  is  higher,  the  white  cells  should 
show  a  progressive  increase.  The  individual  leucocytes  vary  in  size 
and  characteristics,  as  already  described.  2.  Enlargement  of  the  spleen 
or  lymphatic  glands.  3.  The  occurrence  of  hemorrhages  and  dropsies 
unexplainable  by  disease  of  the  heart,  kidneys,  or  other  organs.  4. 
The  symptoms  of  anaemia  of  a  high  grade,  as  dyspnoea.  5.  Leukemic 
retinitis.  6.  Anaemic  fever.  7.  The  presence  of  the  myelocyte  of 
Ehrlich,  "  mast-cells,"  and  nucleated  red  blood-cells.  8.  Specific 
gravity  below  1040.     9.  Excess  of  uric  acid  in  the  urine. 

1  W.  S.  Thayer,  loc.  cit. 


THE  BLOOD.  399 

The  lymphatic  form  of  the  disease  is  rare.  It  is  characterized  by 
enlargement  of  the  lymphatic  glands  and  by  the  great  increase  in  the 
proportion  of  the  lymphocytes.  The  total  increase  in  the  colorless 
elements  is  not  so  excessive.  Eosinophils  and  nucleated  red  cells 
are  rare.  The  myelocyte  of  Ehrlich  is  not  present.  A  case  of  a  purely 
myelogenous  form  has  never  been  authenticated.  Combination-forms 
may  also  occur.  It  must  be  remembered  that  the  number  of  myelo- 
cytes is  no  indication  of  the  involvement  of  the  bone-marrow. 

In  secondary  or  so-called  splenic  ancemia  we  find  the  same  enlarge- 
ment and  the  general  symptoms,  though  hemorrhage  is  not  so  common. 
Leucocythsemia  is  distinguished  from  it  by  the  great  excess  of  leuco- 
cytes and  by  their  special  characteristics. 

In  lymphadenoma,  or  Hodgkin's  disease,  there  is  extreme  anaemia, 
though  the  excess  of  leucocytes  found  in  leucocythsemia  is  seldom 
reached,  and  the  cells  are  smaller.  The  glandular  enlargement  of 
lymphadenoma  is  an  early  and  constant  symptom,  the  spleen  not  being 
much  enlarged.  The  cervical  glands  are  the  ones  usually  first  in- 
volved. 

The  duration  of  leucocythamiia  is  usually  two  or  three  years  ;  but 
some  cases  terminate  in  six  months  or  less,  and  some  last  six  or  seven 
years.  The  size  of  the  spleen  and  the  degree  of  oligocythsemia  appear 
to  have  no  influence.  Gowers  states  that  the  cases  in  which  enlarge- 
ment of  the  lymphatic  glands  is  an  early  symptom  run  a  course  appar- 
ently much  more  acute  than  others,  but  he  admits  that  the  number  of 
such  cases  is  comparatively  small. 

Death  results  most  frequently  from  gradual  loss  of  strength.  Hem- 
orrhage from  various  organs  and  surfaces  is  the  immediate  cause  in 
many  cases.  It  occurs  in  about  three-fourths  of  the  cases,  and,  when 
not  directly  fatal,  increases  the  pre-existing  asthenia.  Diarrhoea  and 
pulmonary  complications  are  not  infrequent  causes  of  death. 

Acute  Leukcemia.  Cases  have  been  described,  especially  in  children, 
in  which  there  is  a  diminution  of  red  cells  of  haemoglobin.  Nucleated 
red  cells  are  present  as  well  as  an  excess  of  white  blood-corpuscles, 
which  consist  almost  entirely  of  large  mononuclear  elements,  without 
granulation.  There  is  usually  fever,  and  the  disease  runs  a  course 
much  resembling  an  infectious  one.  The  lesions  are  leucocytic  infil- 
tration of  the  various  organs.1 

1  See  "Acute  Leukaemia."  Fussell,  Jopson,  and  Taylor,  Assoc.  Am.  Phys.,  vol.  x. 
1898  ;  and  Musser,  Trans.  Phil.  Co.  Med.  Soc,  1887. 


CHAPTER    XXIII. 

THE  MORBID  PROCESSES  AND  THEIR  SYMPTOMATOLOGY. 

Knowledge  of  symptoms  of  morbid  processes  essential ;  they  control  conclusions  drawn 
from  data. — Morbid  processes  are  few.  I.  Alterations  in  blood  and  circulation: 
Ansemia  and  plethora — Hyperemia,  active  and  passive— (Edema  and  dropsy 
— Thrombosis  and  embolism — Hemorrhage — Blood-pressure.  II.  Disturbances 
of  nutrition:  Inflammation  —  Gangrene  and  necrosis  —  Fever  —  Atrophy  and 
hypertrophy.  Degenerations  :  Albuminous  —  Fatty  —  Colloid  —  Mucous  —  Pig- 
mentary— Calcareous — Amyloid — Fibroid.  III.  Anomalies  of  growth:  Tumors 
— Cysts — Cancer. 

Although  we  may  have  secured  all  the  data  obtainable  by  inquiry 
and  by  observation,  and,  if  possible,  made  a  diagnosis  based  upon  them, 
it  frequently  happens  that  the  conclusion  arrived  at  is  not  final  and  per- 
haps cannot  be,  from  the  nature  of  the  case.  We  are  prompted,  there- 
fore, to  view  the  case  from  a  different  stand-point,  to  utilize  our 
knowledge  of  the  phenomena  of  morbid  processes,  and,  for  the  purpose 
of  comparison,  to  review  the  features  of  such  as  apparently  resemble 
the  process  under  consideration.  Thus,  for  instance,  in  an  obscure 
case  of  fever,  the  objective  and  subjective  phenomena  have  been  fully 
inquired  into  —we  are  unable  to  decide  whether  the  disease  under  con- 
sideration is  a  septic  process  with  obscure  lesion,  a  form  of  miliary 
tuberculosis,  or  of  malignant  endocarditis.  The  known  symptoms  of 
each  are  considered  (our  knowledge  of  such  symptoms  depending  upon 
our  knowledge  of  the  phenomena  of  the  respective  morbid  process)  and 
compared  with  the  symptoms  presented  by  the  case  in  question.  In 
this  manner  a  diagnosis  by  exclusion  is  made.  Moreover,  after  a  diag- 
nosis is  made,  a  review  of  the  symptomatology  of  morbid  processes 
serves  as  a  check  upon  the  conclusions  that  have  been  reached.  We 
should  also,  after  making  a  diagnosis,  compare  the  symptoms  of  the 
process  as  exhibited  in  the  patient  with  the  symptoms  which  we  know 
to  be  common  in  the  suspected  disease. 

It  is  necessary,  therefore,  that  the  student  should  fully  know  the 
symptoms  of  morbid  processes.  Each  process  is  characterized  by 
special  phenomena  by  which  it  can  be  recognized.  The  symptoms 
are  modified  by  the  function  and  anatomical  structure  of  the  organ  in 
which  the  process  takes  place.  Thus  the  pathological  products  of  in- 
flammation of  the  mucous  membranes  of  the  bronchial  tubes  and  of 
the  stomach  are  the  same,  but.  the  symptoms  differ,  because  of  the 
difference  in  their  functions,  and  hence  we  have  cough  in  the  former 
case,  in  the  latter,  vomiting.  Very  frequently  the  symptoms  differ 
because  of  the  physical  alterations.  Thus  inflammation  of  the  pericar- 
dium is  similar  to  inflammation  of  the  pleura,  but  the  pressure-symp- 


MORBID  PROCESSES  AND  THEIR  SYMPTOMATOLOGY.    401 

toms  of  pericarditis  are  entirely  different,  because  of  the  anatomical 
relations,  from  the  pressure-symptoms  of  pleuritis. 

The  morbid  processes  are  not  many.  They  include  :  I.  Alterations 
in  the  blood  and  circulation ;  II.  Disturbances  of  nutrition  ;  III. 
Anomalies  of  growth. 

I.  Alterations  in  the  Blood  and  Circulation.  The  composition 
and  distribution  of  the  blood  affect  all  the  tissues  for  weal  or  woe. 
The  quantity  of  the  blood  alone  will  be  referred  to  ;  changes  in  quality 
will  be  considered  under  diseases  of  the  blood.  Practically  the  symp- 
toms, when  the  quality  is  affected,  are  those  of  anaemia  plus  the  symp- 
toms (physical  and  functional)  of  the  primarily  diseased  organ — as  the 
spleen  in  leucocythsemia.  The  quantity  may  be  increased  or  dimin- 
ished. 

1.  Increased  Quantity  of  Blood,  or  Plethora.  Formerly 
this  was  considered  an  entity,  and  the  symptoms  of  flushed  face,  hot 
and  full  head,  throbbing  pain,  throbbing  temporals,  a  full,  strong 
pulse,  sluggish  intellect,  were  thought  to  indicate  an  excess  of  the 
general  bulk  of  the  blood.  True  plethora  is  rarely  permanent.  If 
transitory,  the  veins  and  not  the  arteries  are  overfilled.  The  symp- 
toms are  not  due  to  general  plethora  but  to  excess  of  blood-pressure 
or  to  special  fluxions  of  blood  to  superficial  vessels,  determined  by  a 
nervous  mechanism.  Increase  in  one  of  the  cellular  elements  of  the 
blood,  the  leucocytes,  is  not  a  plethoric  condition. 

2.  Diminished  Quantity  of  Blood,  or  An-emia.  Anaemia  em- 
braces the  diminution  of  the  bulk  of  the  blood  as  well  as  of  the  red 
blood-cells  and  their  haemoglobin. 

The  term  might  be  used  for  loss  of  the  water  of  the  blood,  as  in 
cholera  Asiatica  (see  Infectious  Diseases),  or  in  serous  purging.  The 
symptoms  are  those  of  collapse. 

Oligaeinia  or  spanaeruia  are  terms  that  may  be  used  to  define  the 
general  thinness  or  poverty — atrophy  of  the  blood.  Clinically,  anaemia 
is  divided  into  simple  anaemia,  general  poverty  of  the  blood  ;  per- 
nicious or  idiopathic  anaemia,  reduction  in  the  number  of  red  cells  ; 
chlorosis,  reduction  in  the  quantity  of  haemoglobin  ;  leucocythaemia, 
relative  loss  of  red  and  increase  of  white  corpuscles.  (See  Diseases  of 
the  Blood.) 

3.  Local  Disturbance  of  the  Circulation.  A.  Hyper jemia 
or  Congestion.  The  process  may  be  acute  or  chronic.  It  is  usually 
local,  although  it  may  be  general.  When  the  latter,  many  organs  may 
be  simultaneously  involved  from  a  common  cause. 

Acute  Hyperemia .  The  acute  or  active  form  of  hyperaemia  is 
always  local  and  arterial.  There  is  an  excess  of  blood  in  the  part. 
If  the  skin  is  the  seat,  there  are  redness  and  increased  heat,  and  throb- 
bing or  pulsation  may  be  seen.  The  parts  are  swollen.  The  excita- 
bility of  the  nerves  is  increased,  with  local  symptoms  of  warmth,  fulness, 
or  itching. 

The  morbid  blushing,  or  flushing,  that  occurs  at  the  menopause  or 
reflexly  from  internal  disorder  is  a  hyperaemia,  and  in  erythema  of  the 
skin  hyperaemia  is  also  very  marked. 

26 


402  GENERAL  DIAGNOSIS. 

Causes.  Arterial  hyperemia  is  caused  by  (1)  neuroparalysis  of  the 
inhibitory  or  vasoconstrictor  fibres,  of  the  cervical  sympathetic, 
splanchnic,  and  other  sympathetic  and  some  mixed  nerves,  as  the 
sciatic  ;  (2)  neurotonic  stimulation  of  the  actively  dilating  or  vaso- 
motor dilator  nerves,  as  the  chorda  tympani.  There  is  relaxation  of 
the  arterial  walls.  This  may  also  occur  directly  through  the  vasomotor 
system,  being  induced  by  heat,  electricity,  or  chemical  irritants,  or 
from  paralysis  of  muscular  fibres,  after  spasmodic  contraction  due  to 
cold,  as  in  frost-bite. 

(1)  Neuroparalytic  Hypercemia.  Destruction  of  the  cervical  sympa- 
thetic nerve  by  abscess,  wounds,  or  a  tumor  pressing  upon  it,  produces 
hypersemia  of  the  side  of  the  face,  rise  of  temperature,  and  contraction 
of  the  pupil.  Later  on  the  vascular  conditions  are  reversed.  Lesion 
of  the  fifth  nerve,  or  one  of  its  branches,  causes  hypersemia  of  the  iris, 
the  conjunctiva,  the  cheek,  the  gums,  and  other  structures  supplied  by 
it,  with  associate  loss  of  sensation  followed,  by  atrophy.  The  sensory 
symptoms  have  nothing  to  do  with  the  vascular  paralysis. 

(2)  Neurotonic  Hypercemia.  '  After  wounds  of  the  brachial  plexus 
hyperemia  of  the  fingers  is  seen.  (See  Fingers.)  The  local  temper- 
ature rises  and  there  is  neuralgic  pain.  Local  hypersemia  with  hyper- 
sesthesia,  known  as  erythromelalgia,  belongs  to  the  same  class,  being 
due  to  affections  of  the  nerve-trunks,  or  the  peripheral  nerve-endings. 
It  must  be  remembered  that  a  reflex  hypersemia  is  possible. 

Cheonic  ob  "Venous  Hypee^emia  (passive  congestion).  The  blood 
accumulates  in  the  veins,  and,  by  backward  pressure,  in  the  capillaries. 
The  venous  capillaries  are  over-distended  and,  as  compared  with  the 
arterial,  much  enlarged.     They  contain  venous  blood. 

Any  congested  part,  as  the  exterior,  is  bluish  or  purple  in  tint, 
often  swollen  (clubbed  fingers),  cooler  than  normal,  with  lessened  sen- 
sation, and  without  pulsation.  (See  Cyanosis.)  The  dependent  parts 
are  first  affected,  as  the  legs,  or  the  lungs.  In  fevers  a  weak  heart  and 
recumbent  posture  predisposes  to  congestion  of  the  lungs. 

Causes.  Obstructive  heart  and  lung  diseases  cause  general  venous 
congestion.  Local  venous  congestion  is  caused  by  tumors,  the  preg- 
nant uterus,  or  collections  of  fseces  pressing  upon  the  veins.  It  is  also 
caused  by  inflammation  of  the  veins,  and  thrombosis. 

B.  Local  Anaemia.  This  may  be  due  to  arterial  thrombosis  or 
embolism,  arterial  obstruction  through  endarteritis,  or  to  arterial  spasm. 
Raynaud's  disease  is  a  form  of  arterial  spasm.  The  grave  effects  of 
arterial  obstruction  are  seen  in  cerebral  anaemia  from  endarteritis,  or 
myocarditis  from  obstruction  of  the  coronary  arteries. 

C.  (Edema  and  Dbopsy.  The  changes  of  the  circulation  which 
produce  these  conditions  have  been  referred  to  in  previous  chapters  of 
this  book.  The  symptoms  and  signs  of  the  condition  are  also  noted 
in  the  same  section. 

D.  Theombosis  and  Embolism.  The  student  should  be  familiar 
with  the  symptoms  of  these  conditions,  and,  what  is  fully  as  important, 
with  the  causes  that  give  rise  to  them.  Thrombi  may  form  in  the 
heart,  the  arteries,  or  the  veins.  Emboli  may  be  formed  in  either 
heart  or  vessels,  but  lodge  in  the  vessels  only. 


MORBID  PROCESSES  AND  THEIR  SYMPTOMATOLOGY.     403 

Thrombosis.  The  symptoms  of  thrombosis  are :  1.  Mechanical. 
The  channel  is  obstructed ;  hyperaeinia,  engorgement,  oedema,  and 
cyanosis  arise.  Its  most  typical  form  is  seen  in  femoral  thrombosis, 
with  cyanosis,  and  oedema  of  the  leg.  When  an  artery  is  obstructed 
the  symptoms  are  like  those  of  occlusion  under  other  circumstances  (see 
Embolism) ;  when  a  vein,  the  mechanical  symptoms  vary  according 
to  the  particular  vein  affected.  Thus,  in  thrombosis  of  the  coronary 
vein,  the  heart's  action  is  interfered  with.  In  thrombosis  of  the  portal 
vein,  jaundice  (not  because  of  the  obstruction),  oedema  (ascites),  and 
congestion  of  mucous  membranes  (gastric  and  intestinal)  occur,  as  from 
obstruction  in  any  vein.  In  thrombosis  of  the  cerebral  veins,  disturb- 
ance of  the  function  of  the  brain  is  seen ;  of  the  pulmonary  veins, 
dyspnoea.  2.  Inflammatory  or  septic.  If  it  should  happen  that  the 
thrombosis  developed  secondarily  to  an  inflammation  of  septic  origin, 
as  in  the  extension  of  an  inflammation  into  the  radicles  of  the  portal 
vein  from  an  abscess  about  the  rectum  or  vermiform  appendix,  the 
liver  would  be  infected  with  micro-organisms.  An  infectious  inflam- 
mation with  chills,  fever,  sweats,  and  other  phenomena  of  a  septic 
character  would  result  (pyelophlebitis).  3.  Embolic.  From  the  throm- 
bus emboli  are  sometimes  swept  off ;  hence,  embolic  symptoms  arise  in 
the  course  of  thrombosis. 

While  thrombosis  is,  as  a  rule,  easily  recognized,  it  is  necessary  to 
call  attention  to  the  very  great  importance  of  going  a  step  farther  to 
look  for  the  cause.  A  thorough  knowledge  of  the  causes  of  thrombosis 
often  leads  to  the  diagnosis  of  a  thrombus  when  without  such  knowl- 
edge its  presence  would  never  have  been  suspected.  The  causes  are 
not  many.  1.  Stagnation  or  stoppage  of  blood.  It  is  seen  chiefly  in 
the  veins  and  the  heart.  External  pressure  upon  the  veins  :  as  upon 
the  pelvic  veins  in  pregnancy  or  abdominal  tumor,  upon  the  hemor- 
rhoidal veins,  upon  the  portal  veins  by  tumor,  upon  the  pulmonary 
veins  by  mediastinal  tumor.  It  must  be  remembered  that  some  change 
takes  place  in  the  internal  coat  of  the  vein  also,  but  that  the  pressure 
is  primary.  Then  we  have  weakness  of  the  heart  as  a  cause  of  stagna- 
tion. Feeble  contractions  lead  to  the  formation  of  cardiac  thrombi. 
2.  Thrombosis  from  changes  in  the  vessel's  walls.  The  change  is 
usually  inflammatory  and  often  proceeds  from  wounds.  If  the  wound 
was  septic,  the  inflammation  will  be  septic.  In  the  heart,  endocarditis  ; 
in  the  aorta,  atheroma  leads  to  the  development  of  thrombi.  3.  Throm- 
bosis from  the  entrance  of  a  foreign  substance  into  the  vessels.  A 
carcinoma  or  other  new  growth  inav  extend  into  the  veins.  Micro- 
organisms  penetrate  the  vein  and  cause  inflammation  and  thrombosis, 
or  infect  a  previously  existing  thrombus.  The  clot  is  then  broken  and 
distributed  throughout  the  system,  causing  pyaemia.  4.  Thrombi  are 
produced  by  extension.  A  clot  enlarges  by  coagulating  the  blood  next 
to  it.  A  large  venous  distribution  may  become  blocked,  as,  first  the 
uterine  veins,  then  the  internal  iliac,  then  the  external  iliac,  and  after 
that  the  femoral — causing  the  affection  which  frequently  occurs  in  the 
puerperal  form,  phlegmasia  alba  dolens. 

Embolism.  An  embolus  is  a  substance  which  is  swept  into  and 
plugs  a  vessel.     It  may  be  a  fragment  of  a  blood-clot  (thrombus),  vege- 


404  GENERAL  DIAGNOSIS. 

tations  from  valves  of  the  heart,  parasites,  new  growths  -which  had 
entered  the  veins,  fat,  or  air.  If  obstruction  of  the  vessel  alone  is  pro- 
duced, the  embolism  is  said  to  be  simple ;  if  a  new  process,  as  inflam- 
mation, accompanies  the  obstruction,  it  is  specific.  Fragments  from  a 
thrombus  in  the  systemic  veins  may  become  an  embolus  and  block 
the  pulmonary  artery ;  a  clot  or  portion  of  valve-leaflet  from  the  left 
heart  may  block  a  systemic  artery,  as  a  cerebral  artery  or  the  femoral 
artery  or  its  branches ;  a  clot  in  the  portal  vein  may  obstruct  branches 
in  the  liver. 

The  symptoms  occur  suddenly  and  depend  upon  the  artery  obstructed. 
The  cutting  off  of  the  blood-supply  causes  cessation  of  function  beyond 
the  point  of  obstruction.  In  pulmonary  venous  embolism  dyspnoea  is 
pronounced,  the  heart's  action  rapid  and  irregular,  and  many  cases  are 
said  to  be  "  heart-failure."  In  the  middle  cerebral  artery  the  embolus 
causes  aphasia  and  monoplegia  or  hemiplegia.  In  embolism  of  the 
pulmonary  artery  cough  and  hemorrhage  with  dyspnoea  occur  suddenly. 
The  patient  in  whom  this  occurs  usually  has  had  antecedent  mitral 
regurgitation  and  dilated  right  heart. 

The  blocking  of  an  artery  may  lead  to  various  symptoms.  If,  for 
instance,  the  main  artery  of  the  leg  is  blocked,  anastomosis  may  be  set 
up  ;  if  it  does  not,  gangrene  ensues.  If  an  artery  supplying  any  inter- 
nal organ  is  blocked,  anastomosis  may  occur,  if  the  artery  is  not  termi- 
nal. If  the  artery  is  terminal,  there  results  rapid  necrosis  or  softening, 
as  in  the  brain  ;  gradual  wasting,  as  of  the  kidney,  or  engorgement  of 
the  arterial  area  and  diffuse  hemorrhage.  The  latter  is  known  as  a 
hemorrhagic  infarct.  This  may  occur  in  the  lungs  (pulmonary  artery), 
spleen,  kidneys,  retina,  and,  rarely,  the  intestinal  canal.  The  symp- 
toms of  hemorrhagic  infarct  are  swelling  and  hemorrhage.  In  the 
lungs,  there  are  physical  signs  of  consolidation,  with  haemoptysis, 
cough,  and  dyspnoea  ;  in  the  kidneys,  pain  and  hematuria  ;  in  the 
spleen,  pain  and  at  times  enlargement ;  in  the  retina,  blindness  with 
ophthalmoscopic  changes  ;  in  the  intestine,  pain  and  hemorrhage  with 
sloughing  of  mucous  membrane.  Infective  emboli  cause  abscesses. 
Capillary  embolism  is  seen  in  the  skin  and  mucous  membranes  in  many 
infective  diseases,  notably  ulcerative  endocarditis.  Fat-embolism  occurs 
in  the  pulmonary  capillaries,  and  is  due  to  fat-globules  which  some- 
times enter  the  circulation  in  pregnant  women,  or  in  patients  with  bone 
disease,  as  osteomyelitis,  or  fractures.  The  symptoms  are  those  of 
intense  dyspnoea.  It  may  cause  sudden  death.  Air-embolism.  Air 
may  enter  wounds  of  the  veins  of  the  neck.  It  accumulates  in  the 
heart,  and  as  the  ventricle  cannot  contract  on  it  the  blood  is  not  pro- 
pelled. Death  takes  place  with  the  symptoms  of  heart-clot,  the  heart 
being  in  asystole. 

Hemorrhage.  Hemorrhage  may  be  arterial,  venous,  or  capillary. 
It  may  occur  because  the  blood  soaks  through  the  walls,  by  diapede- 
sis  ;  or  it  may  occur  from  rupture,  or  rhexis.  Hemorrhage  by  dia- 
pedesis  takes  place  in  venous  engorgement,  stasis,  or  inflammation.  It 
is  the  small  passive  hemorrhage  of  congestion,  as  in  pulmonary  conges- 
tion from  heart  disease  ;  it  is  venous  or  capillary  ;  the  blood  is  dark. 
Hemorrhage  by  rupture  is  arterial,  venous,  or  capillary.    If  the  artery 


MORBID  PROCESSES  AND  THEIR  SYMPTOMATOLOGY.     405 

ruptures,  it  has  been  torn  by  violence,  destroyed  by  ulceration  or  sup- 
puration, or  it  is  the  seat  of  endarterial  change.  Veins  are  also  diseased, 
or  their  walls  destroyed,  before  rupture  takes  place.  Rupture  of  capil- 
laries occurs  from  violence  or  great  internal  pressure.  In  death  from 
suffocation  the  capillaries  are  the  seat  of  hemorrhage  because  of  the 
increased  venous  pressure.  Such  capillary  hemorrhage  occurs  in 
typhus,  hemorrhagic  smallpox,  and  scarlatina.  The  state  of  the  blood 
is  sometimes  the  cause  of  hemorrhage,  as  in  scurvy,  purpura,  and  other 
conditions.  Haemophilia  is  a  peculiar  hereditary  affection  possibly 
due  to  the  state  of  the  blood,  more  likely,  however,  due  to  the  condi- 
tion of  the  bloodvessels. 

The  special  forms  of  hemorrhage  and  their  symptoms,  etiology,  and 
diagnosis  will  be  considered  in  the  sections  to  which  the  names  in  the 
following  list  point : 

Bleeding  from  the  nose — epistaxis. 

Vomiting  of  blood — hcematemesis. 

Bleeding  from  the  lungs — hcemoptysis. 

Blood  passed  with  the  urine — hcematuria. 

Blood  passed  from  the  uterus — menorrhagia  or  metrorrhagia. 

There  is  also  intestinal  hemorrhage — melcena. 

Hemorrhages  underneath  the  skin  are  known  as  peteehice  if  small, 
and  ecchymoses  or  suffusions  if  large. 

Hemorrhage  into  internal  organs  receives  its  name  from  the  organ 
affected,  and  is  known  as  a  parenchymatous  hemorrhage.  Apoplexy  is 
applied  to  hemorrhage  into  the  substances  of  organs,  particularly  if  it 
occurs  suddenly  and  is  localized — as  pulmonary  apoplexy,  cerebral 
apoplexy,  spinal  apoplexy.  Long  usage  has  associated  the  term  with 
hemorrhage  into  the  brain,  so  that  it  is  applied  to  that  form  alone  by 
most  writers.  Hcematoma,  or  blood-tumor,  is  a  collection  of  blood  that 
has  coagulated  in  a  cavity,  organ,  or  tissue.     (See  Ear.) 

The  symptoms  of  hemorrhage  vary  in  degree,  depending  upon  the 
amount  of  blood  which  escapes  from  the  vessel,  and  whether  the  hem- 
orrhage is  external  or  internal.  By  external  hemorrhage  we  mean  one 
which  is  accompanied  by  a  discharge  of  blood  visible  to  the  bystander. 
An  internal  or  concealed  hemorrhage  is  not  apparent  by  any  outward 
sign  of  blood. 

The  symptoms  by  which  external  hemorrhage  is  recognized  need  not 
be  detailed.  The  show  of  blood  in  situations  or  at  times  other  than 
normal  is  sufficient.  It  must  be  remembered  that  arterial  blood  is 
bright  red,  venous  blood  dark.  It.  must  also  be  remembered  that  the 
character  of  the  blood  coming  from  internal  organs  is  modified  by  the 
secretion  of  the  affected  organ.  Thus  the  blood  from  the  stomach  is 
coagulated  and  black,  like  coffee-grounds  ;  blood  from  the  intestine, 
tarry.  The  general  symptoms  of  the  various  degrees  of  external  hem- 
orrhage are  similar  to  the  symptoms  of  internal  hemorrhage,  which 
will  be  described  later.  Both  vary  with  the  rapidity  of  the  flow  of 
blood.  If  the  bleeding  is  slow,  large  quantities  may  be  lost  and  more 
or  less  profound  anaemia  result.  It  is  often  more  difficult  to  determine 
the  source  of  hemorrhage.  The  mode  of  recognition  of  the  anatomical 
varieties  of  hemorrhage  will  be  discussed  under  the  respective  systems 


406  GENERAL  DIAGNOSIS. 

which  are  the  seat  of  the  bleeding.  Hemorrhage  may  take  place  in  a 
cavity,  as  the  stomach,  bowels,  or  bladder,  and  after  the  blood  has 
undergone  changes  it  may  cause  symptoms  of,  and  be  discharged  as, 
a  foreign  body. 

Although  internal  hemorrhage  presents  vivid  phenomena,  they  may 
not  be  characteristic,  and  its  recognition  is  often  impossible  without 
some  knowledge  of  the  history  of  the  case.  The  symptoms  are  com- 
plex. First,  we  have  pain,  a  symptom  due  to  rupture  of  a  vessel  or 
to  the  filling  of  a  tissue  with  blood.  In  the  beginning  the  pain  is 
sharp,  severe,  and  of  itself  may  cause  shock.  In  the  second  place,  the 
symptoms  due  to  loss  of  blood  arise.  After  pain,  sudden  prostration 
ensues  ;  pallor  spreads  rapidly ;  the  extremities  become  pallid  and 
cold  ;  a  cold  sweat  breaks  out  on  the  forehead  ;  the  features  become 
pinched  and  shrunken  ;  the  pulse  becomes  weak  and  rapid,  and  later 
thready,  or  disappears  altogether  at  the  wrist ;  the  carotids  pulsate  ; 
the  heart  throbs  violently  and  a  diffuse  impulse  is  seen,  at  first  vigor- 
ous, soon  like  a  slap  against  the  chest-wall,  and  then  it  fades  away 
completely.  On  examination  of  the  heart  and  vessels  so-called  anaemic 
murmurs  are  heard.  The  patient  is  restless,  and  sighs  and  yawns 
frequently.  The  respiration  becomes  slow  and  shallow.  Nausea  and 
sometimes  vomiting  may  occur.  He  may  faint  but  once  or  repeatedly, 
to  be  restored  again  and  again,  or  the  syncope  may  terminate  in  death. 
In  the  intervals  between  the  syncopal  attacks  the  mind  is  clear.  If, 
however,  profound  shock  is  associated  with  the  hemorrhage,  there  is 
dulness  or  stupor ;  the  intellect  is  dazed ;  otherwise  delirium  and  agi- 
tation may  be  present.  When  the  hemorrhage  is  profuse  convulsions 
may  take  place.  The  temperature  of  the  body  falls.  If  the  patient 
has  fever  at  the  time,  the  temperature  suddenly  falls  to  or  below  nor- 
mal. We  have,  therefore,  the  following  conditions  in  hemorrhage  : 
syncope,  shock,  and  collapse.  They  may  all  be  present  in  the  same 
subject,  or  one  or  two  may  be  absent.  The  same  symptoms  may,  how- 
ever, occur  from  other  causes,  which  must  be  excluded.  Sometimes  the 
shock  may  be  due  to  the  same  cause  as  the  hemorrhage.  The  causes  of 
shock  are  so  evident  that  they  serve  to  distinguish  it  from  the  collapse 
of  hemorrhage.  They  are  injury,  anaesthesia,  railway  accidents,  surgi- 
cal operations,  perforative  peritonitis,  strangulated  hernia,  intestinal 
obstruction,  profound  mental  impression,  and  pain. 

Shock  from  hemorrhage  must  be  distinguished  from  concussion. 
In  the  latter  the  intellectual  disturbance  occurs  at  once,  and  is  more 
marked  than  the  circulatory  symptoms.  The  absence  of  the  usual 
phenomena  of  hemorrhage  serves  to  distinguish  syncope  due  to  concus- 
sion from  that  due  to  the  many  well-known  causes  of  fainting. 

There  are  many  forms  of  internal  hemorrhage  sufficiently  grave  to 
have  a  probably  fatal  result,  or  at  least  to  create  alarming  symptoms. 
In  the  chest,  diseases  of  the  lungs  or  the  aorta  cause  hemorrhage.  In 
concealed  pulmonary  hemorrhage  the  blood  accumulates  in  a  large 
phthisical  cavity.  When  the  aorta  or  an  aneurism  ruptures  the  blood 
may  enter  the  mediastinum  or  the  pleura.  Under  these  circumstances 
a  knowledge  of  the  previous  history  is  essential.  Careful  examination 
of  the  lungs  or  of  the  heart  or  bloodvessels  must  be  made  in  a  case 


MORBID  PR  0  CESSES  AND  THEIR  S  Y MP  TO  MA  TO  LOGY.     407 

which  presents  the  above-mentioned  symptoms  of  internal  hemorrhage. 
Internal  concealed  hemorrhage  into  organs  or  cavities  of  the  abdomen 
occurs  in  gastric,  duodenal,  or  intestinal  ulceration  ;  in  aneurism  or  in 
ulceration  of  large  vessels,  from  septic  inflammation  around  them.  It 
must  not  be  forgotten  that  alarming  or  fatal  internal  concealed  hemor- 
rhage may  be  due  to  haemophilia  or  purpura. 

II.  Disturbances  of  Nutrition. 

Hypeeteophy  and  Ateophy.  (See  the  Size,  Chapter  VI.,  and 
Muscles.) 

Inflammation.  Inflammation,  a  process  largely  attended  with  vas- 
cular alteration,  but  also  with  disturbance  of  nutrition.  It  may  be 
acute  or  chronic.  It  is  due  to  injury,  mechanical,  physical,  chemical, 
or  vital.  The  invasion  of  micro-organisms  or  the  irritation  of  their 
products  is  the  most  frequent  cause  in  cases  that  come  within  the 
province  of  the  physician.  The  symptoms  are  modified  by  the  struc- 
ture affected  and  by  the  cause  of  the  inflammation.  The  intensity  and 
the  character  also  modify  them.  The  classical  symptoms  —pain,  heat, 
redness,  and  swelling — are  indicative  of  the  tissue-process.  In  addition 
we  have  exudation  and  alteration  of  function.  Pain  varies  in  degree 
with  the  sensibility  of  the  part.  It  is  increased  by  pressure  or  move- 
ment, and  by  the  functional  activity  of  the  affected  organ.  Heat  is 
detected  by  the  hand  or  surface-thermometer.  It  may  be  described  by 
the  patient,  in  abscess  within  the  peritoneum,  or  pyosalpinx,  as  a  ball 
of  fire.  The  surface-temperature  over  an  inflamed  lung  or  pleura  is 
higher  than  over  the  healthy  side.  Redness  can  only  be  observed  in 
parts  open  to  inspection,  as  the  nasal,  oral,  faucial,  and  other  cavities. 
Swelling  is  observed  with  the  redness  ;  it  is  shown  by  enlargement  of 
the  affected  organ,  if  the  latter  can  be  measured  by  palpation  or  per- 
cussion. Exudation  takes  place  from  mucous  surfaces,  into  serous 
cavities,  into  the  connective  or  any  affected  tissue,  or  into  tubes  or 
channels  (heart  and  bloodvessels,  lymphatics,  etc.).  The  symptoms 
are  :  characteristic  discharges  from  mucous  surfaces ;  pressure  and 
physical  signs  from  accumulation  in  cavities  ;  symptoms  of  the  obstruc- 
tion of  channels.  Grave  pressure-symptoms  arise  when  the  exudation 
presses  upon  the  nerves,  nerve-centres,  or  nerve-tracts  (brain  cord, 
peripheral  nerves).  The  pressure-symptoms  are  often  more  pronounced 
than  the  inflammatory  in  simple  or  tuberculous  meningitis.  Alteration 
of  function :  The  symptoms  cannot  be  detailed  here  ;  each  organ  and 
structure  must  be  referred  to.  The  function  may  be  stimulated  at 
first,  but  is  soon  perverted,  or  suppressed. 

General  Symptoms.  Fever  is  the  general  expression  of  the  local 
process.  It  may  be  primary  from  reflex  irritation  of  afferent  nerves 
which  influence  the  heat-centre  and  disturb  the  thermotaxic  mechan- 
ism. It  may  be  secondary,  the  products  of  inflammation  (pus,  toxins, 
etc.)  irritating  the  centres.  The  degree  depends  upon  the  cause.  Active 
inflammation  may  not  be  attended  by  fever.1 

Suppuration.     The  character  of  the  fever  indicates  the  variety  of 

1  Musser :   "Abscess  of  Liver,"  Univ.  Med.  Magazine,  1892. 


408  GENERAL  DIAGNOSIS. 

the  inflammatory  process.  In  most  inflammations  the  fever  is  con- 
tinuous. When  there  is  suppuration,  however,  it  becomes  intermittent 
or  remittent.  The  presence  of  suppuration  is  also  made  known  by 
hectic,  in  which  the  fever  is  attended  by  chills  and  sweats.  The  appe- 
tite is  lost  or  impaired.  There  is  also  leucocytosis.  The  urine  con- 
tains a  large  amount  of  indican.  In  obscure  inflammations  about  the 
peritoneum  the  indicanuria  points  to  a  suppuration.  While  fever- 
symptoms  in  inflammation  are  similar,  save  in  degree  and  in  the  pecu- 
liar type  of  the  temperature-range — intermittent,  remittent,  or  contin- 
uous— septic  inflammations  are  attended  early  by  cerebral  symptoms, 
prostration,  and  the  typhoid  state.     (See  Fever,  pages  218  and  224.) 

As  a  corollary,  when  fever  is  present,  local  inflammation  must  be 
sought  for.  Chronic  inflammations  may  only  give  rise  to  altered  func- 
tion and  cause  exudation  (swelling,  effusion,  etc.). 

Inflammation  of  Various  Structures.  The  symptoms  vary  according 
to  the  anatomical  and  physiological  peculiarities  of  the  structure. 

Inflammation  of  mucous  membranes.  Pain  is  not  excessive  ;  heat  is 
complained  of  (rectum)  ;  redness  is  marked  and  varies  with  the  in- 
tensity from  bright  to  dark  red  ;  swelling  is  always  present.  In  narrow 
channels,  as  the  nose,  or  the  gall-ducts,  it  causes  occlusion.  The 
exudation  is  at  first  mucous,  then  mucopurulent,  and  then  purulent. 
Before  exudation  there  is  a  stage  of  dryness.  The  microscopical 
appearance  of  the  exudate  varies  with  the  anatomical  character  of  the 
membrane  affected.  Its  peculiar  epithelium  is  always  present,  also 
micrococci,  pus,  red  cells  ;  from  the  lungs  or  liver,  special  crystals. 
The  functions  are  impaired.  Fever  is  usually  not  very  high  and  is 
continuous.  The  causes  are  direct  local  irritants  or  congestions  from 
external  impressions  (cold  ?). 

Inflammation  of  serous  membranes.  Pain  is  extreme  and  may  cause 
collapse.  Heat,  swelling,  and  redness  cannot  be  estimated.  The  surface- 
temperature  rises.  Exudation  occurs  after  a  brief  dry  _  stage.  The 
cavities — pleura,  pericardium,  peritoneum,  joints,  cerebro-spinal  canal 
— are  filled,  causing  mechanical  symptoms  and  physical  signs.  Fever 
is  excessive  in  some  forms.  Function  is  impaired  or  abolished.  Gen- 
eral symptoms  are  more  pronounced.  Shock  or  collapse  is  common  in 
peritonitis.  The  affections  are  always  secondary  to  a  general  process 
(rheumatism),  to  infection,  to  disease  of  neighboring  structures,  or  to 
Bright' s  disease,  diabetes,  cancer,  scurvy,  or  other  diathetic  condition. 

Inflammation  of  muscles  (rare),  of  connective  tissue,  and  of  glands  is 
characterized  by  symptoms  common  to  the  morbid  process,  with  alter- 
ation of  function. 

Inflammation  of  bone  and  'periosteum  presents  the  same  group  of 
symptoms.  The  pain  may  be  intense  or  of  a  dull,  aching,  or  boring 
character. 

Inflammation  of  the  heart  and  vessels  is  also  attended  by  the  cardinal 
symptoms.  When  the  central  organ  is  the  seat  of  the  disease  pain  is 
not  common,  but  in  the  arteries  or  veins  it  is  of  frequent  occurrence. 
The  striking  symptom,  however,  is  the  obstruction  to  the  channels. 
It  is  characteristically  seen  in  phlebitis,  as  of  the  femoral  vein. 
(Edema  of  the  leg,  and  cyanosis,  reveal  the  obstruction.     In  the  heart 


M ORB  ID  PROCESSES  AND  THEIR  SYMPTOMATOLOGY.     409 

the  acute  process  or  the  results  of  the  process  give  rise  to  all  the  symp- 
toms of  obstructive  heart  disease. 

Inflammations  of  the  nerves,  the  .spinal  cord,  and  the  brain  are  fol- 
lowed more  strikingly  by  pressure-symptoms  and  by  the  symptoms  <  >f 
degenerations  secondary  to  the  inflammatory  process.  Hence,  while 
pain  and  tenderness  are  present  in  the  exposed  nerves,  increased  irrita- 
bility, then  abeyance,  perversion,  or  abolition  of  function  are  the  princi- 
pal signs  of  inflammation  of  these  regions. 

Inflammation  of  internal  organs,  lung,  liver,  kidneys,  and  pancreas,  is 
made  known  by  pain  (minimum  amount)  and  swelling  (enlargement  of 
liver),  and  by  change  in  the  function,  indicated  by  modifications  of  the 
respective  secretions  as  well  as  by  functional  and  physiological  symp- 
toms. 

Local  Death,  Necrosis,  and  Gangrene.  If  nutrition  is  not 
complete,  the  life  of  the  cell  is  endangered.  This  process  is  known  as 
necrosis  or  gangrene.  The  nutrition  is  annulled  :  1.  By  stoppage  of 
the  circulation.  2.  By  the  direct  action  of  an  irritant  which  destroys 
the  cells.  3.  By  abnormal  temperature.  A  combination  of  the  three 
causes  quickly  produces  gangrene.  Stoppage  of  the  circulation  may 
be  due  to  an  embolus  or  thrombus,  or  to  stagnation  by  pressure,  or  to 
capillary  stasis  alone.  Sloughing  and  "  bed-sores  "  ensue  in  the  latter 
instance  ;  gangrenous  eschars  in  the  former.  The  cells  are  destroyed 
by  corrosives  and  caustics,  by  heat  and  cold,  by  bacteria.  Where 
decomposition  takes  place,  as  in  retained  and  infiltrating  urine,  cell- 
destruction  and  sloughing  ensue.  All  pathogenic  bacteria  cause  necro- 
sis to  a  greater  or  less  degree.  Frost-bite  and  burn  illustrate  the  destruc- 
tive power  of  abnormal  temperature. 

Xerve-lesions,  trophic  disorders,  produce  necrosis.  We  have,  allied 
to  bed-sores  and  known  as  decubitus,  a  form  of  necrosis  in  spinal-cord 
diseases.  The  sloughing  is  extensive  and  rapid.  Trophic  disorders 
cause  paralytic  hyperemia,  and  hence  necrosis. 

It  must  not  be  forgotten  that  debility,  cachexia,  and  feeble  circula- 
tion play  a  great  part  in  assisting  the  local  changes. 

Gangrene  of  internal  structures  concerns  us.  This  form  is  nearly 
always  due  to  stoppage  of  the  circulation.  It  is  seen  in  constriction 
of  the  intestine,  from  hernia,  or  obstruction.  It  occurs  in  phthisis 
from  thrombi.  Clinically,  we  see  it  frequently  in  diabetes.  The  lung, 
the  brain,  the  intestines,  are  most  frequently  affected. 

The  symptoms  of  necrosis  or  gangrene  are  modified  by  the  tissue 
involved,  the  function  interfered  with.  If  external,  the  decomposing 
structures  emit  a  foul  odor,  there  is  rapid  prostration  and  development 
of  the  typhoid  state.  Fever  ensues  from  intoxication  by  decomposing 
substances — sapraemia.  Often  the  symptoms  are  latent.  A  man  aged 
sixty,  in  my  ward,  was  about  all  the  time.  He  died  suddenly  of  pul- 
monary hemorrhage,  the  result  of  gangrenous  ulceration  of  a  large 
vessel';  at  the  autopsy  gangrene  of  the  lung  was  found.  The  only 
symptom  was  the  characteristic  odor.  In  the  course  of  inflammatory 
processes  the  onset  of  gangrene  is  frequently  attended  by  the  cessation 
of  pain,  the  peculiar  odor  when  it  communicates  with  the  exterior,  and 
the  development  of  exhaustion  and  the  typhoid  state.     The  character 


410  GENERAL  DIAGNOSIS. 

of  the  discharge  points  to  gangrene.  When  the  lungs  are  affected 
the  expectoration  is  like  prune-juice  ;  when  the  bowels,  the  discharge 
is  dark  and  putrid. 

Fever  is  a  morbid  process,  with  the  cause  and  symptomatology  of 
which  the  student  must  be  familiar.  It  has  been  fully  treated  in 
previous  chapters.     (See  Fever.) 

The  Degenerations.  The  symptomatology  varies  with  the  form 
of  degeneration  and  the  organs  affected.  The  prostration  of  the  gen- 
eral economy  is  due  to  the  same  cause  as  the  degenerations  themselves. 

Albuminous  degeneration  occurs  in  fever,  and  causes  the  weak  heart 
and  defective  gland  action.  The  weak  heart  of  the  convalescent  period 
in  diphtheria  and  other  infective  diseases  is  well  known. 

Fatty  Degeneration  and  Infiltration.  In  fatty  degenera- 
tion there  is  cell-destruction.  The  brain,  the  heart,  the  kidneys  in 
Bright' s  disease,  the  liver,  all  undergo  degeneration.  It  may  be  due 
to  phosphorus-poisoning  or  to  snake-bite.  It  is  seen  in  acute  yellow 
atrophy  of  the  liver.  It  is  caused  by  other  toxic  agents.  Fatty  infil- 
tration or  lipomatosis  is  seen  in  the  ' •  fat "  heart  of  brewers,  the  en- 
larged liver,  the  excess  of  fat  in  the  abdomen,  etc.  The  affected 
organs  are  enlarged,  but  they  are  iunctionally  weak.  Fatty  infiltra- 
tion of  organs  is  recognized  by  its  etiological  associations.  In  alco- 
holic subjects  of  sedentary  habits,  in  subjects  who  eat  an  excess  of 
fatty  foods,  in  overfed  and  pampered  children,  and  in  tuberculosis  it 
is  commonly  seen.  In  fatty  infiltration  the  cells  are  not  destroyed.  If 
with  the  above  conditions  the  liver  is  enlarged  or  the  heart  weak,  or 
both,  we  may  expect  to  find  fatty  infiltration.  There  is  enlargement 
of  the  affected  organ,  which  is  painless,  smooth,  not  usually  soft  on 
palpation.  The  condition  occurs  at  any  age,  but  usually  in  later  life. 
Emaciation  may  not  be  present.  Lithsemia  is  common  in  fatty  infil- 
tration. 

Amyloid  Degeneration.  This  is  rarely  confined  to  one  organ 
of  the  body.  The  causes  are  syphilis,  malaria,  tuberculosis,  and  pro- 
longed suppuration.  The  liver  and  spleen  are  enlarged,  hard,  smooth, 
and  painless.  There  are  great  pallor,  and  oedema  of  the  feet  and  face. 
There  is  ancemia,  but  no  fever.  The  kidneys  are  affected,  hence  "poly- 
uria and  low  specific  gravity  of  the  urine  ;  a  few  casts  are  found.  The 
bowels  are  likely  to  be  loose  because  the  process  has  involved  the  intes- 
tine. It  occurs  at  any  age.  The  diagnosis  rests  on  the  presence  of  a 
cause,  the  painless  enlargement  of  organs,  the  pallor,  and  the  polyuria. 

Fibroid  Degeneration.  This  is  not  so  much  a  degeneration  as 
an  overgrowth  of  connective  tissue  with  coincident  primary  or  second- 
ary atrophy  of  the  parenchyma.  The  function  of  the  organ  is  impaired 
or  abolished.  Increase  of  connective  tissue  in  the  nerve-structures 
is  known  as  sclerosis,  in  the  liver  or  kidney  as  cirrhosis.  In  the 
artery  it  leads  to  the  changes  known  as  endarteritis.  Whatever  the 
pathology  may  be,  whether  atrophy  of  cell-elements  of  the  affected 
structure  be  primary  or  secondary,  the  condition  is  productive  of  seri- 
ous, even  grave  consequences.  It  is  part  of  the  senile  process.  It 
leads  to  the  manifold  symptoms  of  endarteritis  ;  it  is  the  cause  of 
many  nervous  affections  which  will  be  discussed  in  their  proper  sections. 


MORBID  PROCESSES  AND  THEIR  SYMPTOMATOLOGY.     41 1 

The  varied  phases  of  so-called  interstitial  nephritis  are  due  to  the 
fibroid  changes  primarily  in  the  kidneys,  and  secondarily  in  the  arte- 
rial system.  In  the  lungs  it  attends  emphysema,  or  may  even  be  pro- 
ductive of  that  condition.  The  fibriod  heart  is  another  manifestation 
of  the  same  process.  The  tubes  and  channels  are  closed  by  the  same 
process  as  in  fibrous  stricture  of  the  duodenum.  Wherever  situated 
its  development  means  gradual  abolition  of  function. 

Mucous  Degeneration.  This  form  of  degeneration  is  seen  in 
myxoedema.  The  albuminous  intercellular  substance  is  replaced  in 
the  connective  tissue  by  mucin. 

Pigmentary,  calcareous,  and  colloid  degenerations  are  local  morbid 
processes  without  other  symptoms  than  those  of  the  primary  affection. 

III.  Anomalies  of  Growth. 

Tumors.  Tumors,  other  than  cancer  or  sarcoma,  produce  only 
mechanical  symptoms,  and  must  be  considered  in  their  special  section. 
The  mechanical  symptoms  are  due  :  1.  To  the  tumor  (foreign  body). 
2.  To  obstruction  of  any  channel  in  near  relation. 

New  Growths.  They  cause  local  symptoms.  This  is  most  striking 
in  structures  which  must  necessarily  be  destroyed  as  the  growth  in- 
creases in  size,  as  in  the  brain  or  spinal  cord,  or  where  tubes  or  chan- 
nels are  closed,  as  in  cancer  of  the  stomach  or  oesophagus.  Local  symp- 
toms may  precede  the  general  symptoms  ;  on  the  other  hand,  general 
symptoms  may  arise  for  which  no  local  cause  can  be  assigned.  The 
local  symptoms  of  cancer  are  variable  and  depend  upon  the  anatomical 
nature  and  physiological  offices  of  the  organ  affected,  and  upon  its 
anatomical  relation  to  surrounding  organs.  This  class  of  symptoms 
will  be  referred  to  in  the  section  on  special  diagnosis.  Suffice  it  to 
say  they  cause  gradual  abolition  of  the  function  of  the  organ,  or  closure 
of  the  channels  in  connection  with  it,  as  the  intestinal  canal,  the  pharynx, 
or  the  hepatic  ducts.  Cancer  and  sarcoma  are  accountable  for  a  group 
of  symptoms  to  which  the  term  cachexia  has  been  applied.  In  addi- 
dition,  a  few  symptoms  belong  to  the  cancerous  process  wherever  situ- 
ated. They  may  or  may  not  all  be  present ;  in  the  large  majority  of 
cases  one  or  more  are  wanting  ;  they  should  always  be  sought  for  in 
order  to  confirm  a  diagnosis  of  cancer.     These  symptoms  are  : 

1 .  Pain,  recognized  by  peculiar  characteristics  in  most  cases  :  (a)  It 
is  sharp  and  lancinating  ;  (6)  it  is  paroxysmal ;  (c)  it  is  increased  by 
irritation,  as  food  when  the  stomach  is  affected  ;  (d)  it  is  increased  by 
functional  activity,  as  speaking  or  swallowing  in  carcinoma  of  the 
larynx  or  pharynx  ;  (e)  at  the  outlet  of  canals,  as  the  bladder  or 
rectum,  it  gives  rise  to  tenesmus. 

2.  Hemorrhage.  If  the  malignant  mass  is  in  communication  witli 
the  exterior,  the  blood  maybe  discharged  per  cias  until  rale*.  In  malig- 
nant disease  of  the  upper  air-passages  or  the  lungs  hemorrhage  is 
likely  to  occur.  It  is  common  in  gastric  carcinoma  as  well  as  in 
uterine  cancer.  If  the  organs  do  not  communicate  with  the  exterior, 
and  the  lesion  gives  rise  to  exudations  or  transudations,  the  latter  are 
frequently  bloody,  as  in  carcinoma  of  the  pleura  or  peritoneum. 

3.  Abnormal  Discharge.      This  occurs  especially  in  cancer  of    the 


412  GENERAL  DIAGNOSIS. 

hollow  viscera  and  of  the  canal-structures.  The  discharge  is  the  result 
of  inflammation,  suppuration,  and  necrosis,  and  particularly  microbic 
inflammation.  It  is  recognized  by  its  more  or  less  bloody  character 
and  by  its  odor,  which  is  peculiar.  It  is  most  offensive  and  pene- 
trating, and,  particularly  in  uterine  cancer,  is  almost  pathognomonic. 
Even  the  utmost  cleanliness  will  not  obviate  it. 

4.  Tumor.  It  may  be  readily  detected  or  elude  all  search.  Some 
swelling  is  certainly  present.  It  is  discovered  by  external  examina- 
tion, by  the  objective  physical  signs  of  enlargement  or  change  of  con- 
tour of  the  affected  organ. 

5.  Foreign  Body.  The  growth  gives  rise  to  symptoms  similar  to 
those  present  when  a  foreign  body  is  fixed  in  any  portion  of  the 
hollow  viscera,  as  the  respiratory  tract,  the  gastro-intestinal,  including 
the  hepatic  and  the  genito-urinary  tract,  a.  Through  reflex  influence 
an  attempt  is  made  to  remove  it,  hence  cough,  vomiting,  diarrhoea 
with  tenesmus,  repeated  and  painful  micturition  with  tenesmus,  etc., 
the  particular  symptoms  varying  with  the  organ  affected,  b.  Obstruc- 
tion of  the  channels,  with  all  the  accompanying  symptoms,  depending 
upon  the  location  of  the  growth. 

6.  Temperature.  A  morbid  process  is  often  recognized  by  its  nega- 
tive symptoms,  if  the  term  may  be  used.  Thus,  fever  is  absent  or  the 
temperature  is  even  subnormal  in  carcinoma. 

7.  The  Cancerous  Cachexia.  Wherever  situated  the  disease  is 
sooner  or  later  attended  by  extreme  general  symptoms  which  are,  in 
a  measure,  striking.  It  is  to  be  admitted  that  cases  of  carcinoma  often 
occur  without  marked  cachexia,  a.  One  symptom  may  always  be 
looked  for ;  it  is  emaciation.  It  may  be  rapid  or  gradual  and  extend 
over  one  or  two  years  ;  toward  the  end  it  is  always  rapid.  Ultimately, 
if  the  patient  does  not  succumb  to  other  conditions,  it  presents  an  ex- 
treme picture.  The  eyes  are  sunken,  all  normal  accumulations  of  fat 
disappear.  The  fat  in  the  rectal  fossae  disappears,  causing  deep  de- 
pression of  the  rectum.  The  abdomen  is  retracted.  The  appearances 
are  most  striking  in  cancer  of  the  oesophagus.  b.  Pallor  (see  Color) ; 
this  may  be  present,  c.  Ancemia,  with  breathlessness,  palpitation, 
vertigo,  d.  Exhaustion.  This  with  accompanying  emaciation  is  pro- 
gressive, and  may  be  the  first  symptom.  Progressive  weakness  is 
often  seen  without  fever  or  local  disorder  to  account  for  it.  Toward 
the  end  it  becomes  so  extreme  as  to  forbid  exertion,  e.  Malnutrition. 
Evidences  of  malnutrition  appear  ;  the  skin  is  hard  and  dry  ;  its  elas- 
ticity is  unpaired  and  it  becomes  the  field  for  parasitic  invasion. 
Tinea  and  other  parasites  may  flourish.  Bacteria  invade  the  suscepti- 
ble areas,  and  boils  make  their  appearance.  The  secretions  are  per- 
verted. In  the  mouth  ulcers  develop  ;  the  fungi  of  this  situation  (the 
throat,  etc.)  become  more  active  ;  the  gums  are  inflamed.  In  the  later 
stages  the  ' '  typhoid  state  "  (see  Fever)  may  ensue.  If  the  gastro- 
intestinal tract  is  invaded,  symptoms  of  acute  intoxication  may  arise. 

8.  Metastasis.  We  are  often  aided  by  the  occurrence  of  this  event, 
particularly  by  involvement  of  the  glands.  In  gastric  carcinoma 
secondary  hepatic  disease  or  enlarged  glands  above  the  left  clavicle 
are  found  ;  in  rectal  carcinoma,  secondary  hepatic  cancer.     In  many 


MORBID  PROCESSES  AND  THEIR  SYMPTOMATOLOGY.     41  3 

instances  the  presence  of  cancer  is  revealed  by  the  metastasis,  even 
when  the  primary  growth  cannot  be  recognized. 

The  diagnosis  rests  upon  the  above  conditions.  In  obscure  cases 
the  age,  the  sex,  the  associate  pathological  conditions,  the  duration  of 
the  disease  become  important  factors  in  the  diagnosis.  Cancer  usually 
occurs  after  forty,  or,  some  authorities  say,  after  fifty  years  of  age. 
The  female  sex  is  most  frequently  affected.  It  may  be  associated 
with  a  history  of  previous  lesion  or  irritation,  as  ulcer  in  vaginal, 
gastric,  or  rectal  cancer  ;  the  irritation  of  teeth  or  a  pipe  in  labial  and 
lingual  cancer  ;  of  gallstone  in  cancer  of  the  bile-ducts  ;  of  renal  or 
visceral  calculus  in  disease  in  that  situation.  A  disease  of  grave  and 
malignant  character,  the  duration  of  which  is  over  eighteen  months  or 
two  years,  is  not,  in  all  probability,  cancer. 

Morbid  Processes  in  Tubes  or  Channels.  The  effects  produced  by 
obstructions. 

When  tubes  or  channels  are  the  seat  of  disease  symptoms  arise  apart 
from  the  special  morbid  process,  which  are  due  to  obstruction  and  are 
common  to  all  tubes  or  channels.  The  symptoms  of  obstruction  of  the 
bloodvessels  and  lymph-channels — cyanosis,  oedema,  gangrene  (throm- 
bosis and  embolism) — have  been  described.  But  in  addition  we  have 
hypertrophy,  a  secondary  condition,  not  referred  to  above,  which, 
nevertheless,  follows  obstruction  of  any  channel.  In  the  cases  of  vas- 
cular obstruction  the  hypertrophy  is  seen  in  the  heart  and  the  arteries. 
(See  Diseases  of  the  Heart.) 

In  obstruction,  therefore,  of  tubes  or  channels  we  have  to  a  greater 
or  less  extent  (1)  hypertrophy  behind  obstruction  ;  (2)  diminution  of 
the  normal  flow  of  fluid  and  consequent  accumulation  of  material 
which  normally  passes  through  the  channels  ;  (3)  atrophy  and  cessa- 
tion of  functional  activity  beyond  the  point  of  obstruction  ;  (4)  dilata- 
tion of  the  primary  hypertrophy ;  (5)  degeneration,  ulceration,  low- 
grade  inflammation  (bacterial),  secondary  rupture  of  the  affected 
viscera.  The  morbid  anatomist  can  readily  point  out  the  examples  of 
the  morbid  changes  sequential  to  obstruction.  Thus  in  cancer  of  the 
oesophagus  there  are  hypertrophy  of  the  muscular  coats,  regurgitation 
of  food,  atrophy  of  the  stomach,  dilatation  with  accumulation  of  food, 
secretions  from  the  glands  of  the  oesophageal  mucous  membrane, 
secondary  ulceration,  rupture  into  the  lungs,  with  gangrene  or  pneu- 
monia. In  obstruction  at  the  pylorus  there  are  (1)  hypertrophy  ;  (2) 
accumulation;  (3)  intestinal  atrophy;  (4)  dilatation  of  the  stomach, 
with  its  train  of  symptoms.  In  obstruction  of  the  biliary  channels, 
or  the  bladder,  or  ureters,  the  same  secondary  conditions  arise  plus 
obstruction  to  the  flow  of  bile  or  urine.  Secondary  symptoms  arise 
from  accumulation  of  the  non-escaping  fluids.  Subjective  symptoms, 
it  may  be  said,  are  not  marked;  there  are  pain  and  difficulty  in  the 
performance  of  the  usual  functions.  It  need  scarcely  be  said  that  the 
obstruction  sometimes  gives  rise  to  symptoms  which  are  due  to  the 
abnormal  obstructing  material  which  acts  as  a  foreign  body.  The 
symptoms  are  reflex  and  depend  entirely  upon  the  seat  of  the  foreign 
body. 


414  GENERAL  DIAGNOSIS. 

The  causes  of  obstruction  in  whatsoever  channel  situated  are,  first, 
pressure  from  disease  outside  (growths,  hernia)  ;  second,  disease  of  the 
walls,  with  contraction  ;  third,  occlusion  by  a  foreign  body,  as  gall- 
stone, renal  calculus,  worms,  or  other  material  according  to  the  channel 
obstructed.  The  symptoms  are  most  marked  when  the  obstruction  is 
due  to  disease  outside  the  walls  or  to  obstruction  by  occlusion  within 
the  walls. 

In  all  cases  of  obstruction,  nasal,  faucial,  laryngeal,  bronchial,  oesoph- 
ageal, gastro-intestinal,  biliary,  renal,  or  pancreatic,  look  for  the  symp- 
toms of  the  secondary  morbid  change.  Each  form  of  obstruction  will 
be  specially  considered  elsewhere.     (See  Special  Diagnosis.) 

The  Bloodvessels.  Blood-pressure.  It  must  not  be  forgotten 
that  the  bloodvessels  are  in  a  measure  distinct  from  other  tubes, 
although  subject  to  the  same  laws,  physiological  and  pathological. 
They  contain  fluids,  and  have  a  continuous  function  by  which  the 
fluids  are  propelled.  They  are  subject  to  the  laws  that  govern  the  flow 
of  fluids  under  all  circumstances  in  nature.  Any  derangement  or 
disease  will  effect  changes  which  are  explainable  by  hydrostatic  or 
hydrodynamic  laws.  Fluids  within  vessels  exert  pressure.  Pressure 
produced  by  weight  of  the  fluid  is  known  as  the  hydrostatic  pressure  ; 
that  produced  by  the  flow  is  known  as  the  hydrodynamic  pressure. 
Pressure  can  be  gauged  by  proper  instruments.  In  the  case  of  fluid 
in  the  bloodvessels  it  is  called  the  blood-pressure.  The  blood- 
pressure  is  estimated  at  the  pulse  by  the  educated  finger  and  by  the 
sphygmograph.  A  certain  definite  pressure  is  always  present  in 
health.  It  is  subject  to  slight  fluctuations,  but  tracings  with  a  sphyg- 
mograph follow  a  definite  course.  In  the  description  of  the  pulse, 
modifications  of  blood-pressure  will  be  given  in  detail ;  it  is  sufficient 
here  to  say  a  few  words  regarding  hydrostatic  and  hydrodynamic 
pressure. 

Hydrostatic  pressure  is  modified  by  the  weight  of  the  fluid.  It  is 
of  pathological  importance  in  the  veins  only,  and  especially  in  those  of 
the  lower  limbs.  When  the  pressure  is  increased  the  increased  weight 
of  the  blood-column  causes  increased  bulk  and  over-distention,  as  in 
varicose  veins,  unless  the  support  to  the  blood-column  is  increased. 
Inflammations  of  the  lower  limbs  are  attended  by  venous  accumulation 
and  followed  by  ulceration.  For  this  reason  dropsies  arise  more 
readily  in  these  portions.  The  common  occurrence  of  gout  in  the  feet 
may  be  due  to  slow  circulation. 

Hydrodynamic  pressure  is  variable.  Its  changes  indicate  increase 
or  diminution  of  blood-pressure.  The  bloodvessels  are  resisting  elastic 
tubes  ;  the  resistance  is  always  equal  to  the  pressure  within,  hence 
blood-pressure  and  arterial  tension  are  equivalent  terms.  We  speak 
of  increased  or  diminished  pressure,  or  correspondingly  of  high  or  low 
tension.  Now,  the  hydrodynamic  or  blood-pressure  depends  upon  :  (1) 
Variations  in  the  volume  of  blood  ;  (2)  variations  in  the  capacity  of  the 
vascular  system  ;  (3)  facility  of  the  capillary  circulation  ;  (4)  the  force 
of  the  heart.  The  tension  of  the  artery  depends  upon  the  same 
conditions. 


MORBID  PROCESSES  AND  THEIR  SYMPTOMATOLOGY.     415 

1.  Variations  in  the  volume  of  the  blood,  a.  Volume  increased. 
Causes  :  absorption  of  fluid  after  meals  or  drinking  to  excess.  Result : 
increased  blood-pressure  and  increased  tension.  Controlled  in  health 
by  action  of  the  vasomotors  relaxing  the  vessels,  and  by  enlargement 
of  the  veins.  b.  Volume  diminished.  Cause  :  hemorrhage,  serous 
purging.  Result :  diminished  blood-pressure,  lowered  tension.  Con- 
trolled in  health  by  contraction  of  arteries  through  vasomotor  nerves. 
In  hemorrhage  the  loss  of  blood  produces  anaemia.  The  latter  is  a 
stimulant  to  the  vasomotor  centre  in  the  medulla,  and  produces  con- 
traction of  peripheral  arteries  and  high  tension. 

2.  Variations  in  the  capacity  of  the  vessels,  a.  Diminution  of  the 
capacity  of  the  blood-channels  (volume  of  blood  not  lessened).  Cause  : 
cutting  off  of  a  vascular  area  by  ligation  or  obstruction,  by  narrowing 
the  calibre  of  the  wall,  as  in  arterial  spasm  or  endarteritis,  by  disease 
of  the  kidneys,  contracting  the  lessening  channels  in  the  aortic  circuit, 
or  disease  of  the  aorta,  causing  obstruction  to  the  outflow  of  blood. 
Result :  increased  pressure,  high  tension.  Controlled  by  normal  regu- 
lating vasomotor  apparatus,  or  by  diminution  of  the  volume  of  blood. 
b.  Increase  of  capacity  of  blood-channels.  Cause  :  relaxation  of  mus- 
cular coats  •  of  vessels.  Result :  diminished  blood-pressure,  lowered 
arterial  tension.  Controlled  by  contraction  of  vessels  or  increase  in 
amount  of  blood.  In  shock,  the  vasomotor  sympathetic  system  of  the 
splanchnic  arteries  is  so  disturbed  that  the  arteries  are  dilated  and  all 
the  blood  is  sent  into  the  abdominal  vessels  (fall  of  pressure). 

Mode  of  action  of  the  vasomotor  apparatus.  Centres  in  the  medulla, 
in  the  spinal  cord,  and  locally  in  the  sympathetic  ganglia  of  different 
parts,  control  the  vasomotor  nerves,  which  influence  hydrodynamic 
pressure.  1.  If  the  centres  are  stimulated,  tonic  contraction  of  the 
vessels  is  produced.  This  may  be  general  or  local.  Increased  press- 
ure or  heightened  tension  is  the  result.  It  may  be  reflex  from  the 
periphery,  or  due  to  some  state  of  the  blood.  2.  If  the  centres  are 
paralyzed,  or  inhibited,  or  cut  off  from  the  arteries,  the  latter  become 
relaxed  (dilated).  The  pressure  is  lowered,  the  tension  is  less.  Shock, 
pain,  certain  drugs,  reflexes  (probably)  produce  inhibition. 

3.  Facility  of  capillary  circulation.  Obstruction  to  outflow  of  blood 
from  capillaries  into  the  veins  increases  blood-pressure.  Cause  :  the 
same  as  when  arteries  contract.  Result :  increased  blood-pressure,  high 
tension.  Regulated  in  the  same  manner  as  arteries.  Relaxed  capilla- 
ries produce  opposite  conditions. 

4.  The  force  of  the  heart,  a.  Heart's  action  (left  ventricle)  increased. 
Cause  :  hypertrophy,  palpitation.  Hence  the  greater  force  of  blood- 
impact,  greater  resistance  by  arteries.  The  tonic  resistance  narrows 
the  calibre  of  the  vessels.  Result :  increased  pressure,  higher  tension. 
6.  Heart's  action  weakened.  Hence,  less  force  of  blood,  less  resistance. 
Result :   lessened  pressure,  low  tension. 

The  recognition  of  variations  in  tension.     (See  Pulse.) 

1.   High  arterial  pressure  or  tension.     By  (a)  incompressibility  and 

tension  of  the  arteries  ;  (6)  accentuation  of  the  aortic  second  sound  ; 

(c)  prolongation  of  the  left  ventricle  first  sound  ;   (d)  increased  flow  of 

urine,  pale  and  watery  ;   (e)  characteristic  pulse-tracing  by  sphygmo- 


416  GENERAL  DIAGNOSIS. 

graph.     If  the  high  tension  is  permanent,   (/)   hypertrophy  of  the 
heart ;   (g)  atheroma,  more  or  less. 

2.  Low  arterial  pressure  or  tension.  By  (a)  soft,  compressible,  often 
dicrotic  pulse  ;  (6)  enfeebled  sounds,  aortic  second  and  left  ventricle  ; 
(o)  scanty,  high-colored  urine  ;  (d)  special  pulse-tracing.  If  perma- 
nent, stases,  congestions,  cyanosis,  with  general  weakness  and  impaired 
nutrition. 


PART  II. 

SPECIAL  DIAGNOSIS. 


CHAPTER    I. 

THE  NOSE  AND  LAEYNX. 

The  Nose. 

The  symptoms  of  disease  of  the  nose  result  from  disturbance  of  the 
function  or  alteration  of  the  structure  of  the  organ  and  the  morbid 
process.  Physiological  symptoms :  Impairment  of  the  sense  of  smell, 
ansemia,  and  symptoms  of  obstruction  may  occur.  Obstruction  causes 
retention  of  secretions.  These  secretions  are  exposed  to  infection. 
Putrefaction  and  fermentation  set  in  and  give  rise  to  offensive  odoi*s. 
More  serious  is  the  effect  of  the  obstruction  on  the  rest  of  the  respira- 
tory tract.  The  patient  becomes  a  mouth-breather.  The  appearance 
of  the  face  is  altered  ;  the  voice  changes,  snoring  is  common,  mastica- 
tion is  interfered  with,  and  there  is  a  diminution  in  the  amount  of  air 
passing  to  the  lungs.  As  a  result  a  vacuum  is  created  which  is  com- 
pensated for  by  external  pressure.  In  children  the  result  is  marked 
deformity  of  the  chest,  leading  to  the  development  of  the  "  pigeon  "  or 
"  chicken  breast."  (See  the  Lungs,  Chapter  II.,  Part  II.)  The  general 
symptoms  attending  mouth-breathing  will  be  referred  to  again. 

Symptoms  due  to  the  Anatomical  Structure.  The  nose  is  an  open  space 
or  a  series  of  air-spaces  lined  with  mucous  membrane.  The  mucous 
membrane  is  the  frequent  seat  of  infectious  inflammation,  as  in  hay 
fever,  influenza,  and  measles.  Most  of  the  nasal  symptoms  are  due  to 
disease  of  the  mucous  membrane.  The  membrane  is  subject  to  affec- 
tions that  are  common  to  all  mucous  membranes,  and  the  subjective 
and  objective  symptoms  are  similar  to  those  that  arise  in  other  organs, 
modified  by  the  function  and  anatomical  arrangement. 

The  abundance  of  bloodvessels  and  glands  is  the  cause  of  one  of  the 
symptoms — namely,  the  discharge.  Moreover,  the  difficulty  of  removing 
the  discharge  from  the  various  cavities  in  the  nose  in  which  they  are 
pent  up  leads  to  putrefaction  and  odor.  Because  the  air  is  constantly 
passing  over  the  parts,  discharges  are  very  liable  to  become  dry,  and 
hence  crusts  and  scabs  form.  Again,  the  vascularity  of  the  structures 
of  the  nose  is  the  cause  of  development  of  symptoms.  The  blood- 
vessels are  richly  supplied  with  nerves,  which  cause  them  to  contract 
or  dilate,  on  comparatively  slight  provocation,  by  reflex  action.  Chilli- 
ness of  the  body,  or  of  local  areas  of  the  body,  chilling  of  the  extremi- 

27 


418  SPECIAL  DIAGNOSIS. 

ties,  and  other  peripheral  impressions,  are  followed  by  congestion  of 
the  nasal  mucous  membrane,  which  may  go  on  to  inflammation.  The 
vascularity  predisposes  to  hemorrhage. 

The  nose  is  richly  supplied  with  nerves  (in  addition  to  the  olfactory 
nerve),  which  are  susceptible  to  various  irritations  or  impressions — 
impressions  made  by  the  air  laden  with  unusual  material,  as  fumes  of 
a  chemical  nature,  emanations  from  animals,  or  plants,  and  certain 
substances  not  yet  isolated,  which  are  decidedly  irritating.  There 
is  often  local  irritation  from  polyps  and  adenoid  growths,  and  foreign 
bodies,  or  enlarged  bone.  The  nerves  are  connected  by  a  mechanism 
directly  with  the  centres  in  the  medulla,  with  particularly  the  pneumo- 
gastric  centre.  The  effect  of  peripheral  nasal  irritation  may  be  felt 
reflexly  in  the  area  of  distribution  of  that  nerve  ;  hence  an  unpleasant 
odor  may  bring  on  sudden  nausea  or  vomiting.  But  of  more  striking 
and  frequent  pathological  significance  is  the  occurrence  of  asthma,  or 
sudden  dyspnoea,  from  reflex  excitation  of  the  pulmonary  division  of  the 
pneumogastric  nerve. 

Morbid  processes  in  the  nose  are  symptomatic  of  some  general  affec- 
tions. The  occurrence  of  asthma,  or  of  deformity  of  the  chest  and 
general  ill-development,  has  been  spoken  of.  Acute  inflammations  are 
significant  of  the  exanthematous  diseases,  particularly  measles.  An 
acute  inflammation  (as  pointed  out  by  Meigs),  with  great  obstruction 
of  the  nares  and  an  abundant,  puriform  discharge,  is  a  complication  or 
symptom  of  Bright' s  disease  that  may  portend  the  onset  of  uraemia. 
Chronic  inflammations  may  be  due  to  syphilis  or  other  chronic  infection. 

The  Data  Obtained  by  Inquiry. 

Of  the  data  obtained  by  inquiry,  that  belonging  to  the  social  history, 
the  family  history,  and  the  history  of  previous  diseases  yield  but 
little  information  of  diagnostic  value.  It  is  true  the  acute  inflamma- 
tions secondary  to  measles  and  other  exanthemata  occur  at  an  early 
age,  while  the  chronic  attacks  occur  late  in  life,  as  do  also  tumors, 
except  adenoid.  Foreign  bodies  are  more  likely  to  be  found  in  chil- 
dren and  the  feeble-minded.  Those  occupations  which  are  in-doors,  in 
overheated  apartments,  and  among  noxious  vapors  predispose  to 
catarrhs.  In  the  family  history  we  must  look  for  gout,  rheumatism, 
syphilis,  and  affections  which  lead  to  osseous  changes.  More  marked 
than  all  is  the  influence  of  syphilis.  A  chief  predisposing  factor  in 
the  production  of  nasal  disease  is  the  morphological  arrangement  of 
the  parts,  which  may  be  congenital,  or  the  result  of  early  infantile  dis- 
ease. Thus,  when  congenital,  the  high  palatal  arch,  etc.,  is  looked 
upon  as  the  stigmata  of  degeneration. 

On  inquiry  of  the  history  of  previous  diseases,  we  look  for  syphilis, 
the  exanthemata  of  early  life,  the  occurrence  of  gout  or  rheumatism, 
and  of  those  gastrohepatic  and  nutritional  disorders  which  lead  to 
catarrhs. 

The  Subjective  Symptoms.  General.  They  are  often  accom- 
panied by  extreme  distress,  but  do  not  lead  to  a  fatal  termination. 
The  general  subjective  symptoms  are  like  those  of  inflammation  of 
other  mucous  membranes. 


THE  NOSE  AND  LARYNX.  419 

1.  Lassitude  occurs  when  there  is  fever.  It  is  a  frequent  precursor 
of  rhinitis,  and  is  pronounced  in  croupous  and  diphtheritic  rhinitis  ; 
extreme  prostration  may  attend  the  latter. 

2.  Chilliness  following  the  lassitude,  or  rigor,  may  occur  in  the 
same  class  of  cases.  If  distinct  rigors  occur,  an  abscess  in  one  of  the 
cavities  may  be  suspected,  if  the  subjective  and  objective  symptoms 
point  to  it ;  or  glanders  may  be  present. 

3.  Fever.  This  occurs  in  the  inflammations  ;  it  is  never  marked, 
and  is  not  of  diagnostic  significance.  It  is  most  severe  in  glanders. 
It  is  then  attended  by  general  symptoms  of  rigor,  with  pain  in  the 
trunk  and  limbs.  In  the  first  twenty-four  hours  there  may  be  nausea 
and  vomiting.  Locally,  a  small  pimple  is  seen  which  is  quite  painful. 
A  yellowish  sanious  discharge  oozes  from  the  nostrils.  Hard  pustules 
appear  about  the  nose  and  other  parts  of  the  body.  (See  Infectious 
Diseases.)  It  is  of  low  type  in  diphtheria,  and  of  hectic  character  when 
there  is  abscess.  High  fever  associated  with  inflammations  of  the  nose 
points  to  influenza  or  one  of  the  exanthemata  as  the  primary  cause  of 
the  rhinitis.  Foreign  bodies  in  the  nose  may  cause  fever.  Emacia- 
tion occurs  with  malignant  growths. 

Local.  Pain,  varying  in  degree,  occurs  in  all  acute  affections  of 
the  nose.  Its  seat  and  character  are  of  some  diagnostic  significance. 
Smarting  or  burning  pain  at  the  root  of  the  nose  accompanies  acute 
rhinitis  and  attends  post-nasal  catarrh.  The  pain  is  diffuse  and  indefi- 
nite in  dry  catarrh  and  in  diphtheria.  The  most  severe  pain  occurs 
when  foreign  bodies  are  present  in  the  nose  and  in  cases  of  glanders 
and  primary  syphilis.  Foreign  bodies  of  a  vegetable  nature  by  swell- 
ing and  germinating  induce  pain,  which  increases  gradually  in  in- 
tensity. 

In  tropical  regions  parasites  may  be  found  in  the  nostrils.  They 
are  the  larva?  of  the  lucilia  hominivora.  It  is  said  that  the  pain  is  so 
severe  at  the  root  of  the  nose,  extending  backward,  as  to  cause  mani- 
acal delirium.  Sleeplessness  is  marked,  and  there  may  be  extensive 
destruction  of  the  bones  and  skin.     There  is  a  fetid,  sanious  discharge. 

Pain  Over  the  Frontal  Sinus.  The  pain  of  an  inflamed  frontal 
sinus  is  more  severe  than  the  pain  of  inflamed  nostrils.  It  is  some- 
times intense  and  agonizing.  Pain  may  be  located  in  the  cheek  from 
inflammation  or  tumors  of  the  antrum.  In  disease  of  the  nose,  if  the 
pain  radiates  to  the  ear,  the  Eustachian  tubes  are  probably  involved. 

Headache  is  frequently  caused  by  nasal  disease  of  all  forms.  (See 
Chapter  IV.,  Part  I.) 

Disturbance  of  the  Sense  of  Smell.  (See  the  Nerves.)  Anosmia  and 
Parosmia.  Loss  of  smell,  or  anosmia,  occurs  to  a  moderate  degree  in 
all  the  inflammatory  and  obstructive  diseases  of  the  nose.  The  in- 
tensity depends  upon  the  degree  of  change  in  the  mucous  membrane. 
It  may  also  be  due  to  disease  of  the  nerves  or  the  olfactory  centre  in 
the  brain.  Parosrfria  is  the  perception  of  abnormal  odors,  and  may 
be  a  neurosis  or  psychical  difficulty  entirely,  and  hence  purely  subjec- 
tive, or  there  may  be  inability  to  distinguish  an  odor  when  presented 
to  the  nostril.  All  odors  may  appear  the  same,  or  agreeable  odors 
may  seem  to  the  patient  very  disagreeable.     In  addition,  the  patient 


420  SPECIAL  DIAGNOSIS.      ■ 

may  complain  of  the  perception  of  an  odor  in  connection  with  the 
nasal  disease  with  which  he  is  affected.  Parosmia  is  due  to  an  involve- 
ment of  the  olfactory  nerves. 

A  sense  of  dryness  is  a  symptom  of  which  the  patient  frequently 
complains,  particularly  in  the  early  stages  of  acute  rhinitis  and  through- 
out the  entire  course  of  dry  catarrh,  or  atrophic  rhinitis. 

Obstruction  or  Stenosis.  This  sometimes  causes  the  greatest 
discomfort  to  the  patient.  There  may  be  simply  a  seuse  of  stuffiness 
and  fulness  in  the  nasal  and  frontal  region,  or  complete  obstruction, 
causing  difficulty  in  breathing.  In  infants  it  prevents  nursing,  and 
should  always  suggest  inherited  syphilis.  It  occurs  in  all  the  obstruc- 
tive diseases  of  the  nose  and  nasopharynx,  as  acute  rhinitis,  chronic 
inflammation  (except  the  atrophic  form),  hyperemia,  the  hypertro- 
phies, polyps,  tumors,  deviations  of  the  septum,  foreign  bodies,  and 
adenoid  vegetations. 

Deafness  is  present  when  the  Eustachian  tubes  are  invaded  or  ob- 
structed from  inflammation  or  stenosis.  When  associated  with  anosmia 
it  may  be  of  central  origin.  Tinnitus  annum  frequently  accompanies 
the  deafness. 

Cough.  The  discharge  may  pass  into  the  pharynx  and  the  larynx 
and  cause  cough.  (See  Chapter  on  Cough.)  It  occurs,  therefore,  in 
the  catarrhs  and  obstructive  diseases,  and  is  not  diagnostic  of  any  nasal 
condition.  When  the  nostrils  are  too  wide,  as  in  atrophic  rhinitis, 
cough  may  occur  because  irritating  particles  are  admitted  through  the 
widened  aperture.  A  so-called  reflex  cough  occurs  in  hypertrophic 
and  post-nasal  disease. 

Reflex  Neuroses. 

Hay  Fever.  Hay  fever  is  an  acute  affection  ushered  in  by  paroxysmal 
sneezing,  itching,  and  smarting  of  the  inner  canthus  of  each  eye,  or  of 
the  throat  or  nose.  After  hours  or  days  of  sneezing  coryza  develops. 
The  disease  continues  for  a  varying  length  of  time,  is  more  pronounced 
at  certain  seasons  of  the  year,  particularly  the  late  fall.  Coughing  may 
be  an  additional  symptom,  and  paroxysms  of  asthma  may  develop 
which  are  hard  to  distinguish  from  true  bronchial  asthma.  The  attack 
may  be  excited  by  vegetable  emanations,  particularly  the  pollen  of 
plants,  but  other  emanations  may  also  induce  it.  Certain  conditions 
of  the  nasal  mucous  membrane  predispose  to  the  attack.  Local  inflamma- 
tion of  the  nose  or  obstructive  diseases  from  hypertrophies  are  primarily 
present.  To  the  exciting  cause  and  the  local  predisposing  cause  may 
also  be  added  a  neurotic  factor.  The  disease  affects  families  of  ner- 
vous constitution,  and  may  occur  through  several  generations.  It  is 
more  common  in  this  country  than  in  other  countries,  and  dwellers  in 
cities  are  more  subject  to  it  than  residents  in  the  country.  Asthma  may 
be  due  to  disease  of  the  nose,  but  the  only  proof  that  it  is  of  nasal  origin 
is  that  it  disappears  after  the  nose  has  been  treated  for  the  various  ail- 
ments that  are  supposed  to  cause  it. 

Idiopathic  Rhinorrhcea.  Characterized  by  a  sudden  profuse 
discharge  of  yellowish  water.  It  ceases  as  suddenly  as  it  develops,  and 
is  thought  to  be  due  to  some  functional  derangement  of  the  fifth  nerve. 


THE  NOSE  AND  LARYNX.  421 

The  Data  Obtained  by  Observation. 

The  Objective  Symptoms.  Of  the  general  objective  symptoms, 
fever  has  been  noted.  In  certain  affections  of  the  nose  defective  de- 
velopment of  the  general  system  is  observed.  This  is  particularly  the 
case  in  adenoid  vegetations  of  the  nasopharynx  in  children.  (See 
Diseases  of  the  Pharynx.) 

Local  Examination.  The  Exterior.  The  external  appearance 
of  the  nose  is  of  diagnostic  significance  when  marked  deformity  takes 
place.  Its  true  shape  is  changed  in  niyxoedenia  (q.  v.).  It  is  changed 
in  disease  of  the  bone  due  to  syphilis.  The  bridge  of  the  nose  is  sunken 
or  depressed.  It  must  not  be  confounded  with  the  depression  that 
occurs  in  fracture.  The  nose  may  be  broadened  in  cases  of  tumors  of 
an  expanding  nature  in  the  nasal  cavities.  The  local  change  soon 
extends  to  the  cheek.  The  nose  is  also  the  seat  of  eruptions,  as  acne 
and  hyperemia,  but  they  are  usually  of  local  origin.  They  may  be 
suggestive  of  a  gouty  diathesis. 

Internal  Examination.  The  examination  of  the  cavities  of  the 
nose  consists  of  two  procedures,  both  of  which  are  necessary  to  deter- 
mine with  accuracy  the  condition  of  the  organ.     These  are  : 

1.  Anterior  Rhinoscopy.  For  this  are  needed  a  good  light,  a  nose 
speculum  of  some  form,  probes,  a  10  per  cent,  solution  of  cocaine,  and 
a  head-mirror  with  central  opening. 

The  examiner  proceeds  as  follows  :  The  patient  is  seated  facing  the 
surgeon,  with  the  light  behind  and  at  one  side  of  the  head,  as  nearly 
as  possible  on  a  level  with  the  eye  of  the  operator.  He  must  sit  with 
shoulders  and  head  a  little  forward.  The  operator  adjusts  his  head- 
mirror  so  that  the  central  aperture  is  in  front  of  his  own  eye,  and  the 
reflected  light  falls  on  the  nose  of  the  patient.  It  is  very  important 
for  nose-examination  that  the  operator  look  through  the  aperture  and 
not  under  the  mirror.  The  speculum  is  then  taken  in  one  hand  and 
the  nostril  dilated,  so  that  the  view  of  the  interior  is  unobstructed. 
Do  not  try  to  dilate  the  bony  part  of  the  nose,  but  only  the  nostril. 
Proceed  from  before  backward  with  the  examination,  carefully  focus- 
ing the  light  on  each  part  in  succession,  and  gradually  tilting  the 
head  of  the  patient  backward.  Thus  the  floor  of  the  nose,  the  septum, 
inferior  turbinated  bones,  middle  turbinated  bones,  and  sometimes  the 
superior  turbinated  bones,  are  brought  into  view  successively.  In  a 
broad  nose  one  may  at  times  see  the  posterior  wall  of  the  pharynx, 
which  is  distinguished  by  its  peculiar  wave-like  movement  when  the 
patient  swallows.  The  use  of  the  probe  is  important,  and  without  it 
no  positive  diagnosis  can  be  made.  With  the  probe  the  operator  tries 
the  condition  of  the  mucous  membrane,  tests  the  consistency  of  tumors 
or  hypertrophies,  and  so  judges  of  the  character  of  the  condition.  After 
this  the  enlarged  parts  should  be  touched  with  cocaine  and  the  result 
observed.  Contraction  of  a  swelling  under  its  influence  proves  its 
vascular  origin. 

2.  Posterior  Rhinoscopy .  This  is  the  most  difficult  part  of  the  ex- 
amination and  requires  much  practice  on  the  part  of  the  operator. 
The  instruments  needed  are  a  tongue  depressor,  head-reflector,  two 


422 


SPECIAL  DIAGNOSIS. 


sizes  of  throat-mirrors,  a  palate-hook  or  flat  strings  for  holding  for- 
ward the  soft  palate,  and  a  curved  applicator  for  cocaine,  or  a  spray 
bottle  with  tip  turned  upward. 

The  patient  is  seated  as  before,  the  tongue  held  down  by  the  tongue- 
depressor,  and  the  patient  is  told  to  breathe  freely  through  both  mouth 
and  nose.  The  light  is  directed  into  the  pharynx  and  a  mirror  of  the 
largest  possible  size  inserted  carefully  behind  the  soft  palate.  The 
proper  angle  and  the  movement  necessary  to  bring  all  parts  into  view 
can  only  be  learned  by  practice.     As  a  rule,  it  is  best  to  hold  the 


Fig.  110. 


Rhinoscopic  mirror  in  position.     (Bosworth.) 

handle  well  up  at  first,  and  note  the  condition  of  the  vault  of  the  phar- 
ynx, then  gradually  depress  it,  examining  the  choanse  from  above 
downward.  Do  not  keep  the  mirror  too  long  in  the  throat.  It  is 
better  to  insert  it  several  times  than  to  weary  the  patient  by  attempting 
to  see  everything  the  first  time.  After  the  choanse  have  been  exam- 
ined a  turn  of  the  mirror  to  either  side  will  bring  into  view  the  orifices 
of  the  Eustachian  tubes,  and  the  examination  is  complete.  If,  after 
repeated  attempts,  it  is  found  to  be  impossible  to  see  the  posterior 
nares,  one  must  first  seek  to  accustom  the  patient  to  the  presence  of 


THE  NOSE  AND  LARYNX.  423 

the  instruments  ;  if  this  fails,  it  may  be  necessary  to  resort  to  the 
palate  hook  or  the  cords  to  hold  the  uvula  forward.  The  best  hook  is 
White's.  It  is  necessary  to  apply  cocaine  to  the  soft  palate  before  in- 
serting the  hook.  Another  plan,  which  is  preferred  by  some,  is  to 
take  the  flat  cords  used  for  corset-laces,  soak  them  in  mucilage  and  dry 
them.  These  are  then  stiff  enough  to  pass  through  the  nostril,  yet 
flexible  enough  to  pull  down  and  out  through  the  mouth  with  forceps. 
Then  by  drawing  forward  both  ends  the  soft  palate  is  pulled  out  of 
the  way.  This  is  almost  always  necessary  when  applications  are  to  be 
made  to  any  spot  in  the  pharynx. 

Sometimes  a  view  of  the  posterior  nares  may  be  obtained  by  making 
the  patient  breathe  in  short,  quick  gasps,  by  which  the  uvula  is  re- 
leased. In  ordinary  breathing  it  is  often  tightly  pressed  against  the 
posterior  wall  of  the  pharynx. 

Fig.  111. 


2  3  I  ''~''m*m& 

12 

Rhinoscopic  image. 
1.  Vomer  or  nasal  septum.    2.  Floor  of  nose.    3.  Superior  meatus.    4.  Middle  meatus.    5.  Superior 
turbinated  bone.    6.  Middle  turbinated  bone.    7.  Inferior  turbinated  bone.    8.  Pharyngeal  orifice 
of  Eustachian  tube.    9.  Upper  portion  of  Rosenmtiller's  groove.    11.  Granular  tissue  at  anterior 
portion  of  vault  of  pharynx.    12.  Posterior  surface  of  velum.    (Seiler.) 

By  the  above  methods  we  are  to  determine  the  appearance  and  nutri- 
tion of  the  mucous  membrane,  relative  size  of  the  cavities,  the  nature 
of  the  discharge,  and  the  presence  of  ulceration  or  perforation  of  the 
nares.  Deviations  of  septum,  enlargement  or  contraction  of  turbinated 
bones,  the  size  of  the  cavities,  and  the  presence  of  foreign  bodies  or 
abnormal  growths  are  also  detected. 

Inspection.  Appearance  of  the  Mucous  Membrane.  The 
observer  may  find  it  unusually  pale.  This  is  seen  in  tuberculosis 
and  in  atrophic  rhinitis.  If  a  protuberant  mass  is  observed  to  be 
transparent  and  shining,  as  well  as  pale,  it  is  due  to  a  polypus.  If  the 
mucous  membrane  is  bright  red,  it  may  be  due  to  acute  inflammation, 
to  glanders,  or  to  syphilis.  It  is  dull  red  in  chronic  catarrhs  and  caseous 
rhinitis.  The  coatings  of  the  mucous  membrane  are  of  significance. 
If  a  dry  mucus  covers  the  part,  it  is  due  to  dry  catarrh  ;  on  the  other 
hand,  a  dirty-gray  membrane  is  indicative  of  diphtheritic  rhinitis. 

It  is  swollen  and  bathed  with  a  serous,  seropurulent,  or  purulent 
discharge,  the  character  depending  on  the  stage  of  inflammation.     The 


424  SPECIAL  DIAGNOSIS. 

contractile  tissue  over  the  turbinated  bones  is  congested  and  swollen. 
When  probed  it  is  elastic,  and  when  cocaine  is  applied  it  shrinks. 

In  chronic  hypertrophic  rhinitis  the  uvula  is  thickened  and  elon- 
gated, on  'account  of  the  hawking.  The  outer  surface  or  the  edges  of 
the  turbinated  bones  are  enlarged  throughout  or  hi  localities.  The 
mucous  membrane  covering  these  spots  is  thickened,  hard,  and  rough. 
If  cocaine  is  applied,  the  mucous  membrane  does  not  contract,  as  in 
the  swelling  due  to  hyperemia.  The  posterior  ends  of  the  inferior  or 
middle  turbinated  bones  are  enormously  enlarged,  forming  round 
tumors  which  obstruct  more  or  less  the  posterior  nares  and  project  into 
the  pharynx  ;  polyps  and  deviation  of  the  septum  complicate  these 
cases. 

The  same  appearances  are  seen  in  chronic  post-nasal  catarrh,  and 
in  addition  a  mammillated  and  thickened  appearance  of  the  pharyngeal 
mucous  membrane  and  that  of  the  posterior  third  of  the  septum.  In 
dry  catarrh  the  mucous  membrane  is  coated  with  mucus  or  covered 
with  crusts.  The  membrane  is  thin,  pale,  hard  to  the  touch,  and  cov- 
ered with  a  layer  of  dried  secretions  and -crusts  in  atrophic  rhinitis. 
The  nasal  passages  are  abnormally  wide  and  one  or  both  turbinated 
bones  are  atrophied. 

Abnormal  Growths.  A  grayish  yellow  or  greenish  shiny  mass,  with 
a  broad  base,  soft  and  yielding  on  probing,  is  a  nasal  polypus.  It 
cannot  usually  be  circumscribed.  The  passages  are  enlarged  in  atrophic 
rhinitis.  One  may  be  occluded  by  an  enlarged  turbinated  bone  or  by 
deviation  of  the  septum. 

Ulceration.  Ulceration  of  the  mucous  membrane  is  usually  a 
manifestation  of  lupus,  tuberculosis,  or  tertiary  syphilis.  In  lupus  the 
ulceration  has  extended  from  the  exterior.  If  ozaena  is  present  in  a 
patient  with  lupus  it  is  probable  that  there  is  also  lupus  of  the  nasal 
passages.  The  ulcers  may  be  followed  by  necrosis  and  caries  of  the 
bones.  If  the  ozama  is  not  removable  by  antiseptic  sprays  the  bones 
are  probably  affected.  A  discharge  of  sequestra  makes  the  diag- 
nosis positive.  Rhinoscopy  and  careful  palpation  may  reveal  the  ulcer 
and  a  carious  bone.  Tuberculous  ulcers  are  usually  found  in  the  septum. 
They  are  rarely  primary.  They  present  a  whitish-gray  surface,  with 
elevations  of  infiltrated  tissue.  They  bleed  on  the  slightest  provoca- 
tion. The  mucous  membrane  surrounding  them  is  torn.  Tubercle 
bacilli  can  be  found  in  the  scrapings  from  the  ulcer.  In  syphilis  the 
ulcers  are  situated  anywhere  in  the  nares.  A  history  of  infection,  or 
of  secondary  and  tertiary  manifestations,  can  be  obtained.  The  stench 
of  the  breath  is  sickening,  and  the  patient  complains  of  stenosis  and 
loss  of  smell.  There  is  some  localized  tenderness,  and  sleeplessness, 
debility,  and  emaciation  may  ensue.  They  may  be  mere  superficial 
excoriations,  or  deep  serpiginous  ulcers  surrounded  by  an  inflammatory 
zone.  Caries  can  be  detected  with  a  probe.  The  ulcerated  surfaces 
are  covered  with  a  dry,  greenish  crust.  Foreign  bodies  usually  cause 
ulceration  if  impacted. 

Xeuro-paralytic  ulcers  are  painless  and  spread  rapidly  over  consider- 
able surface  ;  they  follow  paralysis  of  the  fifth  nerve.  They  are  dry 
and  sluggish  and  do  not  extend  to  the  skin.     Post-febrile  ulcers  follow 


THE  NOSE  AND  LARYNX.  425 

measles,  scarlatina,  typhoid,  and  variola,  and  are  due  to  rupture  of 
small  abscesses,  with  the  subsequent  formation  of  ulcer.  They  are 
usually  anterior  on  the  septum  or  inside  the  alse,  and  scabs  form  over 
the  surface.  They  are  very  irritable.  Ulcers  may  perforate  the 
septum  or  the  floor  of  the  nose.  They  are  usually  due  to  syphilis. 
Simple  perforating  ulcer  of  neuro-paralytic  origin  may  also  occur. 

Nasal  Secretion.  The  odor  of  the  discharge  is  suggestive  of 
diphtheria  and  also  of  the  presence  of  foreign  bodies.  The  discharge 
in  the  latter  instance  is  sanious  or  purulent.  Animal  parasites,  as 
well  as  pease  and  beans,  cause  pain,  symptoms  of  obstruction,  and  ulcer- 
ation.    In  syphilis  with  caries  the  odor  is  marked,  usually  gangrenous. 

Atrophic  Rhinitis,  or  Ozaena.  The  odor  is  characteristic,  and  is 
diagnostic  if  syphilis  is  excluded.  A  sense  of  dryness  is  complained 
of.  Occasional  obstruction  arises  from  accumulation  of  crusts,  other- 
wise the  passage  is  unduly  open.  There  are  constant  hawking  and 
spitting  of  brownish-green  crusts,  which  are  often  blood-tinged.  Frontal 
headaches  may  occur  in  paroxysms.  The  patient  is  often  depressed  in 
spirits.     The  bridge  of  the  nose  may  fall  in  slightly. 

Physical  Character.  The  character  of  the  secretions  is  of  diag- 
nostic significance.  They  may  be  liquid,  semi-solid,  or  solid.  The 
liquid  secretions  may  be  serous,  mucous,  or  purulent.  Serous  secretions 
occur  in  acute  rhinitis,  hay  fever,  and  idiopathic  rhinorrhcea,  and  follow 
bursting  of  cysts.  The  secretion  of  mucus  occurs  in  the  later  stages 
of  inflammation  of  the  mucous  membrane  and  in  chronic  forms.  A 
mucopurulent  secretion  is  seen  in  chronic  rhinitis,  and  pure  pus  in 
abscesses  of  the  septum  or  cavity.  In  hereditary  syphilis  it  is  at  first 
mucopurulent,  then  purulent,  and  then  sanious.  A  sanious  acrid  dis- 
charge, with  false  membrane  discharged  or  evident  on  inspection,  is 
due  to  diphtheria.  A  fetid,  sanious,  or  ichorous  discharge,  with  fre- 
quent attacks  of  epistaxis,  attends  malignant  nasal  growths.  A  dis- 
charge of  blood  is  known  as  epistaxis.  (See  page  426.)  The  semi- 
solid secretions  may  be  due  to  mucus  alone,  or  to  blood-clots  mingled 
with  serum  or  with  pus.  The  latter  occur  in  atrophic  and  hyper- 
trophic catarrhs. 

Caseous  Rhinitis.  A  semi-solid  secretion  is  diagnostic.  On  exami- 
nation the  cavities  in  this  affection  are  found  to  be  filled  with  cheesy 
matters,  easily  broken  up  with  the  probe.  The  mucous  membrane  is 
dull  red.  The  material  is  discharged  in  masses  at  intervals  through  the 
mouth  or  nostrils,  relieving  the  previous  extreme  stenosis.  If  neglected 
for  a  long  time,  deformity  of  the  face  and  disease  of  the  bones  and  car- 
tilages ensue  from  pressure. 

The  solid  secretions  may  be  mucous  crusts,  as  in  acute  and  chronic 
catarrhs,  blood-crusts  after  epistaxis  and  traumatism,  membrane  in 
diphtheritic  rhinitis,  slough  from  ulcers,  and  rhinoliths.  The  latter 
are  gray  or  greenish-brown  in  color,  hard  and  rough,  either  fixed  or 
movable. 

Microscopical  Character.  The  normal  secretion  from  the  nose  con- 
tains squamous  and  ciliated  epithelium,  isolated  leucocytes,  and  vari- 
ous fungi.  The  fluid  is  thick,  alkaline  in  reaction,  and  lias  a  slight 
odor.     It  contains  mucin.     In  disease  of  the   nasal  cavities  the  fluid 


426  SPECIAL  DIAGNOSIS. 

changes.  In  acute  nasal  catarrh  it  is  niore  copious  and  thinner.  It 
remains  alkaline,  and  contains  epithelium  and  fungi.  When  the  stage 
of  suppuration  is  reached,  the  secretion  may  consist  entirely  of  pus. 
Cerebro-spinal  fluid  may  also  be  discharged  through  the  nose  in  certain 
brain-tumors.  In  such  fluid  albumin  is  absent.  Detection  of  this 
fluid  is  of  diagnostic  value,  as  it  points  to  the  central  lesion. 

The  Charcot-Leyden  crystals  are  found  in  the  nasal  secretion  in 
asthmatic  patients,  and  sometimes  in  acute  coryza. 

Bacteriological  Character.  In  diphtheria  the  characteristic  micro- 
organism is  seen.  Recognition  of  glanders  may  be  based  upon  finding 
the  bacillus  in  the  nasal  secretion.  (See  page  336.)  Cultivations 
may  be  made.  The  nature  of  ulcers  may  be  determined  by  microsco- 
pical examination.  The  tubercle  bacillus  can  sometimes  be  detected. 
A  pneumococcus  or  bodies  that  resemble  it  have  been  found  in  the 
secretion  in  ozsena.  Thrush-fungi  have  also  been  found,  as  well  as 
some  mould  fungi. 

Mouth-breathing.  Much  valuable  information  is  obtained  by 
noting  the  breathing  and  the  condition  of  the  voice.  Mouth-breathing 
may  be  present  if  the  face  is  drawn  and  vacant  and  there  are  cracks 
and  fissures  in  the  mouth.  The  voice  is  usually  nasal.  The  resonating 
quality  is  lost  entirely.  Snoring  accompanies  these  conditions.  (See 
Obstructive  Symptoms.) 

Palpation.  The  probe  is  used  to  determine  the  character  of  en- 
largements or  tumors,  and  the  patulency  of  foramina  ;  also  to  examine 
the  mucous  membrane  as  to  induration  and  the  presence  of  caries  or 
necrosis.  By  the  finger  the  nasal  pharynx  is  palpated  to  confirm  the 
results  of  rhinoscopy.  In  this  manner  adenoid  vegetations  and  hyper- 
trophy of  the  inferior  turbinated  bones  are  detected.  The  finger  should 
be  protected  by  the  use  of  a  mouth-gag  or  by  a  jointed  thimble. 

Epistaxis.  The  blood  may  flow  in  drops,  or  a  continuous  stream 
may  pour  out  from  the  anterior  nares.  Sometimes  it  falls  into  the 
pharynx  and  is  hawked  up,  or  is  swallowed  and  then  vomited. 

It  may  be  due  to  local  causes,  or  to  constitutional  conditions.  Trau- 
matisms (scratching  the  nose),  new  growths,  and  foreign  bodies  are 
causative  agents  ;  it  may  be  due  to  fractured  skull.  Local  causes  : 
On  inspection,  the  cause  may  be  found  in  enlarged  veins  at  the  anterior 
inferior  portion  of  the  septum,  a  bleeding  ulcer,  a  new  growth,  or 
the  ulceration  of  a  foreign  body.  The  general  conditions  wThich  are 
causal  are  :  (1)  Plethora ;  (2)  engorgement  due  to  the  ascent  of  an 
elevation  ;  (3)  all  forms  of  ansemia  ;  (4)  hseinophilia  ;  (5)  cerebral  con- 
gestion and  severe  headache  ;  (6)  the  commencement  of  fevers,  particu- 
larly typhoid  fever ;  (7)  early  stages  of  leprosy.  In  children  exposed 
to  the  sun,  and  after  exertion,  it  is  of  frequent  occurrence,  and  is  seen 
often  at  puberty  in  delicate  children. 

Diseases  of  the  Nose. 

The  subjective  and  objective  symptoms  previously  described  are  due 
in  general  to  inflammations,  malformations,  morbid  growths,  and  foreign 
bodies.  They  are  recognized  by  their  subjective  and  objective  signs, 
by  rhinoscopic  examinations,  and  by  bacteriological  and  microscopical 


THE  NOSE  AND  LARYNX. 


427 


research.  The  inflammations  may  be  acute  or  chronic,  primary  or 
secondary.  When  secondary,  both  acute  and  chronic  inflammations 
may  be  due  to  infections.  To  the  acute  varieties  belong  the  acute 
catarrh  of  measles,  glanders,  hay  fever  or  influenza  ;  to  the  chronic 
belong  syphilis  and  tuberculosis. 

Simple  Acute  Rhinitis.  Acute  Coryza,  "  Cold  in  the  Head." 
Ushered  in  with  a  feeling  of  lassitude,  aching  in  the  back  and  limbs, 
and  feverishness,  a  sense  of  fulness  is  felt  in  the  nostrils,  with  sneezing. 
After  twenty-four  hours  an  irritating  discharge  begins.  During  this 
time  the  malaise  has  increased.  The  pain  in  the  forehead  and  cheeks 
has  become  more  pronounced,  and  a  nasal  twang  is  given  to  the  voice. 
The  feverishness  continues,   reaching  101°  in  the  more  pronounced 

Fig.  112. 


Vertical  section  through  nasal  cavities.    (Diagrammatic.)    (Seiler.) 
1.  Superior  turbinated  bone.    2.  Middle  turbinated  bone,  with  posterior  hypertrophy.    3.  Section 
of  hypertrophied  pharyngeal  tonsil.     4.  Inferior  turbinated  bone.     5.  Orifice  of  Eustachian  tube. 

cases,  with  thirst  and  loss  of  appetite.  At  the  height  of  the  fever,  in 
twenty-four  or  forty-eight  hours,  a  crop  of  herpes  very  often  develops 
on  the  lips.  The  general  symptoms  then  subside  and  the  local  symp- 
toms change.  The  discharge  becomes  thick  and  purulent,  the  fulness 
continues,  but  the  pain  is  diminished.  The  inflammation  often  extends 
up  to  the  tear-ducts  and  to  the  eyelids.  The  latter  are  congested  and 
smart  very  much.  Very  frequently,  also,  the  inflammation  extends 
to  the  pharynx,  causing  soreness  of  the  throat  and  stiffness  of  the  neck, 
and  the  larynx  even  may  be  involved.  A  slight  deafness  may  result 
from  the  inflammation  extending  into  the  Eustachian  tube. 

Chronic  Rhinitis.     Four  varieties  are  distinguished,  to  all  of  which 
the  term  nasal  catarrh  is  applied.     In  one  there  is  hypertrophy  of  the 


428 


SPECIAL  DIAGNOSIS. 


turbinated  bones  ;  in  the  second  there  is  extension  of  the  disease  to  the 
post-pharynx — chronic  post-nasal  catarrh  ;  in  the  third  there  is  abso- 
lute dryness  of  the  mucous  membrane — rhinitis  sicca,  or  dry  catarrh  ; 
hi  the  fourth  there  is  atrophy  of  the  mucous  membrane — atrophic 
rhinitis,  or  ozsena. 

Chronic  Hypertrophic  Rhinitis.    The  affection  comes  on  gradually 
after  repeated  acute  attacks  of  coryza.     The  only  symptoms  may  be 


Fig.  113. 


Dilated  nostril,  showing  anterior  hypertrophy.    (Seiler.) 


slight  fulness  in  the  nose  and  a  little  hoarseness  of  the  voice.  In  more 
advanced  stages  the  symptoms  of  stenosis  are  marked  with  oral  breath- 
ing, snoring,  and  nasal  sound.  There  is  a  constant  discharge  of  muco- 
pus  backward  into  the  pharynx,  causing  hawking.  The  hearing  is 
frequently  impaired,  as  well  as  the  taste  and  smell.     The  discharge 


Rhinoscopic  image  from  a  case  of  posterior  hypertrophy  on  the  middle  turbinated  bone.    (Seilek.) 

often  affects  the  larynx,  causing  an  irritating  cough.  The  hypertro- 
phied  tissue  on  the  turbinated  bones,  and  the  pressure  of  the  bone  on 
the  septum,  may  lead  to  reflex  attacks  of  asthma. 

Chronic  Post-nasal  Catarrh  is  an  extension  of  the  rhinitis  into  the 
pharynx.  It  is  distinguished  by  discomfort  or  pain  in  the  soft  palate 
and  posterior  nares.  There  are  tingling  and  a  sense  of  fulness  at  the 
root  of  the  nose,  with  frontal  headache  ;  the  patient  complains  of  a 


THE  NOSE  AND  LARYNX.  429 

bad  taste  in  the  back  of  the  mouth  and  of  constant  flow  of  thick  secre- 
tion into  the  pharynx,  causing  snoring  and  hawking.  The  same  per- 
version of  the  senses  of  taste,  smell,  hearing,  and  of  the  voice  occurs 
as  in  acute  rhinitis.  Headache  seems  to  be  due  to  the  condition  of 
the  pharynx.     (See  Atrophic  Rhinitis,  page  425.) 

Dry  Catarrh,  or  Rhinitis  Sicca,  is  also  chronic  in  its  course,  accom- 
panied by  tingling  and  dryness  of  the  nostrils.  A  faint,  musty  odor 
is  detected,  but  there  is  no  discharge  or  sense  of  obstruction.  In  severe 
cases  there  may  be  sharp  pain  in  the  nose  extending  to  the  forehead. 

Syphilitic  Coryza  is  seen  in  infants  and  young  children  affected 
with  hereditary  syphilis.  The  nostrils  are  swollen  and  red  at  the 
edges,  sometimes  completely  occluded,  causing  oral  respiration  and 
inability  to  take  the  breast  or  bottle. 

Pustules,  fissures,  and  ulcers  are  found  in  the  nose  and  at  the  margin 
of  the  orifices.  They  are  also  seen  in  the  pharynx  and  larynx.  Hem- 
orrhages may  occur.    Other  evidences  of  hereditary  syphilis  are  present. 

The  Auxiliary  Cavities  of  the  Nose. 

The  Antrum  is  subject  to  abscess,  cysts  and  polypi,  parasites,  and 
tumors. 

Abscess.  An  odor  somewhat  like  that  of  ozsena,  a  putrid  taste, 
nausea,  anorexia,  pain  in  the  cheek  and  root  of  the  nose,  often  neural- 
gia in  the  frontal  region,  and  malaise  are  present.  A  very  character- 
istic symptom  is  the  discharge  of  pus  from  one  nostril  on  leaning  the 
head  forward.  There  is  often  a  bad  tooth  on  the  same  side  in  the 
upper  jaw. 

The  Sinuses.  The  frontal,  ethmoidal,  and  sphenoidal  sinuses  are 
subject  to  inflammation,  abscess,  traumatism,  and  the  irritation  of 
foreign  bodies,  usually  parasites. 

The  frontal  sinuses  are  the  only  ones  which  exhibit  external  symp- 
toms. When  these  cavities  are  inflamed  the  patient  complains  of  pain 
and  tenderness  over  the  frontal  protuberances  ;  if  the  process  goes  on 
to  the  formation  of  abscess,  there  may  be  redness  and  swelling  and 
finally  fluctuation.  If  the  communication  is  not  closed,  there  is  a 
fetid  discharge  from  the  middle  meatus. 

When  the  sphenoidal  and  ethmoidal  sinuses  are  affected  there  are  no 
external  symptoms  unless  the  enlargement  is  so  great  as  to  affect  the 
orbit.  There  is  deep-seated  pain.  Pus  is  seen  exuding  into  the  supe- 
rior meatus  and  flowing  backward  into  the  pharynx.  Parasites  cause 
intense  pain  and  lead  to  abscess,  caries,  and  necrosis.  Rhinoscopic 
examination  in  disease  of  the  antrum  shows  rough  hypertrophic  en- 
largement on  the  under  surface  of  the  middle  turbinated  bone  and  a 
flow  of  pus  into  the  middle  meatus.  Sometimes  a  probe  can  be  passed 
into  the  antrum  from  the  nose.  Often  an  exploratory  puncture  is 
necessary.  When  the  foramen  is  obstructed  there  is  a  dull  aching  pain 
in  the  upper  jaw,  with  deformity  of  the  orbit,  face,  hard  palate,  and 
nostril.     Fluctuation  can  usually  be  found  at  some  point  after  a  time. 

The  lacrymal  duet  and  sac  are  often  the  seat  of  inflammation  by  ex- 
tension, causing  pain,   obstruction   in   the   nose,  and  epiphora.     On 


430  SPECIAL  DIAGNOSIS. 

examination  pus  will  be  seen  flowing  forward  over  the  inferior  meatus. 
When  the  lacrymal  probe  is  introduced  the  ducts  are  found  to  be 
painful  and  obstructed,  and  pus  exudes. 

The  Larynx. 

The  structural  composition  of  the  larynx  does  not  differ  from  that 
of  other  parts  of  the  respiratory  passage.  Mucous  membrane,  connec- 
tive tissue,  cartilages,  and  muscle  are  similar  to  the  same  tissues  situ- 
ated elsewhere. 

The  result  of  their  anatomical  association  in  the  larynx  is  the  estab- 
lishment of  the  functions  of  that  organ,  the  formation  of  the  voice  and 
the  admission  of  air.  Now,  the  morbid  processes  that  affect  the  larynx 
do  not  differ  from  morbid  processes  elsewhere  in  which  similar  tissues 
are  involved.  Each  tissue  is  liable  to  congestion,  to  inflammation,  to 
degeneration,  to  new-growth  formation  ;  the  joints  may  become  anky- 
losed,  the  muscles  either  paralyzed  or  the  seat  of  spasm,  and  we  have, 
therefore,  all  the  symptoms  common  to  morbid  processes  in  each  class 
of  tissue.  We  meet  with  other  symptoms  beside,  which  result  from 
the  anatomical  position  of  the  larynx  and  of  its  functions.  The  cords 
cannot  vibrate,  or  the  muscles  and  articulations  cannot  move,  and  dys- 
phonia  or  aphonia  occurs.  The  narrow  chink  of  the  glottis  soon  be- 
comes occluded,  giving  rise  to  dyspnoea.  Obstruction  to  the  pathway 
or  pain  from  inflammation  or  ulceration  causes  dysphagia.  The  sensi- 
tiveness of  the  mucous  membrane  provokes  cough  on  the  slightest 
provocation. 

The  larynx  is  a  highly  specialized  organ,  and  is  well  innervated. 
Large  central  nuclei,  connected  by  a  large  nerve  which  passes  over  a 
circuitous  route  and  which  anastomoses  with  other  nerve-cords,  preside 
over  the  function  of  phonation.  Affections  of  the  central  nuclei,  affec- 
tions of  the  nerve-trunk  or  of  adjacent  structures  exerting  pressure 
upon  the  trunk,  have  their  expression  in  disorder  of  the  larynx,  par- 
ticularly if  phonation  is  disturbed.  In  other  words,  the  phenomena 
of  laryngeal  disease  may  be  symptomatic  of  affections  of  the  brain  or 
of  the  nerve-trunk,  as  well  as  of  the  larynx.     (See  Nervous  Diseases.) 

Owing  to  the  anatomical  position  and  special  function  of  the  organ 
the  symptoms  of  disease  of  the  larynx  are  very  striking,  pointing  at 
once  to  the  seat  of  trouble.  Laryngeal  affections  are  not  likely  to  be 
mistaken  for  disease  of  contiguous  parts,  although  retropharyngeal 
abscess,  abscess  at  the  side  of  the  pharynx,  disease  of  the  thyroid  gland, 
and  inflammation  of  the  lymphatics  or  cellular  tissue  in  the  neck  may 
cause  symptoms  suggestive  of  laryngeal  disease. 

Finally,  morbid  processes  in  the  larynx  determined  by  the  symp- 
toms and  physical  appearances  may  be  symptomatic  of  general  processes  : 
acute  inflammation,  of  erysipelas,  typhoid  fever,  smallpox,  or  measles  ; 
chronic  inflammation  or  ulceration,  of  the  rheumatic  or  gouty  diathesis, 
syphilis  or  tuberculosis  ;  scars,  of  syphilis  ;  ankylosis,  of  rheumatic 
gout.  The  laryngeal  symptoms  of  brain  disease  or  of  affections  of  the 
nerve-trunk  have  been  referred  to. 

The  practical  point  of  all  this  is  that  affections  of  the  larynx  are  not. 


THE  NOSE  AND  LARYNX.  431 

due  to  primary  disease  of  that  organ  alone,  but  are  often  secondary 
either  to  general  processes  or  to  local  morbid  processes  elsewhere. 

Therefore,  when  laryngeal  symptoms  or  lesions  are  observed,  seek 
beyond  the  larynx,  as  well  as  in  it,  for  their  cause. 

The  Data  Obtained  by  Inquiry. 

The  Social  History.  Acute  laryngeal  diseases  are  more  common 
in  childhood,  chronic  diseases  in  late  life.  Those  occupations  which 
compel  the  inhalation  of  noxious  vapors  or  excessive  use  of  the  voice 
predispose  to  laryngeal  diseases.  Alcoholic  subjects  and  those  who 
use  tobacco  to  excess  are  liable  to  laryngeal  affections.  As  with  the 
nose  so  with  the  larynx,  no  special  disease  is  inherited  and  need  be 
looked  for  in  the  family  history.  But  we  may  inquire  for  a  diathetic 
condition,  as  gout  or  rheumatism,  which  predisposes  to  a  mucous  mem- 
brane inflammation,  or  a  family  type  which  leads  a  parent  to  say  his 
child  ' '  has  a  tendency  to  croup,"  a  popular  expression  which  has  in  it 
an  element  of  truth.  That  condition  or  state  which  predisposes  to 
"  colds  "  belongs  also  to  a  family  type. 

On  inquiry  as  to  previous  disease  various  acute  infections  and  syph- 
ilis and  tuberculosis  are  to  be  looked  for.  In  a  study  of  the  present 
disease  it  must  be  borne  in  mind  that  laryngeal  affections  notably  may 
be  secondary,  and,  therefore,  the  presence  of  other  diseases  must  be 
inquired  into.  Particularly  do  we  inquire  for  nervous  diseases,  and  in 
children  for  rhachitis.  One  thing  is  to  be  borne  in  mind — one  attack 
of  acute  laryngitis  predisposes  to  subsequent  attacks. 

Subjective  Symptoms.  Paix.  Pain  in  the  larynx  maybe  sharp, 
stabbing  in  character,  or  simply  a  tickling  or  burning  with  a  feeling 
of  pressure.  It  is  increased  by  pressure  and  by  speaking  or  swallow- 
ing. Pain  is  sometimes  so  intense  as  to  render  speaking  and  swallow- 
ing impossible.  In  acute  laryngitis  the  pain  is  cutting  and  burning. 
In  the  milder  inflammations,  in  dry  catarrh,  and  in  lupus  it  amounts 
to  soreness  only.  The  pain  is  severe  and  sharp  in  cases  of  cancer  and 
tuberculosis,  rarely  in  syphilis,  and  when  foreign  bodies  are  present  .in 
the  structures.  The  pain  may  be  very  severe  and  intense  when  there 
is  destructive  ulceration.     It  is  a  diagnostic  symptom  of  perichondritis. 

Perichondritis.  Inflammation  about  the  cartilages  or  perichondritis 
is  usually  phlegmonous  in  character,  and  leads  to  the  formation  of 
abscess.  The  collateral  oedema  is  so  great  as  to  cause  some  obstruction, 
with  cough  and  hoarseness.  On  palpation  the  larynx  is  extremely 
tender.  The  pain  is  increased  by  movement  of  the  larynx,  as  in  speak- 
ing or  swallowing.  If  the  inflammation  involves  the  arytenoid  carti- 
lages, pain  extends  toward  the  ear,  the  vestibule  is  swollen,  the  car- 
tilage fixed.  On  the  other  hand,  when  the  cricoid  is  diseased  there 
are  pain  on  swallowing  of  solid  food,  on  account  of  interference  with 
the  muscular  attachments,  dyspnoea,  and  paralysis  of  the  posterior 
crico-arytenoid  muscles. 

Inflammation  of  the  thyroid  cartilage  may  open  externally  or  inter- 
nally. In  the  latter  case  the  abscess  can  be  seen  in  the  larynx.  Dis- 
charge of  pus  and  necrosed  cartilage  confirms  the  diagnosis.     By  means 


432  SPECIAL  DIAGNOSIS. 

of  a  sound  the  bare  cartilage  can  be  detected,  giving  further  proof  of 
the  presence  of  the  disease.  The  pain  niay  extend  to  the  ears  in  carci- 
noma.    The  pain  is  propagated  by  the  auricular  branches  of  the  vagus. 

Paresthesia.  Peculiar  sensations  are  frequently  complained  of. 
They  may  be  burning,  tickling,  or  itching  in  character,  or  it  may  seem 
as  if  a  foreign  body  were  present  in  the  part,  as  a  hair,  or  it  may  seem 
like  a  draught  of  cold  air  striking  the  parts.  Sometimes  after  a  foreign 
body  has  actually  been  present,  the  sensation  of  its  presence  will  con- 
tinue a  long  while  after  its  removal.  A  sense  of  pressure  or  fulness, 
the  feeling  of  a  lump  in  the  throat,  is  frequently  complained  of,  pro- 
voking a  desire  to  swallow.  The  patient  will  seek  advice  on  account 
of  it.  It  is  known  as  the  globus  hystericus,  and  is  recognized  by  the 
absence  of  local  changes  in  the  larynx,  by  its  association  with  other 
phenomena  of  hysteria,  and  by  its  disappearance  or  aggravation  under 
the  influence  of  excitement.  This  abnormal  sensation  is  seen  in  hys- 
teria and  hypochondriasis.  It  is  one  of  the  nerve-perturbations  in 
chlorosis  and  anaemia. 

A  feeling  of  dryness  is  frequently  complained  of,  and  attends  the 
first  stage  of  acute,  and  any  stage  of  chronic  laryngitis.  The  sense  of 
fulness,  or  pressure,  or  feeling  of  the  presence  of  a  foreign  body  is  com- 
plained of  in  all  forms  of  laryngitis,  in  croup,  in  oedema  of  the  glottis, 
or  epiglottis,  and  in  syphilitic  infiltration. 

Hyperesthesia  and  Anesthesia.  When  there  is  hyperesthesia 
there  is  constant  desire  to  cough  (see  page  435),  and  the  act  is  induced 
by  the  slightest  irritation.  The  desire  to  cough,  independently  of  the 
act,  however,  is  of  itself  an  extreme  annoyance.  It  is  a  disagreeable 
sensation  present  in  acute  inflammations  and  in  early  phthisis.  At 
times  of  menstruation  and  during  pregnancy  both  symptoms  are  fre- 
quently complained  of.  Hypersesthesia  is  easily  recognized  with  the 
probe.  In  ancesthesia  particles  of  food  fall  into  the  larynx.  The 
mucous  membrane  is  insensitive  to  the  contact  of  the  probe.  Anaesthe- 
sia occurs  in  hysteria,  diphtheritic  paralysis,  paralysis  of  the  superior 
laryngeal  nerve,  bulbar  paralysis  and  cerebral  softening  or  hemor- 
rhage, or  coma  from  any  cause. 

Dysphoria.  The  most  common  symptom  of  affections  of  the 
larynx  is  disturbance  of  the  function  of  speech.  The  voice  is  changed 
in  character,  or  may  be  lost  in  any  affection  which  causes  swelling  of 
the  mucous  membrane,  or  occlusion  of  the  orifice,  or  which  interferes 
with  the  action  of  the  vocal  cords.  The  voice  may  be  hoarse  in  acute 
and  chronic  inflammations,  in  tumors  and  in  specific  ulcerations  about 
the  larynx,  and  in  paralysis  of  the  cords.  From  simple  hoarseness  it 
may  vary  in  intensity  to  complete  aphonia.  Laryngoscopic  examina- 
tion is  necessary  in  order  to  detect  the  presence  or  absence  of  paralyses. 
(See  Paralyses.) 

Chronic  Laryngitis.  Chronic  hoarseness  may  be  due  to  chronic 
laryngitis.  This  affection  either  originates  in  an  acute  attack  or  comes 
on  slowly.  Prolonged  use  of  the  voice  in  a  higher  key  than  natural, 
or  in  the  open  air,  the  use  of  alcohol,  constant  exposure,  are  exciting 
causes.  It  is  symptomatic  of  syphilis  and  tuberculosis.  It  frequently 
results  from  inflammation  of  the  upper  air-passages,  particularly  chronic 


THE  NOSE  AND  LARYNX.  433 

pharyngitis.  It  occurs  after  middle  life  more  frequently,  and  usually 
in  the  male  sex.  There  is  discomfort  on  long  speaking,  with  dryness 
and  tickling.  At  first  the  secretion  of  mucus  is  very  slight,  but  after 
hawking  and  coughing  it  increases  in  amount.  Hoarseness  occurs,  and 
if  the  patient  is  careless  or  persists  in  the  baneful  occupation,  complete 
aphonia  may  result.  The  voice  is  clearest  in  the  morning,  after  expec- 
toration of  the  mucus  that  accumulated  in  the  night,  but  becomes  husky 
toward  night.  The  aphonia  may  occur  in  paroxysms,  and  is  relieved 
by  coughing  up  a  dry  secretion.  The  cough  is  never  severe.  The 
sputum  is  small  in  amount,  glairy,  and  is  often  in  little  balls  or  crusts. 

Lupus.  Slight  hoarseness,  deepening  to  dysphonia  or  even  aphonia, 
attended  by  soreness,  and  later  some  dysphagia,  is  seen  in  lujius.  In- 
filtration and  scar-contractions  cause  dyspnoea  later  in  some  instances. 
Dysphonia  from  inflammation  or  oedema  is  also  a  symptom  of  leprosy, 
which,  however,  is  present  in  other  situations  as  well.  The  duration 
may  be  significant.  Hoarseness  of  long  duration  (years)  is  said  to  be 
prodromal  of  cancer  (Ziemssen). 

Functional  Dysphonia  or  aphonia  may  occur  after  excessive  use 
of  the  voice  and  in  hysteria.  Hysterical  aphonia  occurs  in  women 
and  young  girls  ;  the  laryngoscope  reveals  nothing  ;  the  acts  of  cough- 
ing, laughing,  and  sneezing  are  normal,  and  a  sound  may  be  created 
in  either  act ;  it  appears  and  disappears  suddenly. 

Tone  of  the  Voice.  The  character  of  the  voice  may  change. 
When  one-sided  paralysis  of  a  cord  is  present  the  voice  is  flat  and 
toneless.  In  cases  of  paresis  of  the  tensors  of  the  cords  a  falsetto  voice 
results.  Diplophonia  occurs  in  one-sided  paralysis,  and  in  some  cases 
in  which  small  tumors  lying  between  the  cords  come  up  during  the 
act  of  phonation  and  form  nodes.  Two  tones  are  formed  at  the  same 
time.     Frequently  only  certain  tones  are  doubled. 

Dyspncea.  This  is  one  of  the  frequent  symptoms — and  the  most 
serious — of  laryngeal  disease.  It  may  be  due  (1)  to  obstruction  by 
inflammatory  or  oedematous  swelling ;  (2)  to  spasin  ;  (3)  to  tumors  or 
foreign  bodies  in  the  larynx  ;  (4)  to  the  cicatrization  of  ulcers  after 
syphilis  or  lupus ;  (5)  to  paralysis  of  the  abductors  or  adductors  of  the 
larynx.     It  may  be,  therefore,  organic  or  spasmodic. 

Duration.  Dyspnoea  from  disease  of  the  larynx  may  develop  grad- 
ually and  continue  over  a  long  period  of  time,  or  it  may  be  acute  in 
onset,  depending  upon  the  character  of  the  morbid  process  which  has 
brought  about  the  obstruction.  Acute  paroxysms  of  dyspnoea,  one  of 
which  may  end  in  death,  sometimes  occur  in  the  course  of  affections  in 
which  chronic  dyspnoea  is  present ;  thus  sudden  oedema  may  occur  in 
cases  of  syphilitic  or  tuberculous  ulceration. 

Laeyngeal  Dyspncea  must  be  distinguished  from  other  forms  of 
dyspnoea  :  1.  Dyspnoea  from  diseases  of  the  heart  and  lungs.  2. 
Dyspnoea  from  pressure  upon  the  trachea.  The  larynx  is  not  markedly 
moved  during  the  respiratory  acts,  and  the  patient  bends  the  head  for- 
ward instead  of  backward.  3.  Dyspnoea  from  pressure  on  the  larynx. 
Cellulitis  of  the  neck,  tumors  of  the  lymph-glands,  goitre,  and  retro- 
pharyngeal abscess  are  provocative  of  this  form  of  laryngeal  dyspnn'ji. 
Examination  of  the  respective  localities  by  inspection  and  by  touch 

28 


434  SPECIAL  DIAGNOSIS. 

reveals  the  cause.  It  may  be  worthy  of  remark  that  dyspnoea  in 
diphtheria,  frequently  thought  to  be  due  to  internal  occlusion,  may  be 
due  to  pressure  of  enlarged  glands  on  the  bronchus  and  larynx. 

Inspiratory  Dyspnoea.  Dyspnoea  may  vary  in  degree  from  slight 
inconvenience  in  breathing,  noticeable  to  the  patient,  to  the  violent 
struggling  for  breath  which  is  seen  in  cases  of  extreme  stenosis  of  the 
larynx.  If  carefully  observed  in  either  case  the  larynx  is  seen  to  rise 
and  fall.  In  extreme  forms  of  obstruction  the  head  is  bent  back,  the 
neck  stretched,  the  muscles  of  the  neck  contracted.  The  spaces  above 
the  sternum  and  at  the  sides  of  the  trachea  are  drawn  in  with  inspira- 
tion, and  the  alee  of  the  nose  work  vigorously.  Further  evidence  that 
sufficient  air  does  not  enter  the  lungs  is  found  in  recession  of  the  epi- 
gastrium and  drawing  in  of  the  ribs  at  the  base  of  the  chest  during 
the  act  of  inspiration.  The  countenance  is  dusky  or  ashy-gray,  the  lips 
become  cyanosecl,  and  the  nails  bluish  as  the  dyspnoea  persists  and 
increases.  A  cold  perspiration  breaks  out  on  the  forehead,  and  finally, 
from  exhaustion,  the  respiration  becomes  slower  and  slower  until  mere 
gasps  are  seen.  The  heart's  action  increases  in  frequency  as  the  ste- 
nosis increases.  Death  usually  takes  place  from  asphyxia,  the  child 
first  falling  into  a  stupor,  on  account  of  carbonic-acid-poisoning. 

Sounds  attend  the  act  of  inspiration,  the  character  depending  on  the 
nature  of  the  obstruction.  In  obstruction  from  simple  spasm,  or  from 
intense  inflammation  of  the  larynx,  without  secretion,  the  sound  of 
inspiration  is  harsh  and  stridulous.  In  obstruction  from  oedema  or 
from  exudation,  as  in  laryngeal  diphtheria,  the  sound  of  the  inspiration 
is  loud  and  stridulous,  but  not  shrill.  The  expiration  is  usually  noise- 
less and  prolonged.  The  short,  stridulous,.  or  gasping  inspiration  is 
followed  by  prolonged  gentle  expiration.  In  spasmodic  croup  the 
expiration  is  like  snoring.  The  interval  between  expiration  and  inspi- 
ration is  lessened,  the  respirations  are  hurried. 

Laryngismus  Stridulus.  In  this  form  of  dyspnoea  the  act  of 
breathing  ceases  in  the  midst  of  inspiration,  and  is  attended  by  a 
characteristic  sound.  It  is  seen  usually  in  poorly  nourished  children. 
It  is  of  frequent  occurrence  in  rickets,  its  presence  suggesting  that 
disease  when  other  manifestations  of  it  are  obscure. 

The  symptoms  occur  suddenly  and  are  very  alarming.  The  child 
awakes  in  the  night,  and  suddenly  stops  breathing  after  a  few  short 
whistling  inspirations.  The  child  is  seized  with  terror,  which  is  de- 
picted on  the  countenance ;  the  eyes  stare ;  the  face  is  pallid  at  first, 
tut  rapidly  becomes  livid.  The  alse  nasi  are  extended,  the  head  is 
thrown  back,  and  the  spine  arched.  A  cold  perspiration  breaks  out 
over  the  forehead.  Carpo-peclal  spasms  may  occur  and  the  urine  and 
feces  be  discharged  involuntarily.  In  a  few  seconds,  or,  at  most,  two 
minutes,  the  child  draws  two  or  more  deep,  noisy  inspirations,  each 
one  lessening  in  depth  and  sound,  when  color  returns  to  the  face,  the 
cyanosis  gradually  disappears,  and  the  child  becomes  tranquil. 

In  mild  forms  the  child  "  catches  its  breath."  It  holds  its  breath, 
and  then  makes  a  noisy  inspiration. 

Attacks  of  laryngismus  stridulus  are  more  rare  in  adults.  They 
may  occur  in  hysterical  subjects.     In  the  attack  there  occurs  a  series 


THE  NOSE  AND  LARYNX.  435 

of  long,  harsh,  whistling  or  stridulous  inspirations,  followed  by  short, 
noisy  expirations.     Rarely  is  there  complete  closure  of  the  glottis. 

In  both  children  and  adults  general  convulsions  may  occur  during 
the  attack,  or  carpo-pedal  spasms  alone  may  be  seen.  Among  adults 
the  convulsions  occur  only  in  hysterical  subjects. 

The  diagnosis  of  laryngismus  stridulus  is  based  upon  the  absence  of 
laryngeal  symptoms  prior  to  the  attack,  the  absence  of  cough  or  hoarse- 
ness, and  complete  disappearance  of  all  laryngeal  symptoms  when  the 
attack  subsides.  The  absence  of  pain  and  fever  and  of  laryngoscopic 
signs  is  noteworthy.  This  applies,  of  course,  to  spasm  that  occurs  in- 
dependently of  laryngeal  disease. 

Expiratory  Dyspnoea.  In  some  forms  of  laryngeal  obstruction 
the  exit  of  air  is  interfered  with,  as  in  a  movable  tumor  below  the  vocal 
cords.  We  have  expiratory  dyspnoea.  The  act  of  inspiration  is  com- 
plete, the  act  of  expiration  is  suddenly  checked  by  the  obstruction,  on 
account  of  which  the  lungs  become  overfilled  with  air  and  an  emphy- 
sema develops. 

Dysphagia.  Difficulty  in  swallowing  is  most  marked  when  destruc- 
tion of  tissue  in  the  larynx  takes  place,  or  when  there  is  acute  inflam- 
mation about  the  muscles  or  their  attachments  ;  hence,  when  ulcers, 
tuberculous  or  malignant,  are  present,  or  perichondritis  arises,  the 
difficulty  is  so  great  as  to  prevent  the  taking  of  food. 

Dysphagia  is  recognized  by  pain  and  by  the  falling  of  particles  of 
food  into  the  larynx,  exciting  cough.  It  must  be  distinguished  from 
the  dysphagia  of  pharyngeal  affections  by  ocular  examination,  the  loca- 
tion of  the  pain,  and  the  non-association  of  rheumatism. 

Inflammation  of  the  Epiglottis.  When  the  epiglottis  is  the  seat 
of  acute  inflammation  there  is  great  dysphagia  on  account  of  pain,  or  on 
account  of  the  obstruction.  The  sensation  of  a  lump  in  the  throat  at 
the  base  of  the  tongue  or  the  top  of  the  larynx  is  complained  of,  and 
there  is  pain  on  swallowing.  The  pain  becomes  very  intense  at  times. 
Fluids  cannot  be  taken,  for  the  fluid  enters  the  larynx  when  the  patient 
attempts  to  swallow,  because  the  epiglottis  does  not  protect  the  glottis. 
The  voice  is  usually  clear  throughout  the  attack,  and  the  general  symp- 
toms are  not  marked. 

When  the  epiglottis  is  fixed  or  ulcerated,  and  in  some  forms  of  ulcer- 
ation of  the  larynx,  the  food  enters  the  larynx,  and  hence  produces 
dysphagia. 

Mis-S wallowing,  or  "  swallowing  the  wrong  way,"  occurs  in  all 
conditions  in  which  food  is  allowed  to  enter  the  larynx.  Although 
conditions  favorable  for  its  occurrence  are  present,  it  may  not  take 
place  unless  the  patient  is  off  his  guard  during  the  act  of  swallowing, 
as  when  he  is  laughing.  It  may  then  occur  even  in  normal  cases. 
It  is  associated  with  anaesthesia  of  the  larynx,  and  occurs  in  central 
nerve  affections  which  cause  that  condition. 

Cough.  (See  Diseases  of  the  Lungs.)  Sometimes  valuable  infor- 
mation is  derived  from  the  character  and  severity  of  the  cough.  Sev- 
eral forms  are  noted  : 

First,  the  dry  cough,  as  seen  in  acute  laryngitis.  It  is  almost  con- 
stant, and  is  aggravated  when  the  patient  speaks,  takes  fluid,  or  inspires 


436  SPECIAL  DIAGNOSIS. 

deeply.  In  children  it  is  abrupt,  brassy,  or  metallic,  stridnlous  or 
whistling,  so-called  ( c  croup-cough,"  as  seen  in  cases  of  ' '  false  croup  " 
and  laryngitis  with  cedenia. 

Second,  a  dry  hoarse  cough  occurs  in  the  course  of  chronic  laryngitis. 

Third,  cough  with  whoop.  With  the  act  of  coughing  a  whooping 
sound  may  be  heard  in  inspiration.  After  rapid  violent  expiratory 
acts  the  whoop  takes  place  with  inspiration.  It  is  spasmodic  and  con- 
vulsive, and  is  followed  by  retching,  and  often  by  vomiting.  (See 
Pertussis.) 

Fourth,  the  cough  is  of  such  a  character  as  to  give  one  the  idea  that 
it  is  suppressed  in  membranous  and  oedematous  laryngitis. 

Fifth,  a  cough  frequently  occurs  without  any  local  anatomical  changes 
in  the  larynx,  which  seems  to  be  purely  of  nervous  origin.  Two  forms 
are  seen  :  a.  Paroxysmal.  Severe  coughing  occurs  suddenly,  and  can- 
not be  controlled  by  the  patient.  It  ceases  without  cause,  returning 
in  a  few  hours.  There  is  no  expectoration,  b.  Continued  and  rhythmi- 
cal. It  is  not  so  severe  as  in  the  paroxysmal  form,  but  consists  in  a 
regularly  recurring  cough  more  or  less  loud.  It  does  not  occur  while 
eating  or  speaking  and  ceases  entirely  during  sleep.  It  is  usually 
tvorse  when  the  patient  is  under  observation.  Examination  with  the 
laryngoscope  reveals  absence  of  disease.  This  form  of  cough  is  seen 
after  diphtheria,  when  sexual  disturbances  are  present,  at  puberty,  in 
cases  of  anaemia  and  chlorosis,  or  of  neurasthenia  or  hysteria.  The 
tone  is  usually  high. 

Hemobehage.  Hard  coughing  or  an  unusual  straining  of  the 
voice  may  lead  to  the  occurrence  of  slight  hemorrhage.  Only  after 
injuries  are  hemorrhages  from  the  larynx  at  all  copious.  Moderate 
hemorrhages  occur  in  scurvy,  haemophilia,  hemorrhagic  smallpox, 
typhus  fever,  and  leukaemia. 

Disttjbbaxce  of  Co-oedixation.  Several  forms  of  such  disturb- 
ance are  seen.  Spasm  of  the  glottis  may  occur  with  each  effort  to 
speak,  causing  either  serious  interference  or  complete  inability  to  utter 
a  word,  as  in  stuttering.  Sometimes,  instead  of  the  glottis  opening  to 
complete  the  act  of  inspiration,  it  may  close.  Sudden  inspiratory 
dyspnoea,  therefore,  occurs,  and  is  attended  with  stridor. 

Spasm  of  the  glottis  is  a  frequent  complication  of  disease  of  the 
larynx.     It  is  seen  in  "  crises,"  as  in  locomotor  ataxia. 

The  Data  Obtained  by  Observation. 

Objective  Symptoms.  The  objective  symptoms  are  determined  by 
inspection  and  palpation.  Inspection  of  the  exterior  of  the  larynx  re- 
veals the  presence  of  swelling,  and  the  movements  of  the  organ  as  a 
whole.  Local  swelling  of  the  tissues  over  the  larynx  may  occur  in 
inflammations  of  the  cartilages  ;  they  are  usually  of  syphilitic  origin, 
but  may  attend  carcinoma  or  tumor.  There  is  more  or  less  marked 
swelling  in  inflammation  of  the  cartilages,  which  after  a  time  fluctu- 
ates, and,  when  opened,  discharges  pus  and  necrosed  cartilage.  The 
objective  signs  of  inflammation  are  noted. 

The  movement  of  the  larynx  is  increased  in  cases  of  dyspnoea.     It 


THE  NOSE  AND  LARYNX. 


437 


is  accompanied  by  recession  of  the  spaces  above  the  sternum  and  the 
clavicles,  with  clonic  contraction  of  the  sterno-cleido-mastoid  muscle. 

The  interior  of  the  larynx  is  studied  by  inspection  (laryngoscopy), 
and  by  palpation  (probe  or  fingers). 

Laryngoscopy.  The  first  requisite  is  a  good  light,  sunlight,  a  good 
student's-lamp,  or  an  Argand  "or  Welsbach  gas-burner  ;  the  electric 
light  is  not  satisfactory.  Second,  a  good  reflector  is  required.  It  may 
be  attached  to  a  head-band  or  a  spectacle-frame.  It  should  be  concave 
for  artificial  light,  plain  for  sunlight,  and  should  be  pierced  in  the 
centre.  Third,  laryngeal  mirrors  of  different  sizes  and  a  curved  probe 
complete  the  instruments  necessary  for  examination  of  the  larynx. 


Fig. 115. 


Laryngeal  mirror  in  position,  displaying  the  laryngeal  image.    (Cohen.) 

Ex.vmixatiox.  The  patient  is  seated  with  the  source  of  the  light 
at  one  side  and  behind  him  ;  the  head  and  shoulders  are  brought  well 
forward  and  the  head  slightly  raised.  The  operator  takes  a  seat  in 
front  at  a  proper  distance  for  the  focal  length  of  the  reflector,  and 
focuses  the  licjht  on  the  patient's  mouth,  warms  the  laryngeal  mirror 


438  SPECIAL  DIAGNOSIS. 

over  the  flame  and  tests  its  temperature  on  the  back  of  the  hand.  It 
should  be  moderately  heated,  so  that  when  it  is  placed  in  the  mouth 
the  vapor  of  the  breath  will  not  precipitate  on  its  surface.  The  patient 
must  open  the  mouth  and  protrude  the  tongue,  which  is  grasped  be- 
tween the  folds  of  a  napkin  by  the  thumb  and  fingers  of  the  operator. 
The  tongue  should  be  gently  but  firmly  grasped.  The  mirror  is  then 
inserted  carefully  and  quickly,  face  downward,  into  the  pharynx. 
Care  must  be  taken  not  to  touch  the  tongue  or  palate,  otherwise  the 
patient  may  be  made  to  retch  and  become  alarmed.  The  mirror  is 
passed  to  the  posterior  wall  of  the  pharynx,  and  so  directed  that  the 
image  of  the  larynx  is  reflected  to  the  eye  of  the  operator.  The  patient 
is  made  to  phonate  "a"  or  "  ee,"  not  "  ah,"  and  then  to  respire. 
The  various  structures  and  the  action  of  the  cords  are  observed.  The 
appearances  of  the  mucous  membrane  are  studied  during  quiet  respira- 
tion. 

The  epiglottis  is  very  dependent,  so  that  often  the  larynx  can  only 
be  seen  by  having  the  patient  stand  while  the  operator  remains  seated. 
The  patient's  head  is  bowed  on  his  chest  and  the  examination  proceeds. 

The  first  examination  may  not  result  satisfactorily,  but  little  being 
observed  on  account  of  the  spasm  of  the  pharyngeal  muscles.  Re- 
peated sittings  may  remove  apprehension  and  accustom  the  mucous 
membrane  to  the  presence  of  the  instrument.  This  object  may  be 
attained  by  administering  bromides,  or  by  applying  cocaine  to  the 
pharynx. 

The  probe  is  needed  only  to  ascertain  the  consistency  of  tumors  and 
growths.     Cocaine  must  be  applied  before  it  is  used. 

Appearance  of  the  Larynx  in  Health.  Fig.  115  shows  the  larynx 
as  it  is  seen  in  the  laryngoscopic  mirror.  Above  (upper  part)  is  the 
arched  epiglottis,  below  it  the  cavity  of  the  larynx.  In  the  centre  are 
the  vocal  cords,  white  and  glistening  ;  on  each  side  of  these  the  pink 
folds  of  the  false  cords.  At  the  bottom  of  the  mirror  are  the  aryte- 
noid bodies,  and  between  them  the  folds  of  the  inter-arytenoid  space. 
Below  and  outside  the  arytenoid  bodies  are  the  fossse.  The  mucous 
membrane  is  pink  throughout  except  on  the   cords.      In   respiration 

Fig.  116.  Fig.  117. 


Laryngeal  image  during  respiration.  Laryngeal  image  during  phonation. 

the  arytenoids  separate,  carrying  the  ends  of  the  cords  which  are 
attached  to  them  with  them,  and  leaving  a  triangular  opening — the 
glottis — through  which  the  rings  of  the  trachea  can  be  seen.  (See  Fig. 
116.)  In  phonation  the  arytenoids  approach  each  other,  obliterating 
the  inter-arytenoid  space  ;  the  inner  edges  of  the  cords  come  in  con- 
tact and  close  the  glottis.     (See  Fig.  117.) 


THE  NOSE  AND  LARYNX.  439 

Appearance  in  Disease.  A  note  must  be  made  of  the  color  of  the 
various  parts,  of  the  presence  or  absence  of  swelling,  of  ulceration,  of 
new  growths,  and  of  alterations  of  the  movements  of  the  parts  concerned 
in  phonation,  particularly  of  the  cartilages  and  the  cords. 

Color.  The  color  is  an  indication  of  the  degree  of  congestion. 
Anaemia  of  the  larynx  may  be  merely  a  part  of  a  general  anaemia  from 
any  cause.  In  chlorosis  it  is  seen  before  the  external  appearance  is 
marked.  An  intense  anaemia  of  the  larynx  is  an  early  and  valuable 
symptom  of  pulmonary  tuberculosis.     The  mucous  membrane  is  pale. 

Hypoxemia  may  be  active  or  passive.  It  is  readily  recognized  by 
the  intense  redness. 

Active  hyperemia  occurs  in  acute  laryngitis,  either  of  the  primary 
or  secondary  forms. 

Passive  hyperaemia  occurs  in  general  obstruction  to  the  circulation, 
as  emphysema  or  valvular  lesions  ;  pressure  on  veins  by  tumors  ; 
forced  expiration  and  holding  the  breath  ;  in  paroxysmal  cough,  espe- 
cially whooping-cough.  Active  hyperaemias  lead  to  catarrhs,  passive 
to  oedema. 

Swelling  and  Infiltration.  Swelling  of  the  epiglottis  and  of  the 
aryteno-epiglottidian  folds  is  seen  in  ©edematous  laryngitis,  in  acute, 
submucous,  and  chronic  laryngitis.  In  oedema  of  the  glottis  the  swell- 
ing is  below  the  vocal  cords.  The  swelling  may  be  circumscribed 
and  undergo  suppuration.  Swelling  and  oedema  is  also  seen  in  peri- 
chondritis. 

Tuberculosis.  Swelling  and  infiltration  succeeds  the  primary 
anaemia  or  catarrh  of  the  first  stage  of  laryngeal  tuberculosis.  At  first 
there  is  slight  intumescences  of  tubercular  infiltration,  not  well  out- 
lined, and  gray  in  color.  They  are  most  frequently  found  in  the  inter- 
arytenoid  space,  less  often  on  the  false  cords  and  arytenoid  cartilages, 
rarely  on  the  epiglottis. 

1.  A  hill-like  prominence  between  the  arytenoid  cartilages  either  in 
the  middle  or  on  one  side.     In  phonation  it  presses  between  the  cords. 

2.  When  a  false  cord  is  affected  the  whole  of  it  is  usually  infiltrated, 
forming  a  tumor-like  swelling  which  often  hides  the  vocal  cords. 

3.  Vocal  cords.  Usually  only  one  cord  is  at  first  affected.  It  is 
thickened  and  the  free  border  is  red.  Sometimes  the  free  edge  seems 
split.  The  infiltration  may  extend  to  the  subcordal  region  and  cause 
a  hypoglottic  laryngitis. 

4.  Epiglottis.  Infiltration  of  the  epiglottis  is  rarer  than  oedema 
after  ulceration,  and  care  must  be  taken  not  to  confound  these  condi- 
tions. The  whole  epiglottis,  or  only  portions  of  it,  may  be  affected. 
It  is  thickened  and  curled  upon  itself,  and  not  freely  movable. 

5.  Arytenoid  cartilages.  They  appear  enlarged  and  puffy,  and  often 
fixed  from  perichondritis. 

Syphilis.  In  syphilis  we  have  three  forms  of  swelling  : 
1.  Mucous  Patches.  These  are  flat  elevations  of  3  to  7  mm.  diam- 
eter, oval  or  circular,  and  of  a  whitish-gray  color.  When  the  epithe- 
lium is  lost  they  appear  yellow  and  purulent.  There  is  no  tendency 
to  ulceration,  and  the  patches  soon  disappear,  even  without  treatment. 
They  occur  usually  from  three  to  nine  months  after  the  infection. 


440  SPECIAL  DIAGNOSIS. 

2.  Infiltrations.  Usually  these  are  overlooked,  as  they  produce  no 
symptoms.  They  are  diffuse  thickenings  in  various  parts  of  the  larynx, 
most  often  on  the  epiglottis.  This  may  be  uniformly  thickened  or 
only  in  part  around  the  edge.  The  cords  may  be  so  swollen  as  to  cause 
dyspnoea.  Usually  an  ulcerated  spot  is  seen  in  the  centre  of  the  infil- 
tration. The  mucous  membrane  is  either  normal  or  reddened.  Infil- 
trations appear  three  to  four  or  more  years  after  infection. 

3.  Gummata.  They  appear  as  round  prominences  of  the  same  color 
as  the  surrounding  tissue.  They  occur  on  either  side  of  the  epiglottis, 
on  the  aryteno-epiglottic  folds,  often  in  the  inter-arytenoid  space,  on 
the  false  cords,  and  on  the  under  surface  of  the  vocal  cords.  If  they 
break  down,  deep  ulcers  form,  leading  to  extensive  destruction  of  the 
parts. 

Lupus.  In  lupus  isolated  or  grouped  nodes  are  seen  flowing  to- 
gether into  patches,  situated  on  the  epiglottis.  The  disease  is  usually 
present  on  the  face  or  in  the  pharynx  and  mouth.  In  leprosy  the 
epiglottis  is  swollen,  and  nodes  from  the  size  of  a  pin-head  to  that  of 
a  pea  are  seen  on  the  epiglottis,  arytenoid  bodies/  and  false  cords. 

Fissures.     Fissures  and  erosions  are  present  in  chronic  laryngitis. 

Ulcers.  Ulceration  is  seen  in  tuberculosis,  syphilis,  carcinoma,  lep- 
rosy, and  lupus. 

Tuberculosis.     Ulceration  occurs  in  tuberculosis  in  the — 

1.  Inter-arytenoid  space.  The  mucous  membranes  are  notched  with 
irregular  projections.  When  the  ulcer  is  visible  it  is  irregular  and  of 
a  dirty-gray  color. 

2.  False  cords.  The  ulcers  are  flat  and  aphthous,  with  a  pale-white 
base  and  a  membranous  deposit.  The  mucous  membrane  sometimes 
appears  sieve-like. 

3.  Aryteno-epiglottic  ligaments.  The  ulcers  are  superficial  and  run 
lengthwise  of  the  ligament. 

4.  Vocal  cords.  "  The  ulcers  are  either  on  the  upper  surface  or  on 
the  edge  of  the  cords.  The  former  are  superficial  and  seldom  destruc- 
tive. Those  on  the  edge  are  either  small  separate  ulcers  or  long  ones, 
affecting  the  whole  border.  The  circumscribed  ulcers  occur  usually 
at  the  posterior  portion  of  the  cord  and  on  the  processus  vocalis.  The 
ulcers  of  the  whole  border  are  often  very  destructive. 

5.  Epiglottis.  Tubercular  ulcers  of  the  epiglottis  occur  only  on  its 
laryngeal  side.  They  are  either  aphthous  and  superficial,  or  deep,  and 
arise  from  the  breaking  down  of  previous  infiltration.  Sometimes 
tubercles  can  be  seen  at  the  edge  of  the  ulcers,  but  they  are  of  no  diag- 
nostic value,  as  similar  nodes  are  seen  with  non-tubercular  ulcers.  The 
epiglottis  is  usually  thickened  and  oedematous. 

Syphilis.  Syphilitic  ulcers  are  circular,  deep,  with  a  sharp  border 
and  inflammatory  areola,  and  overlaid  with  a  whitish-yellow  deposit. 
They  develop  from  an  infiltration  or  a  gumma,  and  not  on  an  unchanged 
surface.  Ulcers  on  the  upper  surface  of  the  epiglottis  are  always 
syphilitic. 

Tumors  Papilloma.  The  most  common  form  of  the  benign 
growths  is  the  papilloma.  The  growth  may  spring  from  the  true  or 
false  cords,  the  aryteno-epiglottic  ligaments,  rarely  the  posterior  surface 


THE  NOSE  AND  LARYNX.  441 

of  the  epiglottis.  The  tumor  has  a  broad  base.  There  may  only  be 
one,  or  it  may  be  multiple,  and  may  vary  in  size  from  a  split  pea  to  a 
walnut.  Three  varieties  are  met  with  :  1.  Small  warty  growths, 
usually  on  the  cords,  dark  red  in  color,  and  seldom  larger  than  a  bean. 
2.  Groups  of  raised  white  papilla?  on  a  broad  base,  also  growing  on  the 
cords.  3.  Large,  red,  mulberry-shaped  or  cauliflower-shaped  growths, 
partly  villous,  partly  warty,  which  All  up  the  whole  larynx. 

Fibroma.  It  appears  as  a  hemispherical,  pedunculated  tumor  of 
dirty-white,  reddish,  or  dark-red  color,  more  or  less  dense  in  consist- 
ency. It  is  usually  single,  and  grows  most  frequently  from  the  cords. 
When  seen  in  its  smallest  size  it  is  known  as  the  "singer's  node."  It 
may  be  as  large  as  a  hazel-nut. 

Malignant  Tumors.  In  addition  to  the  symptoms  indicated  in 
benign  tumor,  pain  and  hemorrhage  occur.  Both  carcinoma  and  sar- 
coma are  found  ;   the  latter  is  very  rare. 

Carcinoma.  The  most  common  form  is  the  epithelioma,  although 
the  medullary  and  scirrhus  have  been  described.  The  epithelioma  is 
seen  as  a  circumscribed,  hemispherical,  warty,  or  cauliflower-like  forma- 
tion, varying  in  size,  or  as  a  knotty  infiltration  projecting  into  the 
larynx.  The  medullary  form  is  larger,  soft  and  bloody,  and  rapidly 
ulcerates.  Scirrhus  is  firm  and  hard.  The  structure  of  the  larynx  is 
gradually  invaded,  with  necroses  of  the  tissues.  Perichondritis  and 
abscess  frequently  ensue. 

In  carcinoma  of  the  cords  two  kinds  of  growth  are  seen. 

In  the  polypoid  form  the  tumor  develops  on  the  cord  like  a  warty 
growth,  sometimes  papillary  and  of  a  reddish-gray  color.  In  diffused 
cancer  of  the  cord  the  structures  are  red  and  knotty,  and  invade  the 
surrounding  tissue  without  distinct  demarcation. 

Sarcoma.  The  tumor  has  a  broad  base,  is  shining  in  appearance, 
and  sometimes  lobulated.  Sometimes  the  structure  is  dark  red  or 
yellow. 

The  Epiglottis.  The  epiglottis  is  swollen  and  red  in  inflammation 
of  that  structure,  and  may  then  be  palpated  with  the  finger. 

Sputum.  The  sputum  from  the  larynx  is  generally  scanty  ;  it  is 
not  frothy,  and  is  colorless  and  transparent  ;  it  is  often  discharged  in 
small  globules  ;  it  may  be  streaked  with  blood.  Sometimes  pseudo- 
membranes  are  coughed  up.  It  is  doubtful  if  purulent  sputum  ever 
comes  from  the  larynx,  excepting  in  cases  of  perichondritis  in  which 
the  abscess  bursts  into  the  larynx.  Laryngeal  sputum  is  found  in 
catarrh  and  malignant  tumors.  It  is  blood-streaked  when  the  catarrh 
is  very  intense,  or  after  injuries. 

Fever.  Fever  is  present  in  acute  laryngitis  and  tuberculous  ulcer- 
ation. It  is  high  in  acute  laryngitis  with  stenosis  ;  in  tuberculosis  it 
is  of  a  hectic  type. 

Acute  Laryngitis.' 

Acute  laryngitis  is  an  inflammation  of  the  larynx,  characterized  by 
a  sensation  of  fulness  and  dryness,  with  cough,  hoarseness,  and  at  times 
dyspnoea.      Several  varieties  are   observed  :    Simple  acute  laryngitis, 


442  SPECIAL  DIAGNOSIS. 

laryngitis  with  great  stenosis,  laryngitis  with  membrane,  laryngitis  with 
spasm. 

It  is  caused  by  exposure  to  cold  or  by  the  inhalation  of  acrid  vapors. 
Overstrain,  as  in  singers,  excessive  use  of  the  voice,  particularly  in  the 
cold  air,  may  excite  an  attack.  It  may  be  symptomatic  of  the  erup- 
tive fevers,  as  measles  or  smallpox,  or  erysipelas.  Its  occurrence  in 
the  course  of  chronic  diseases  must  be  looked  upon  with  alarm,  partic- 
ularly in  cases  of  Bright' s  disease,  if  dropsy  is  present  in  other  situations. 

The  attack  begins  with  a  feeling  of  chilliness,  followed  by  fever  of 
varying  degree,  but  usually  mild.  The  patient  complains  of  a  feeling 
of  pressure  and  dryness  in  the  larynx,  or  as  if  a  foreign  body  were 
present.  Some  pain  gradually  develops  in  the  height  of  the  attack, 
never  so  severe  as  to  require  an  anodyne.  From  the  first  there  is 
cough.  It  is  dry  and  hacking,  and  slightly  painful.  In  the  more 
intense  forms  the  cough  is  continuous,  disturbing  the  patient  night  and 
day.  Paroxysms  occur  when  the  patient  speaks  or  takes  food.  First 
the  cough  is  dry  ■  within  a  short  time  it  becomes  moist,  and  expecto- 
ration of  clear,  transparent  mucus  takes  place.  The  mucus  may  be 
tinged  with  blood.  At  the  end  of  forty-eight  hours  expectoration  be- 
comes more  yellowish  and  opacpie.  The  voice  may  be  merely  hoarse, 
or  may  be  lost  entirely.  Sometimes  aphonia  without  general  symp- 
toms occurs  in  acute  laryngitis.  In  laryngitis  sicca  cough  and  dyspnoea 
occur  in  paroxysms  and  are  not  relieved  until  a  dry  secretion  is  coughed 
up.  The  paroxysms  take  place  at  night  or  in  the  early  morning,  and 
may  cause  retching  and  vomiting.     It  is  seen  in  adults. 

Acute  Laryngitis  with  Stenosis  Xo  doubt  some  of  the  cases  of 
so-called  membranous  croup  in  children  are  cases  of  acute  laryngitis, 
with  swelling  and  occlusion  of  the  glottis  by  congestion  and  by  tough 
secretion.  CEdema  may  or  may  not  be  present.  The  attack  begins 
with  catarrhal  symptoms.  The  child  is  languid,  refuses  to  eat,  is 
thirsty  and  has  some  chilliness  and  rise  of  temperature.  With  the 
slight  cough,  which  may  be  shrill,  there  are  hoarseness  and  some 
difficulty  in  breathing,  but  no  pain  on  swallowing.  On  the  second 
day,  or  after  the  lapse  of  four  or  five  days,  during  which  time  mild 
fever  continues,  the  catarrhal  symptoms  become  more  marked.  The 
voice  is  more  hoarse  or  may  be  suppressed.  The  harsh,  clanging 
cough  becomes  toneless,  and  soon  the  sound  is  sivppressed.  Dyspnoea 
is  most  severe,  and  the  aspirations  are  hurried  and  noisy,  attended  by 
loud  whistling  inspiration,  and  snoring  expiration.  The  stenosis  is 
inspiratory,  and  during  the  day  or  in  the  succeeding  twenty-four  hours 
may  become  very  intense.  It  is  attended  with  violent  efforts  at  breath- 
ing and  the  occurrence  of  cyanosis  in  its  most  aggravated  form.  The 
larynx  moves  up  and  down,  the  head  is  thrown  back.  There  is  reces- 
sion at  the  root  of  the  neck  and  along  the  margins  of  the  ribs  and  the 
epigastrium.  The  lower  portion  of  the  sternum  may  be  drawn  in. 
Duskiness  of  the  extremities  and  of  the  lips  is  observed  as  the  stenosis 
becomes  more  marked,  finally  deepening  into  cyanosis.  It  may  be 
relieved  from  time  to  time  by  removal  of  the  obstruction,  which  occurs 
after  cough,  vomiting,  or  change  of  position.  A  paroxysm  soon  recurs. 
With  each  paroxysm  lividity  becomes  more  and  more  marked,  the  res- 


THE  NOSE  AND  LARYNX.  443 

pirations  continued  hurried.  The  face  becomes  pale,  the  extremities 
cold,  and  a  cold  sweat  bathes  the  brow.  Restlessness  is  characteristic. 
The  child  tosses  about  in  the  bed  or  from  the  bed  u)  the  arms  of  the 
nurse.  The  heart's  action  is  increased  each  hour  in  frequency  as  the 
stenosis  advances,  and  becomes  weaker.  As  exhaustion  ensues  and 
the  symptoms  of  obstruction  become  more  marked,  stupor  deepening 
into  unconsciousness  develops.  Convulsions  may  occur  at  the  end. 
The  attacks  rarely  recur  if  the  patient  once  recovers.  They  follow 
exposure  to  cold. 

If  recovery  takes  place,  the  child  usually  becomes  more  free  from 
dyspnoea,  the  cyanosis  fades,  and  the  restlessness  disappears.  A  pro- 
longed sleep  follows  relief,  although  the  voice  may  remain  hoarse  or 
suppressed,  and  the  cough  continue  many  days. 

Laryngeal  Diphtheria.  The  same  symptoms  are  seen  in  mem- 
branous croup  and  laryngeal  diphtheria.  In  the  latter  affection  there 
may  be  a  history  of  exposure  or  of  infection.  At  the  commencement 
of  the  attack  the  diphtheritic  patches  may  be  seen  in  the  fauces  or 
nares.  If  a  membrane  can  be  secured  and  a  bacteriological  examina- 
tion made,  the  diagnosis  of  diphtheria  with  stenosis  is  positive.  En- 
larged glands  in  the  neck,  with  marked  physical  depression,  a  mod- 
erate degree  or  entire  absence  of  fever,  and  the  occurrence  of  early 
albuminuria,  also  point  to  diphtheria.  The  distinction  between  the 
two  affections  is  nevertheless  quite  difficult,  and  as  long  as  there  is  a 
shadow  of  doubt,  for  prophylactic  reasons  the  case  should  be  consid- 
ered one  of  diphtheria. 

Acute  Laryngitis,  with  Spasm.  False  Croup  or  Spasmodic 
Laryngitis.  In  children,  in  addition,  another  form  of  laryngitis  asso- 
ciated with  spasm  of  the  larynx  is  seen.  The  catarrhal  symptoms 
are  mild,  so  that  the  child  seems  to  be  well  during  the  day.  Fever 
is  absent,  and  a  slight  cough  or  huskiness  alone  calls  attention  to  the 
larynx.  After  the  first  three  or  four  hours  of  quiet  sleep  the  child 
suddenly  awakes  with  a  barking  cough,  sits  up  and  struggles  for  breath. 
The  dyspnoea  continues  from  a  few  minutes  to  an  hour  or  so,  gradually 
lessening,  to  disappear  entirely  as  the  child  lapses  into  sleep.  Through- 
out the  next  day  the  child  seems  as  well  as  on  the  previous  day,  and 
the  succeeding  night  is  again  seized  with  another  attack  of  "  croup." 
This  may  occur  once  or  twice  during  the  night.  It  seems  to  be  influ- 
enced by  the  weather.  Damp  days  and  an  east  wind  are  provocative 
of  an  attack.     It  recurs  frequently  during  the  same  season. 

(Edema  of  the  Larynx. 

This  condition  arises  in  the  course  of  acute  laryngitis;  frequently 
occurs  in  chronic  diseases  of  the  larynx,  particularly  if  ulceration  is 
present;  and  as  a  complication  of  erysipelas  and  diphtheria.  In  some 
cases  of  Bright's  disease  it  may  develop  suddenly. 

In  the  course  of  the  above-mentioned  disease  symptoms  of  laryngeal 
stenosis  may  occur  suddenly.  The  voice  becomes  husky  and  sup- 
pressed, the  dyspnoea  is  very  extreme,  so  that  in  a  few  hours  grave 
symptoms  of  obstruction  arise.  There  is  no  cough.  The  patient  com- 
plains of  the  sensation  of  a  foreign  body,  and  tries  to  grasp  it. 


444 


SPECIAL  DIAGNOSIS. 


The  Diagnosis  of  Acute  Diseases  of  the  Larynx. 

Acute  affections  of  the  larynx  are  distinguished  from  other  diseases 
without  much  difficulty.  To  recognize  the  various  forms  of  acute 
laryngitis,  however,  is  not  easy.  In  all  there  is  laryngeal  stenosis  to 
a  certain  degree,  and  practically  the  question  to  answer  is,  Which  form 
of  stenosis  is  present  ?  The  accompanying  table  shows  the  differential 
points  for  diagnosis.  It  is  seen  that  the  age,  occurrence  of  previous 
attacks,  the  character  of  the  general  symptoms,  the  existence  of  pre- 
vious laryngeal  disease,  the  association  of  faucial  disease,  the  presence 
or  absence  of  membrane,  and  the  results  of  laryngoscopic  examination 
must  be  considered  before  making  a  positive  diagnosis. 


Simple  Acute  Laryngitis.  - 
Larvnx. ' ' 


-"  Catarrh  of 


Gradual  onset  of  laryngitis,  with  dyspnoea 

very  slight  or  absent. 
All  ages. 

Fever  of  varying  degree. 
Dry  irritating  cough. 
May  be  hoarseness. 
Pharynx  reddened. 
Gradual  increase  and  decline. 

Larynx  red  and  slightly  swollen,  as  seen 
by  laryngoscope. 

Acute  Laryngitis  with  Spasm. — Spasmodic 
Croup. 

May  be  slight  hoarseness  or  cough,  or 
none.  Suddenly,  in  night,  child  wakes 
with  intense  dyspncea  and  crowing  in- 
spiration. 

Children. 

Temporary  high  fever. 

Slight  brassy  cough  during  day. 

May  be  slight  hoarseness  in  day.  Very 
hoarse  in  attack. 


Lasts  a  few  minutes  to  one  hour.  May 
recur,  or  no  attack  until  next  night. 

Slight  redness,  or  nothing  seen  by  laryngo- 
scope. 

(Edema  of  Larynx. 
Some  inflammatory  disease  of  larynx  exists. 
Rapid  development  of  dyspnoea,  increasing 
to  great  severity. 


All  ages. 

Depends  on  cause. 
No  cough. 
No  hoarseness. 


Increases  steadily  to  climax,  then  death, 
or  decline  of  dyspnoea. 

Epiglottis    and    aryteno- epiglottic    folds 
swollen,  pale,  and  waxy. 


Acute  Laryngitis  with  Stenosis. 

Gradual  onset  of  laryngitis,  but  dyspnoea 

develops  to  great  severity. 
Children. 

Fever  of  varying  degree. 
Dry  cough,  often  paroxysmal. 
Hoarseness. 
Pharynx  reddened. 
Gradual    increase,    and    either    death   of 

patient  or  decline  of  dyspnoea. 
Same,  but  swelling  much  greater. 


Laryngismus  Stridulus.  — "Child-crowing." 

No  laryngitis.  .Sudden  attacks  of  dyspnoea 
with  crowing  inspiration,  either  day  or 
night.  Very  severe.  May  be  general 
convulsions. 

Children  or  hysterical  adults. 

No  fever. 

No  cough. 

No  hoarseness. 

Occurs  often  in  rhachitic  and  hysterical 

cases. 
Ends   suddenly,  in  at  most  two  minutes, 

and  occurs  often. 
Nothing  seen  in  larynx. 

Membranous  Laryngitis. — Croup  ; 
Diphtheria. 

Epidemic. 

Gradually  developing  hoarseness  and 
croupy  cough,  with  low  fever  and  lassi- 
tude, then  development  of  dyspnoea, 
gradually  and  without  intermission,  as 
a  rule. 

Children 

Low  fever  and  depression. 

Croupy  cough,  later  suppressed. 

Very  hoarse. 

Fauces  red  and  often  with  membrane  ; 
albuminuria ;  paralysis. 

Increases  steadily,  broken  by  intense  par- 
oxysms- Either  death  or  gradual  im- 
provement. 

Red,  swollen,  with  membrane. 


THE  NOSE  AND  LARYNX.  445 

Foreign  Bodies.  Pertussis.  —  Whooping-cough. 

During  eating  or  while  holding  object  in    Epidemic. 

mouth  sudden  dyspnoea,  varying  in  in-    Bronchitis,  with  cough  developing  in  from 

one  to  three  weeks.  Then  dyspucea 
caused  by  severe  paroxysm  of  coughing 
— absent  between  them. 

Children. 

Only  the  fever  due  to  bronchitis. 

Intense  paroxysm  of  coughing. 

No  hoarseness. 

Hemorrhages  in  various  places  from  strain 
or  emphysema. 

May  be  death  from  exhaustion,  or  gradual 
improvement. 


tensity  according  to  object. 


All  ages. 

No  fever. 

Irritative,  expulsive  cough. 

May  be  hoarseness  or  not. 


Cough  persists  till  removal  of  body,  or 
occasionally  the  larynx  becomes  accus- 
tomed to  its  presence,  and  cough  ceases. 

See  the  foreign  body. 


Nothing  seen,  unless  slight  laryngitis. 


Acute  Submucous  Laryngitis.  The  inflammation  extends  to  the 
submucous  cellular  tissue.  It  arises  in  the  course  of  acute  laryngitis, 
and  is  the  form  seen  in  traumatism,  or  from  burns  and  scalds.  The 
symptoms  are  those  of  intense  laryngitis,  with  stridor.  They  increase 
in  severity  until  stenosis  arises.  If  the  under  surface  of  the  cords  is 
affected,  death  will  occur  from  asphyxia.  Sometimes  the  inflamma- 
tion is  circumscribed  and  is  followed  by  development  of  an  abscess. 

The  chronic  form  of  submucous  inflammation  of  the  larynx  is  usually 
seen  in  drunkards,  and  is  recognized  usually  by  the  laryngoscopic 
examination.     The  symptoms  are  those  of  slight  stenosis. 

Paralyses  of  the  Laryngeal  Muscles. 

They  are  divided  for  convenience  into  groups.  The  symptom  is 
dysphonia,  which,  with  laryngoscopic  appearances,  leads  to  the  recog- 
nition of  the  paralysis. 

1.  Paralysis  of  the  Tensors  of  the  Cord.  The  crico-thyroid 
muscle  is  paralyzed  ;  the  superior  laryngeal  nerve  which  supplies  the 
muscle  is  concerned.  The  voice  is  deep  and  rough,  and  incapable  of 
producing  high  tones.  Usually,  the  whole  nerve  is  involved,  and  the 
result  is  ancesthesia  of  the  larynx  and  paralysis  of  the  epiglottis. 

Laryngeal  Examination.  The  epiglottis  is  fixed,  and  falls  back 
against  the  tongue.     The  glottis  opening  is  a  wavy  line. 

Causal  disease.  The  condition  described  occurs  almost  exclusively 
after  diphtheria. 

2.  Paralysis  of  the  Closers  of  the  Glottis,  or  Adductors  of  the 
Cords.  The  muscles  involved  are  the  crico-arytenoideus  lateralis, 
arytenoideus  transversus,  and  the  thyro-arytenoideus  interims  and 
exteruus.     The  nerve  is  the  recurrent  laryngeal. 

The  symptoms  are  complete  aphonia,  coming  on  suddenly,  and  often 
disappearing  as  suddenly. 

Laryngeal  Examination.  During  pho nation  the  cords  remain  in  the 
inspiratory  position.     The  paralysis  may  affect  one  or  both  sides. 

Sometimes  the  arytenoideus  transversus  alone  may  be  affected.  Then 
there  is  hoarseness  or  aphonia.  The  anterior  portions  of  the  cords 
come  together  in  phonation,  but  the  posterior  portions  do  not,  leaving 
a  triangular  opening  posteriorly.     (See  Fig.  118.) 


446 


SPECIAL  DIAGNOSIS. 


Or,  the  thyro-arytenoideus  interims  alone  may  be  affected.  There 
is  then  dysphonia  or  aphonia,  as  before,  but  the  cords  come  together 
at  both  extremities  and  remain  apart  in  the  middle,  forming  an  oval 
opening.     (See  Fig.  119.) 


Fig.  118. 


Fig.  119. 


Paralysis  of  the  arytenoideus  transversus  in 
phonation.    (Gottstein.) 


Paralysis  of  the  thyro-arytenoideus  internus 
in  phonation.    (Gottstein.) 


Causal  Disease.  These  paralyses  occur  in  hysteria,  catarrh,  or  severe 
overstrain  of  the  voice. 

3.  Paralysis  of  the  Openers  of  the  Glottis,  or  Abductors  of  the 
Cords.  The  muscle  affected  is  the  crico-arytenoideus  posticus,  and 
the  nerve  is  the  recurrent  laryngeal. 

Symptoms.  When  one  side  is  affected  the  respiration  is  free,  but  there 
is  stridor  or  forced  inspiration.     The  voice  is  harsh. 

Laryngeal  Examination.  One  cord  remains  in  the  middle  line.  (See 
Fig.  120.) 

When  both  sides  are  affected  there  is  gradually  developing  inspira- 
tory dyspnoea  with  stridor.     The  voice  is  nearly  normal. 

Fig.  120. 


Paralysis  of  the  left  recurrent  nerve  ;  inspiration.    (Gottstein.) 

Laryngeal  Examination.  The  glottis  is  a  narrow  cleft  which  be- 
comes still  narrower  on  inspection. 

Complete  Paralysis  of  the  Recurrent  Laryngeal  Nerve.  Symp- 
toms. Unilateral  Paralysis.  A  weak,  toneless  voice  which  breaks 
into  a  falsetto  when  the  patient  endeavors  to  speak  loud. 

Laryngeal  Examination.  The  cord  and  arytenoid  body  are  in  the 
cadaveric  position — viz.,  half-way  between  the  phonating  and  the  inspi- 
ratory positions.  In  phonation  the  other  cord  passes  beyond  the  middle 
line,  and  the  glottis  is  slanting.  The  edge  of  the  paralyzed  cord  is 
excavated. 

Bilateral  Paralysis.  Aphonia  and  inability  to  cough  and  ex- 
pectorate. 


THE  NOSE  AND  LARYNX.  447 

Laryngeal  Examination.  Both  cords  are  in  the  cadaveric  position 
and  their  edges  excavated. 

The  adductors  are  usually  paralyzed  before  the  abductors,  and  one 
can  see  all  the  intermediate  stages  by  close  watching. 

Causal  Disease.  The  conditions  which  give  rise  to  the  paralysis 
are  numerous.  It  may  arise  from  simple  catarrh  or  from  hysteria. 
More  often  it  is  due  to  pressure  on  the  vagus  or  recurrent  laryngeal,  or 
some  disease  affecting  these  nerves  or  their  roots. 

The  causes  of  pressure  are  :  Aneurism  of  the  subclavian  or  aorta, 
mediastinal  tumor,  tubercular  bronchial  glands,  the  apex  of  a  tuber- 
cular lung,  cancer  of  the  oesophagus,  goitre,  or  carcinoma  of  the  pleura. 

The  diseases  are  :  Diphtheria,  tumor,  softening  or  hemorrhage  into 
the  brain,  bulbar  paralysis,  neuritis,  typhus,  cholera,  variola,  articular 
rheumatism,  toxaemia  (?),  sclerosis  of  the  cord,  progressive  muscular 
atrophy,  and  paralytic  dementia. 

Tumors  of  the  Larynx. 

Both  benign  and  malignant  growths  are  seen.  At  first  dysphonia 
or  aphonia  takes  place.  The  impairment  of  voice  may  continue  for  a 
long  period  of  time  before  dyspnosa  arises.  This  develops  very  gradu- 
ally, and  in  some  few  cases  is  attended  by  an  irritative  cough.  The 
general  symptoms  are  not  marked  in  benign  cases.  In  the  malignant 
forms  they  are  pronounced,  but  characterized  by  the  development  of 
cachexia  later  than  in  carcinoma  elsewhere. 

The  diagnosis  of  malignant  disease  of  the  larynx  is  based  upon  the 
association  of  symptoms  of  laryngeal  disease  with  pain,  and  with  the 
characteristic  appearances  found  on  inspection,  on  its  occurring  after 
the  middle  period  of  life,  and  lasting  from  six  to  nine  months  only, 
with  the  development  of  cachexia  and  emaciation  without  fever.  En- 
largement of  the  cervical  glands  points  to  cancer.  Simple  and  syph- 
ilitic perichondritis  must  be  excluded. 

Tuberculosis  of  the  Larynx. 

The  existence  of  primary  laryngeal  tuberculosis  is  doubtful.  It 
cannot  be  proved  clinically,  and  the  majority  of  cases,  at  least,  are 
secondary  to  tuberculosis  of  the  lungs.  The  manifestations  of  tuber- 
culosis of  the  larynx  may  be  either  a  simple  persistent  catarrh,  an  in- 
filtration, or  an  ulceration.  (See  pages  439  and  440.)  The  symptoms 
vary  according  to  the  lesion. 

a.  Catarrh.  There  is  a  slight  hoarseness  and  the  voice  tires  easily. 
Often  paresthesia  or  peculiar  sensations  in  the  larynx  are  present. 
Cough,  when  due  to  this  alone  and  not  to  the  process  in  the  lungs,  is 
short  and  dry. 

b.  Infiltration.  At  first  the  symptoms  are  those  of  simple 
catarrh,  then  the  alteration  of  the  voice  increases  even  to  aphonia  ; 
there  is  a  feeling  of  dryness  or  soreness  in  the  larynx,  and  dysphagia. 
The  cough  is  very  slight  and  is  usually  wholly  disguised  by  the  cough 
due  to  the  disease  in  the  lungs.  There  is  some  difficulty  in  expecto- 
ration. 


448  SPECIAL  DIAGNOSIS. 

c.  Ulceration.  The  symptoms  are  the  same  as  those  of  infiltra- 
tion, but  the  dysphagia  and  pain  are  greater. 

Diagnosis.  Tuberculous  ulcer  occurs  most  frequently  in  the  male 
sex,  and  during  the  period  ranging  from  eighteen  to  thirty  years  of 
age.  If  the  symptoms  develop  in  the  course  of  phthisis,  or  in  case 
that  affection  cannot  be  recognized,  if  there  is  a  history  of  infection,  or 
exposure,  and  if  bacilli  are  found  in  the  sputum,  the  diagnosis  is  not 
difficult.  A  portion  of  the  diseased  mass  may  be  removed  for  micro- 
scopic examination  or  inoculation.  In  examining  the  secretion  for 
tubercle  bacilli,  it  is  to  be  remembered  that  the  exudation  may  have 
been  brought  up  from  the  lungs.  The  examination  in  cases  of  phthisis 
is  of  little  practical  value,  except  to  determine  whether  the  ulceration 
present  may  be  syphilitic  and  grafted  upon  a  tuberculous  disease  of  the 
lungs.  Enlargement  of  the  glands  of  the  neck  is  often  present,  but  is 
not  diagnostic. 

Fever  is  present,  and,  indeed,  may  be  an  important  diagnostic 
feature  in  doubtful  cases.  The  temperature  should  be  taken  every  two 
hours,  for  the  morning  or  evening  exacerbations  may  not  be  present. 
Emaciation  ensues,  and  sooner  or  later  the  hectic  phenomena  and  signs 
of  tuberculosis  in  other  structures  arise.  When  tuberculous  ulceration 
of  the  larynx  occurs  in  the  course  of  local  pulmonary  tuberculosis  the 
disease  runs  a  much  more  rapid  course. 

The  laryngeal  symptoms  are  not  diagnostic.  Pain  may  be  the  most 
distinct.  The  appearances  observed  by  the  laryngoscope  are  more 
characteristic.  Local  anaemia  with  paresthesia,  paresis  of  the  cords, 
and  short  cough,  or  an  obstinate  diffuse  catarrh,  are  suspicious  symp- 
toms. The  peculiar  ridged  infiltration  between  the  arytenoids  is 
almost  invariably  tubercular. 

Isolated  thickenings  anywhere  in  the  larynx  that  taper  off  gradu- 
ally into  the  normal  tissue  can  only  be  tuberculous  or  syphilitic.  The 
regularity  and  number,  with  anaemia  and  lack  of  inflammatory  signs, 
will  usually  distinguish  the  tuberculous  from  the  syphilitic.  The 
ulcers  are  non-erosive.  Syphilitic  ulcers  do  not  often  occur,  except  on 
the  edge  and  lingual  side  of  the  epiglottis  and  on  the  cords.  They 
extend  more  rapidly  than  the  tuberculous,  and  may  be  continuous  with 
ulceration  in  the  pharynx.  The  area  of  ulceration  may  extend  to  the 
base  of  the  tongue,  which  is  very  infrequent  in  tuberculous  disease. 
In  syphilitic  ulceration  scars  or  cicatrices  are  seen,  but  they  are  absent 
in  the  tuberculous  form.  Laryngoscopic  examination  in  tuberculous 
ulceration  is  difficult,  as  it  causes  great  pain  ;  in  syphilis  comparatively 
little  pain  attends  examination.     (See  the  Infections.) 

Syphilitic  Affections  of  the  Larynx. 

Mucous  patches,  papules,  infiltrations,  or  gummata  may  be  present 
in  the  larynx  for  some  time  without  exhibiting  any  symptoms.  Usu- 
ally a  change  in  the  voice  is  the  first  symptom  noticed,  due  either  to 
the  catarrh  or  to  ulcers,  scars,  infiltrations,  or  gummata  affecting  the 
cords.  There  is  often  a  feeling  of  pressure  or  a  tickling  sensation. 
Pain    is  not  usual,  and,  when  present,   is   very   slight.       Dysphagia 


THE  NOSE  AND  LARYNX.  449 

occurs  only  when  the  epiglottis  is  extensively  ulcerated.  There  is 
little  or  no  cough. 

The  diagnosis  rests  upon  the  history  of  infection,  the  objective  signs 
of  syphilis  indicated  by  pigmentation  or  recent  eruption,  scars,  perios- 
titis or  nodes  on  the  bone,  and  enlarged  glands.  The  laryngeal  symp- 
toms are  not  diagnostic,  save  that  pain  is  absent  in  spite  of  extensive 
ulceration,  while  difficulty  of  deglutition,  on  account  of  food  entering 
the  larynx,  is  of  frequent  occurrence.  The  laryngoscopic  appearances, 
as  indicated  above,  are  characteristic  of  this  affection.  In  obscure 
cases  the  distinctions  spoken  of  in  tuberculosis  are  of  diagnostic  value. 

Although  the  patient  may  be  broken  down  and  cachectic  the  febrile 
range  is  not  high,  unless  perichondritis  occurs,  or  pneumonia  sets  in, 
on  account  of  food  in  the  air-passages. 

The  Larynx  in  Other  Diseases. 

Laryngeal  symptoms  due  to  lesions  of  the  nervous  system  are  found 
under  the  following  circumstances.     (See  Cerebral  Localization.) 

Cerebral  Hemorrhage.  1.  Aphasia.  The  movement  of  the 
muscles  is  normal,  but  they  cannot  be  controlled  by  the  will.  Caused 
by  hemorrhage  in  the  cortex  or  along  the  course  of  connective  fibres. 

2.  Recurrent  paralysis.     Due  to  hemorrhage  in  the  medulla. 

3.  Symptoms  of  bulbar  paralysis.     Same  cause. 
Encephalomalacia.     (Softening.)     When  in  the  brain,  aphasias 

result ;  when  hi  the  medulla,  bulbar  symptoms. 

Tumors  of  Cerebrum.  The  symptoms  are,  according  to  location, 
aphonia,  aphasia,  or  paralysis  of  the  cords. 

Bulbar  Paralysis.  We  have,  of  course,  the  other  symptoms  of 
the  disease.  The  voice  becomes  weak  and  monotonous  without  modu- 
lation. High  tones  are  impossible.  It  progresses  to  hoarseness  and 
finally  aphonia.  Particles  of  food  and  drink  enter  the  larynx.  Paresis 
or  paralysis  of  the  cords. 

Multiple  Sclerosis.  The  speech  is  low,  uncertain,  and  scanning, 
later  hoarse.  Laughing  and  crying  are  accompanied  by  peculiar  yawn- 
ing inspirations.  Laryngoscopical  examination  :  Slight  paresis  of  the 
cords  is  seen. 

Posterior  Sclerosis  (Tabes).  The  muscles  act  very  slowly. 
Sometimes  symptoms  of  irritation,  as  tickling  or  burning  in  the  larynx, 
with  a  dry  cough,  occasionally  severe  paroxysms  of  coughing,  even  to 
spasm  of  the  larynx,  occur.  "  Laryngeal  crises."  In  rare  cases  a 
phonetic  spasm  has  been  observed.  Less  often  paresis  or  paralyses  of 
the  various  muscles  occur,  most  frequently  the  posticus,  next  the 
recurrent.     Sensibility  may  or  may  not  be  disturbed. 

Amyotrophic  Lateral  Sclerosis.  There  is  a  mixture  of  bulbar 
with  spinal  symptoms.     (See  Sclerosis.) 

Progressive  Muscular  Atrophy.  The  same  mixture  of  symp- 
toms occurs  very  late. 

Paralytic  Dementia.  There  may  be  disturbances  in  articula- 
tion, with  paresis  and  paralysis  of  the  cords. 

Chorea.  There  may  be  a  tremor  of  the  cords  from  under-tension, 
but  probably  no  true  choreic  movements. 

29 


CHAPTER    II. 

DISEASES  OF  THE  LUNGS  AND  PLEURAE. 

The  lungs  are  composed  of  a  relatively  small  amount  of  tissue. 
They  are  made  up  of  tubes  and  canals.  The  tissue  which  composes 
the  structure  of  the  lungs  independently  of  the  canals,  the  connective 
tissue,  is  liable  to  the  same  morbid  processes  that  affect  it  in  other  situ- 
ations. But,  curiously,  it  is  not  often  subjected  to  irritants  which  cause 
acute  inflammation,  while  chronic  inflammations  occur  secondarily,  in 
the  large  majority  of  cases,  to  processes  in  the  channels.  Diseases  of 
the  lungs  are  really  the  disease  of  its  channels,  and  the  symptoms  that 
arise  are  due  to  morbid  alterations  of  them  (1)  by  processes  common 
to  the  structure  of  such  channels  and  (2)  by  obstruction  of  them. 
There  are  three  sets  of  channels  :  First,  for  the  passage  of  air ;  second, 
for  the  flow  of  blood  ;  and,  third,  for  the  flow  of  lymph.  The  symp- 
toms, therefore,  are  due  to  the  morbid  process  or  to  obstruction  of  the 
channels  just  mentioned. 

Physical  Classification.  The  various  affections  of  the  lungs  occur 
without  any  change  in  the  volume  of  air  in  the  lungs,  or  are  attended 
by  an  increase  or  diminution  in  the  amount  of  air. 

I.  Diseases  with  Normal  Amount  of  Air. 

Affections  of  the  Bronchial  Tubes,  except  Asthma. 

II.  Diseases  with  Increased  Amount  of  Air. 

Enlargement  of  the  Chest.  The  enlargement  with  in- 
creased amount  of  air  may  be  unilateral  or  bilateral.  It 
seems  paradoxical  that  the  more  air  there  is  in  the  thorax, 
the  greater  is  the  need  for  air,  and  hence  the  occurrence  of 
dyspnoea. 

1.  Asthma. 

2.  Emphysema. 

III.  Diseases  with  Diminished  Amount  of  Air. 

A.   The  Consolidations.     The  consolidations  may  be  local, 
unilateral,  or  bilateral. 

1.  The  congestions. 

2.  Pulmonary  embolism  and  thrombosis. 

3.  Pneumonia. 

4.  Bronchopneumonia. 

5.  Chronic  interstitial  pneumonia. 

6.  Pulmonary  tuberculosis. 

7.  Abscess  of  the  lung. 


DISEASES  OF  THE  LUNGS  AND  PLEUBJE.  451 

8.  Gangrene  of  the  lung. 

9.  Collapse  of  the  lung. 

10.  Cancer  and  other  new  growths  of  the  lung. 

11.  Hydatid  disease  of  the  lung. 

B.  Diseases  of  the  Pleura. 

1 .  Diminished  amount  of  air  from  inhibition  of  movement, 

on  account  of  pain. 

2.  Diminished  amount  of  air  from  the  physical  condition 

within  the  thorax. 

The  Morbid  Processes. 

Affections  of  the  lungs  may  be  divided  into  the  neuroses,  the  con- 
gestions, the  inflammations,  the  degenerations,  the  morbid  growths  and 
gross  parasites.  Influences  operating  through  the  pneumogastric  and 
phrenic  nerve  may  be  responsible  for  respiratory  neuroses.  The  con- 
gestions are  so  intimately  associated  with  vascular  phenomena  that  the 
latter  may  be  included  in  the  process.  The  inflammations  are  limited 
to  the  bronchi,  to  the  alveoli,  and  to  the  connective  tissues  surround- 
ing both.  The  intimate  relation  of  the  small  bronchi,  the  alveoli,  and 
their  surrounding  connective  tissues  implies  their  conjoint  involvement 
in  many  processes. 

A.  The  Neuroses. 

B.  The  Congestions. 

1.  Active,  including  hemorrhagic  infarct. 

2.  Passive. 

Subsidiary  :  hemorrhage. 

C.  The  inflammations,  chiefly  infectious. 

1.  The  Bronchi. 

Acute. 
Chronic. 

2.  Bronchi  and  alveoli. 

Bronchopneumonia  (an  infection). 

3.  Bronchi,  alveoli,  and  connective  tissue. 

Pneumonia. 

Tuberculosis. 

Abscess  of  the  lung. 

Gangrene. 

Chronic  interstitial  pneu monia — pneumonokoniosis. 

Syphilis  of  the  lung. 

D.  The  Degenerations. 

Emphysema. 
Bronchial  dilatation. 

E.  Morbid  growths. 

F.  Gross  Parasites. 

Hydatid  disease. 
Symptoms  Due  to  the  Morbid  Process.     The  air-tubes  arc  lined 
with  mucous  membrane,  which  is  subject  to  morbid  processes  that 
.attend  any  such  lining — congestion,  or  acute  and  chronic  inflammation 


452  SPECIAL  DIAGNOSIS. 

— with  a  fliis  as  the  characteristic  symptom.  The  muscle  and  elastic 
tissue  of  the  canal  become  involved  in  the  process.  The  former  un- 
dergoes spasm,  with  or  without  mucous  membrane  inflammation 
(asthma).  Grave  consequences  do  not  arise  until  degeneration  takes 
place,  then  the  power  of  confining  the  air  or  driving  it  out  is  lost, 
and  emphysema  results. 

In  the  blood-canals,  hyperemia  (congestion),  embolism  and  throm- 
bosis, and  secondary  cedema  take  place  ;  in  the  lymph-canals,  inflam- 
mation (acute  and  chronic  pleurisy),  and  transudation  (hydrothorax  or 
hsemothorax).  Xow,  the  symptoms  that  arise  in  each  or  all  of  the  above 
processes — pain,  local  discomfort,  mucous  or  purulent  discharge,  serous 
or  purulent  exudation,  and  fever — are  not  different  from  those  which 
are  found  in  diseases  of  similar  tissues  in  other  localities.  (Compare  with 
affections  of  mucous  membranes  in  other  organs  or  of  serous  membranes). 

Symptoms  Due  to  Obstruction  of  Channels.  In  addition  to  these, 
however,  there  is  a  group  of  symptoms  due  to  obstruction  of  the  various 
channels,  and  hence,  interference  with  the  function  of  the  lungs.  The 
symptoms  are  purely  mechanical. 

1.  Dyspxcea  occurs  from  obstruction  of  either  the  bronchial  tubes 
or  bloodvessels  in  addition  to  causes  mentioned  below.  It  is  as  pro- 
nounced in  asthma  or  capillary  bronchitis  as  in  embolic  obstruction 
(fat-embolism)  or  congestion  and  stasis  in  the  bloodvessels.  It  occurs 
when  the  canals  are  occluded  by  extrinsic  causes — foreign  bodies  in 
the  bronchi  or  pleural  effusions. 

2.  Cyaxosis.  As  a  sequence  of  the  above  symptoms  we  have 
another  vivid  picture — the  development  of  cyanosis  from  interference 
with  aeration. 

Symptoms  Due  to  Altered  Muscle  or  Nerve  Mechanism. 
Other  structures  (the  bony  thorax  and  its  muscles)  are  required  for 
the  performance  of  the  function  of  the  lung,  the  aeration  of  blood. 
Of  these  we  have  more  particularly  :  first,  muscles,  to  hasten  the 
movement  of  the  air ;  and,  second,  a  nervous  mechanism  to  control 
the  movement  of  the  muscles.  1.  Inactivity  of  the  former,  from  pain, 
from  debility,  or  from  paralysis  through  disease  of  the  nerves,  practi- 
cally occludes  the  canals,  for  the  normal  contents  slacken  or  cease 
their  movement,  and  therefore  the  amount  of  air  is  lessened — hence 
dyspnoea.  2.  The  nervous  mechanism  not  only  controls  the  large 
muscles  of  the  exterior,  through  a  centre  stimulated  or  depressed 
by  various  influences,  chiefly  the  blood,  but  also  receives  and  sends 
impressions  to  the  muscles  of  the  tubes,  giving  rise  to  (a)  cough 
or  (6)  bronchial  spasm  with  dyspnoea.  This  nervous  mechanism  by  its 
centre  of  control  is  in  relationship  with  higher  and  lower  centres,  and 
the  nerve  that  connects  it  with  the  bronchial  tubes  supplies  other  organs 
or  anastomoses  with  other  nerves.  Hence,  Ave  may  have  :  J..  A  central 
affection,  causing  pulmonic  symptoms  from  the  following  causes  :  1. 
Because  higher  centres  influence  the  lower  pulmonary  centre,  as  we  see 
in  hysterical  cough,  or  emotional  cough,  and  in  asthma — respiratory 
neuroses.  2.  Disease  affecting  the  region  of  the  centre,  as  in  tumor  or 
in  bulbar  or  glosso-labio-laryngeal  paralysis.  3.  Irritants  acting  upon 
the  centre,  as  urea,  exciting  ura?mic  asthma.     B.  An  affection  of  the 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  453 

nerve-trunk,  as  from  the  pressure  of  an  aneurism  or  morbid  growth. 
C.  Reflex  influences  through  the  pneumogastric  and  correlated  nerves. 
The  asthma  of  nasal  disease,  or  of  peripheral  irritation,  and  reflex 
cough  (neuroses)  are  of  this  nature.  Corollary :  Lung  symptoms,  chiefly 
dyspnoea  and  cough,  may  be  due  to  local  'causes  (affections  of  the  mus- 
cles), or  to  causes  at  a  distance,  operating  directly  through  the  pneu- 
mogastric centre,  or  the  nerve-trunk,  or  by  anastomoses  in  a  reflex 
manner.  The  practical  deduction  is  to  look  further  than  the  lungs  in 
the  investigation  of  pulmonic  symptoms.  Lung  symptoms  are  not 
often  expressive  of  disease  in  other  parts,  nor  are  diseases  of  the  lungs 
symptomatic  of  disease  in  other  organs. 

Affections  of  the  Pleura.  In  diseases  of  the  pleura,  one  side  is 
usually  affected.  Simple  inflammation  and  inflammation  with  exuda- 
tion into  the  pleural  cavity  occur.  In  both  forms  there  is  diminution 
of  movement,  and  hence  less  air  entering  the  affected  lung,  although 
the  cause  is  different  in  each  case.  In  acute  inflammation,  the  dimin- 
ished amount  of  air  is  for  physiological  reasons  :  the  movement  of  the 
affected  side  is  inhibited  by  pain — hence  diminution  of  expansion  and 
lessened  ingress  and  egress  of  air.  Enfeeblement  of  breath-sounds  and 
fremitus,  with  diminished  expansion,  alone  indicate  the  diminution. 
On  the  other  hand,  in  acute  inflammation  with  exudation,  the  amount 
of  air  is  diminished  for  physical  reasons.  The  effusion  encroaches 
upon  and  causes  diminution  of  the  air-space,  and  hence  lessens  the 
amount  of  air.  It  will  be  remembered  that  the  physical  signs  of  dimi- 
nution in  the  amount  of  air  from  effusion  are  quite  distinct  from  the 
physical  signs  due  to  consolidation. 

The  Lustgs  axd  Heart.  The  relationship  of  the  pulmonary  vas- 
cular channels  to  the  remainder  of  the  circulation  is  very  close.  Over- 
filling of  the  pulmonic  bloodvessels,  and  hence  dyspnoea,  may  be  due 
to  alterations  or  changes  in  the  central  pump,  the  heart ;  or  in  the 
vessels  between— as  from  the  pressure  of  an  aneurism.  The  nature 
and  importance  of  lung  symptoms  cannot  be  appreciated  without  an 
investigation  of  the  heart  and  the  blood-ways.  Many  pulmonic  con- 
gestions are  due  to  dilatation  of  the  heart,  and  are  relieved  by  digitalis. 
At  the  other  end  of  the  beam,  it  may  be  noted  that  lung  diseases  cause 
heart  disease ;  from  backward  pressure  of  blood-columns  in  over- 
distended  vessels,  a  dilated  right  heart  follows. 

Space  forbids  tracing  out  the  effects  of  the  blocking  of  channels,  but 
it  is  suggestive  that  all  the  aeration  of  the  body  takes  place  through 
the  first  set  of  tubes,  that  all  the  blood  of  the  body  passes  through  the 
second,  and  that  the  third  is  an  enormous  drainage-area  of  lymph. 
The  student  can  readily  appreciate  how  profoundly  diseases  of  the 
lungs  must  affect  the  general  system.  Apart  from  the  nerves,  the  tie 
that  binds  the  other  organs  to  them  is  the  blood.  In  proportion  as  the 
lungs  enrich  them  with  oxygen,  the  other  organs  act  with  vigor.  .  Im- 
perfect oxygenation  soon  causes  diminution  of  all  function,  with  the 
secondary  effect  on  the  blood  of  the  production  of  anaemia,  which,  with 
its  long  train  of  symptoms,  is  seen  in  all  chronic  lung  affections. 

Relative  Value  of  Subjective  and  Objective  Symptoms.  The 
subjective  symptoms  are  few,  and,  as  will  be  seen  later,  are  common 


454  SPECIAL  DIAGNOSIS. 

to  so  many  pulmonary  diseases  that  they  are  of  little  diagnostic  value. 
The  objective  symptoms  are  more  decisive,  and  the  laws  of  physics  as 
applied  to  the  lungs  aid  in  the  distinction.  The  effect  of  the  occlusion 
of  channels  is  mechanical  or  physical,  and  hence  a  physical  change  in 
the  lung  follows.  The  objective  symptoms  occur  (1)  because  of  the 
physiological  movement  of  air.  Sound  attends  the  movement  of  air 
in  health  ;  if  the  air-movement  is  checked,  no  sounds  occur,  or  abnor- 
mal breath-sounds  and  new  sounds  (rales)  are  created.  They  also 
occur  (2)  because  of  physical  changes  in  the  structure.  Air  is  replaced 
by  solid  structure  ;  the  physical  condition  of  the  lung  changes.  The 
objective  signs  of  these  conditions  are  determined  by  inspection,  palpa- 
tion, percussion,  and  auscultation. 

Diagnosis.  The  diagnosis  of  disease  of  the  lungs  is  attained  by  the 
collection  and  consideration  of  data- obtained  both  by  inquiry  and  by 
observation.  By  observation  the  objective  phenomena  are  secured, 
first,  by  physical  examination  ;  second,  by  an  examination  of  the 
sputum  ;  and,  third,  by  an  examination  of  the  fluids  secured  by  punc- 
ture. 

It  is  not  usually  difficult  to  distinguish  diseases  of  the  lungs  from 
affections  of  other  structures.  It  is  true,  pleurisy  and  pleurodynia  are 
often  distinguished  with  difficulty.  AVe  are  called  upon,  also,  to  decide 
between  pleurisy  and  subdiaphragmatic  inflammation,  a  pleural  and 
hepatic  inflammation,  a  pleuritis  and  pericardial  inflammation,  and 
between  cardiac  and  pulmonary  disease,  especially  when  both  are  pres- 
ent and  it  is  desirable  to  determine  which  is  the  primary  affection. 
The  contiguous  relations  of  the  organs  make  this  necessary,  and  with 
care  in  ascertaining  the  history  and  the  subjective  and  objective  symp- 
toms the  distinction  may  not  be  difficult. 

In  chronic  disease,  affections  of  the  lungs,  of  the  mediastinum,  and 
of  the  great  vessels  must  be  distinguished  from  one  another.  An 
aneurism  or  mediastinal  disease  may  simulate  chronic  phthisis. 

Infections.  It  often  happens  in  a  pulmonary  disease  that  some  of  its 
pronounced  symptoms  may  strongly  point  to  an  infection  other  than 
that  of  the  lungs ;  thus  the  cerebral  symptoms  of  pneumonia  may  be 
held  to  be  due  to  meningitis,  or  the  fever  thought  to  be  due  to  typhoid 
fever.  On  the  other  hand,  the  presence  of  a  pulmonary  affection,  as 
tuberculosis,  may  explain  the  nature  of  the  morbid  process  in  other 
organs  or  structures.  Hence,  in  all  cases  in  which  there  is  a  possibility 
of  secondary  tuberculosis  the  lungs  should  be  examined  to  determine  if 
they  are  the  seat  of  the  primary  disease.  In  this  way  the  true  nature 
of  a  meningitis,  a  peritonitis,  or  other  tubercular  affection  may  be  recog- 
nized. So,  too,  in  secondary  ansemia  and  in  protracted  debility  of  un- 
known source  the  lungs  should  be  examined.  It  must  be  borne  in 
mind  also  that  in  chronic  diseases,  as  chronic  renal  disease,  chronic 
arthritis,  diabetes,  etc.,  pulmonary  tuberculosis  may  set  in  most  insidi- 
ously. In  the  same  class  of  diseases  pneumonia  is  frequently  a  ter- 
minal infection,  and  likewise  runs  an  insidious  course.  Finally,  in 
the  extremes  of  life  pulmonary  infections,  as  pneumonia,  present  symp- 
toms out  of  the  usual  run.  In  infancy  and  childhood  the  cerebral 
symptoms  may  mask  the  pulmonary  symptoms  ;  in  senility  the  ab- 


DISEASES  OF  THE  LUNGS  AND  PLEUBM.  455 

sence  of  cough  or  expectoration  may  lead  to  the  dismissal  of  all  thought 
of  pulmonary  disease.  In  short,  the  lungs  should  be  examined  in  all 
affections. 

This  injunction  is  particularly  to  be  observed,  as  lung  diseases  are 
often  secondary  to  other  diseases  ;  phthisis,  to  tuberculosis  elsewhere, 
pneumonia  or  pleurisy  to  all  infectious  disorders,  to  Bright' s  disease, 
cancer,  and  diabetes.  Above  all,  the  possibility  of  a  hydrothorax, 
secondary  to  causes  of  transudations,  must  be  borne  in  mind. 

The  Data  Obtained  by  Inquiry. 

The  Social  Histoey.  A  glance  at  the  various  processes  which 
take  place  in  the  lungs  readily  lead  one  to  infer  the  social  history. 

Age.  In  the  earlier  and  later  periods  of  life  bacterial  invasion  is 
more  likely  to  take  place ;  hence,  at  these  extremes  streptococcus  and 
pneumococcus  infections  are  common  ;  tuberculosis,  on  the  other  hand, 
is  more  common  in  early  adult  life,  although  it  does  not  respect  age. 
The  degenerations  are  more  common  later  in  life,  as  we  may  say  of  the 
morbid  growths,  both  obeying  the  usual  rules  concerning  the  course  of 
these  processes.  The  sex.  As  the  infections  predominate  and  as  one 
at  least  is  more  liable  to  develop  in  those  whose  resistance  is  lessened, 
it  follows  that  tuberculosis  is  more  frequently  seen  in  the  female  sex. 
That  sex  which  follows  occupations  compelling  the  inhalation  of  irri- 
tating particles — the  male — is  more  liable  to  have  fibroid  and  other 
inflammations  of  the  lungs. 

The  Occupation.  From  this  we  gather  little  of  diagnostic  value, 
save  that  the  chronic  inflammations  are  more  prone  to  occur  in  those 
who  inhale  solid  particles,  as  miners,  stone-cutters,  etc.,  while  tubercu- 
losis attends  those  whose  occupations  are  debilitating  and  require  in-door 
duties.  Nor  does  a  knowledge  of  the  habits  lend  much  aid  save  as 
they  depress  the  system  and  render  it  more  vulnerable  to  bacterial 
action.  It  is  needless  to  say  clothing,  exposure,  residence,  and  the 
diet  may  be  hygienic  factors  in  the  life  of  the  patient.  The  amount 
of  exercise,  etc.,  must  be  inquired  into   in  each  case. 

Infections.  It  is  readily  seen,  however,  that  the  facts  in  the  social 
history  of  diagnostic  importance  are  just  those  facts  which  are  predis- 
posing factors  in  many  infectious  disorders.  Most  lung  diseases  are, 
therefore,  correlated  in  their  antecedents  with  the  infections.  It  must 
be  borne  in  mind  it  is  always  well  to  trace  the  source  of  the  infection  if 
possible. 

The  Family  History.  Heredity  plays  a  serious  part,  and  hence 
the  family  history  should  be  sought  for,  particularly  in  the  study  of 
those  affections  which  are  of  tuberculous  origin.  The  tendency  of  this 
infection  to  follow  in  successive  strains  is  well  known.  In  like  man- 
ner we  inquire  in  cases  of  asthma  and  other  neuroses  for  evidence  of 
their  occurrence  in  previous  generations — a  well-known  clinical  fact. 
Then  emphysematous  changes  seem  to  be  a  peculiarity  of  certain  fam- 
ilies. 

The  Occurrence  op  Previous  Diseases  is  to  be  inquired  for. 
Pneumonia  is  likely  to  be  followed    by  other  attacks.      Pleurisy   is 


456  SPECIAL  DIAGNOSIS. 

related  to,  and  may  be  an  expression  of  rheumatism ;  it  may  be  pre- 
ceded by  other  rheumatic  phenomena  ;  it  may  be  the  earliest  expres- 
sion of  tuberculosis,  and  may  precede  the  latter  by  two  or  more  years, 
an  interval  of  health  separating  the  two.  Then  it  must  be  borne  in 
mind  pulmonary  tuberculosis  may  succeed  a  long  antecedent  joint  or 
glandular  tuberculosis — a  history  of  which  should  be  inquired  for. 
The  state  of  the  circulation  should  be  studied,  and  the  occurrence  of 
previous  heart  disease  sought  for.  In  affections  of  the  pleura  we  must 
inquire  for  previous  infections  and  note  the  presence  or  absence  of 
disease  of  contiguous  structures,  as  the  ribs  and  muscles  of  the  chest 
and  the  viscera  below  the  diaphragm. 

The  Subjective  Symptoms.  Dyspncea.  Dyspnoea,  in  its  true 
sense,  means  difficult  breathing.  The  respirations  are  deeper  than 
natural,  but  of  normal  frequency,  or  they  may  only  be  more  frequent 
than  they  should  be,  or  they  may  be  both  deeper  and  more  frequent. 
The  patient  is  usually  conscious  of  suffering  or  of  some  distress  in 
breathing.  Lung  disease  without  dyspnoea :  While  a  common,  indeed 
almost  constant  symptom  of  lung  disease,  it  does  not  -follow  that  be- 
cause a  patient  has  extensive  disease  of  the  lung  he  need  suffer  from 
difficult  or  hurried  breathing.  This  is  because  the  system  requires  no 
more  air  than  the  capacity  of  the  lung  is  able  to  supply.  The  change 
takes  place  very  gradually,  but  many  persons  with  chronic  fibroid 
phthisis,  or  with  emphysema,  in  both  of  which  the  disease  may  be 
extensive,  may  not  have  dyspnoea,  unless  an  unusual  demand  is  made 
upon  the  system.  The  subjects  are  under- weight,  move  slowly,  and 
otherwise  show  that  they  are  deprived  of  an  essential  to  active  being. 

Varieties  of  Dyspncea  Depending  upon  Cause. 

I.  Anything  which  cuts  off  or  lessens  the  normal  amount  of  air  re- 
quired for  oxygenation  of  the  blood.  A.  Obstruction  of  the  air-pas- 
sages. B.  Diminution  of  air-space  from  causes  within  and  outside  of 
the  thorax.  C  Interference  with  the  action  of  the  muscles  concerned 
in  breathing. 

II.  Affections  which  lessen  the  amount  of  blood,  as  obstructive 
heart  disease.     Rarely,  tumors  pressing  upon  the  bloodvessels. 

III.  Affections  in  which  the  red  blood-corpuscles  are  diminished — 
anaemia. 

IV.  Pulmonary  embolism  and  thrombosis.  In  cases  of  weak  heart 
the  vessels  become  occluded.  After  labor  a  clot  of  blood  may  escape 
from  a  uterine  sinus,  be  carried  to  the  right  heart,  and  thence  to  the 
pulmonic  veins.  The  clot  may  arise  from  inflammation  of  the  veins 
in  any  situation. 

V.  Fat-embolism.  Foreign  substances  in  the  blood,  as  fat,  occur- 
ring in  parturient  women  three  or  four  days  after  labor,  after  frac- 
tures, and  in  diabetes. 

VI.  Dyspnoea  due  to  interference  with  the  nervous  mechanism  of 
respiration,  a.  Tumor,  hemorrhage,  or  degeneration  about  the  respi- 
ratory centre  in  the  medulla,  b.  Irritation  of  the  centre  by  toxic 
agents,  as  in  uraemia,  diabetes,  auto-intoxication  from  gastro-intestinal 
disorder.  To  this  class  belongs  "  heat  dyspnoea,"  which  occurs  in  all 
febrile  conditions.     The  warm  blood  acts  as  a  direct  irritant  to  the 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  457 


respiratory  centre  in  the  medulla  oblongata  (Landois).  This  explains 
the  dvspnoea  of  fever  and  the  curious  fact  pointed  out  by  Cohnheim, 
that  the  respirations  in  pneumonia  lessen  as  soon  as  the  fever  disap- 
pears, notwithstanding  the  persistence  of  the  physical  condition,  which 
may  have  accounted  for  the  dyspnoea.  Reflex  dyspnoea  (asthma,  q.  v.) 
belongs  to  this  variety.     The  dyspnoea  of  hysteria  is  of  the  same  class. 

Anything  which  cuts  off  or  lessens  the  normal  amount  of  air  required 
for  oxygenation  of  the  blood  causes  more  or  less  dyspnoea. 

A.  Obstruction  of  the  Air-passages. 

1.  Occlusion  of  the  nares,  unless  compensated  by  mouth-breathing. 

2.  Enlargement  of  the  tonsils,  retropharyngeal  abscess,  or  any  ob- 
struction in  the  throat,  from  diphtheritic  or  oedematous  swelling. 

3.  Disease  of  the  larynx,  causing  stenosis,  also  causes  a  characteristic 
form  of  dyspnoea  known  as  inspiratory  dysjmoea.  (See  Disease  of  the 
Larynx.) 

4.  Obstruction  of  (a)  the  trachea  or  (6)  the  bronchus  from  external 
pressure  or  from  a  foreign  body.  It  must  be  distinguished  from 
dyspnoea,  the  origin  of  which  is  higher  up  in  the  air-passages,  by 
careful  inspection. 

a.  Tracheal  Obstruction.  In  this  form  of  dyspnoea  there  is  no 
increased  movement  of  the  larynx.  There  is  no  change  in  the  voice, 
except  that  it  may  be  weakened,  and  the  sonorous  quality  diminished. 
The  voice  will  be  modified,  however,  if  there  is  at  the  same  time 
disease  of  the  larynx  from  syphilis,  or  paralysis  of  the  muscles 
from  pressure  on  the  recurrent  laryngeal  nerves  by  the  same  cause  as 
the  tracheal  stenosis.  If  so,  on  laryngoscopic  examination  the  tumor 
pressing  upon  the  larynx  can  be  seen  at  times,  especially  if  the  larynx 
is  healthy. 

Expert  operators  can  secure  quite  an  extensive  view  of  the  wind- 
pipe, particularly  if  the  head  is  bent  slightly  forward  and  the  patient 
is  seated  in  the  upright  posture.  A  mirror  must  then  be  placed 
against  the  soft  palate,  with  the  surface  more  horizontal  than  usual. 
By  this  means  an  aneurism  may  be  seen  bulging  into  the  trachea.  It 
must  not  be  mistaken  for  pulsation  of  the  lower  end  of  the  trachea, 
due  to  transmission  of  the  impulse  of  the  aorta  to  the  trachea,  which 
has  been  shown  to  occur  in  healthy  persons. 

The  dyspnoea  is  expiratory,  and  is  never  so  extreme  as  in  laryngeal 
stenosis.  The  lower  ribs  are  therefore  not  sucked  in  during  inspira- 
tion until  late  in  the  disease.  A  stridor  attends  the  dyspnoea,  which  is 
heard  with  the  stethoscope  over  the  trachea,  as  well  as  over  every  part 
of  the  chest.  Sometimes  a  point  over  the  trachea  can  be  determined 
at  which  the  sound  is  heard  loudest.  The  point  may  indicate  the  seat 
of  a  stenosis.  Sometimes  the  sound  is  more  marked  over  the  larynx 
than  over  the  sternum,  when  the  lower  part  of  the  trachea  is  obstructed. 
Demme  has  pointed  out  that  in  cases  of  prolonged  obstruction  in  the 
lower  air-passages  the  upper  portion  of  the  thorax  may  diminish  in 
size.  Not  only  is  the  dyspnoea  constant,  but  paroxysms  may  take 
place  in  which  the  distress  is  very  severe.  These  paroxysms  of  dysp- 
noea may  be  due  to  spasm  of  the  vocal  cords  ;  but  it  is  very  likely  that 
they  are  due,  as  Bristowe  has  shown,  to  swelling  of  the  mucous  mem- 


458  SPECIAL  DIAGNOSIS. 

brane,  or  to  mucus  which  has  accumulated  at  the  point  of  obstruction 
and  cannot  be  dislodged,  or  to  spasm  of  the  muscular  tissue  of  the 
trachea  itself.  In  addition  to  the  subjective  symptom  of  want  of  breath 
the  patient  may  complain  of  pain  or  oppression  behind  the  sternum, 
or  possibly  only  of  a  slight  soreness.  Cough  usually  attends  the  dysp- 
noea, with  expectoration  of  mucus.  Sometimes  the  mucus  is  blood- 
tinged,  and  even  streaks  of  blood  may  be  expectorated  after  a  consid- 
erable time,  in  cases  of  leaking  aneurism. 

If  the  obstruction  is  due  to  a  foreign  body,  the  dyspnoea  is  of  the 
same  type,  but  occurs  suddenly. 

b.  Bronchial  Obstruction.  Laryngeal  movement  is  not  in- 
creased and  the  voice  is  not  changed.  If  a  bronchus  is  obstructed, 
the  lung  of  the  unobstructed  bronchus  becomes  the  seat  of  emphysema. 
When  obstruction  takes  place  gradually,  compensatory  emphysema 
occurs,  developing  slowly,  not  rapidly  as  in  the  former  instance,  the 
degree  depending  upon  the  amount  of  obstruction  in  the  opposite 
bronchus.  The  physical  signs  over  the  lung  of  the  obstructed  bron- 
chus are  pronounced.  The  vesicular  murmur  is  absent,- the  fremitus 
is  absent,  the  movement  of  the  affected  side  is  impaired.  With  these 
changes  the  percussion-sound  is  normal  at  first,  although  its  limits  are 
influenced  less  by  forced  inspiration  and  expiration  ;  later,  it  progresses 
from  impaired  resonance  and  dulness.  As  the  case  advances,  the  affected 
side  may  fall  in  and  measure  less  than  the  opposite  side.  A  snoring  or 
whistling  sound  may  be  heard  over  the  root  of  the  lung,  between  the 
scapula  and  vertebrae,  or  moist  rales  may  be  present. 

The  causes  of  tracheal  and  bronchial  obstruction  are :  («)  External 
pressure.  First,  tumor  of  the  thyroid  gland;  second,  thoracic  aneu- 
rism; third,  mediastinal  tumor  from  other  causes  than  aneurism,  as 
disease  of  the  glands,  cancerous  or  tubercular,  or  mediastinal  abscess ; 
fifth,  cancer  of  the  oesophagus;  and,  finally,  in  rare  cases,  a  dilated 
auricle.  (6)  Diseases  of  the  walls  of  the  trachea.  They  cause  obstruc- 
tion by  narrowing  the  calibre.  Syphilis  is  the  most  frequent  cause  of 
such  obstruction,  (c)  Foreign  body.  The  presence  of  a  foreign  body 
within  the  lumen  causes  obstruction.  The  foreign  body  may  remain 
free  for  a  time,  moving  up  and  down  as  the  patient  coughs,  and,  indeed, 
it  may  be  felt  against  the  side  of  the  trachea  when  the  finger  is  placed 
outside  the  neck.  Later,  the  foreign  body  usually  becomes  fixed  in  the 
right  bronchus,  or  one  of  its  main  divisions,  because  the  opening  of 
the  right  bronchus  is  more  direct  than  that  of  the  left.  In  some  in- 
stances the  body  may  be  dislodged  and  fall  into  the  opposite  bronchus. 
Rarely  it  falls  first  into  the  left. 

B.  Diminution  of  the  Air-space  in  the  Lungs.  All  forms  of 
pulmonary  disease  attended  by  consolidation,  by  compression  of  the 
lung,  or  occlusion  of  the  small  bronchi,  are  included  under  this  sub- 
division. The  degree  of  dyspnoea,  of  course,  depends  upon  the  extent 
of  the  diminution  in  the  air-space.  In  pleural  effusions  from  any  cause 
the  air-space  is  lessened  and  dyspnoea  occurs.  In  bilateral  effusions  it 
is  more  marked  than  in  unilateral.  The  severity  of  the  dyspnoea  de- 
pends somewhat  upon  the  rapidity  with  which  the  effusion  takes  place. 
In  cases  of  sudden  effusion  of  air,  as  in  pneumothorax,  the  dyspnoea  is 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  459 

very  alarming  at  first,  but,  as  accommodation  takes  place,  it  is  grad- 
ually relieved.     In  rapid  effusion  of  serum  it  is  also  serious. 

The  characteristic  form  of  dyspnoea  due  to  lessened  air-space  is  seen 
when  obstruction  of  the  air-tubes  takes  place  on  account  of  spasm. 

Asthma. 

Asthma  is  a  chronic  disease  caused  by  spasmodic  narrowing  of  the 
bronchial  tubes,  and  characterized  by  paroxysmal  attacks  of  dyspnoea, 
diminished  respiratory  movement  of  the  chest,  prolonged  expiration, 
attended  by  a  wheezing  sound  and  sibilant  rales,  and  ending  abruptly 
with  the  expectoration  of  tenacious  mucus.  The  attack  may  be  limited 
to  a  single  night,  or  may  be  prolonged  for  days,  with  nocturnal  exacer-  - 
bations. 

Premonitory  symptoms  are  said  to  occur  in  about  one-half  the  cases. 
These  are  for  the  most  part  nervous,  such  as  headache,  neuralgia,  irri- 
tability of  temper,  vertigo,  drowsiness.  Hyde  Salter  found  that  there 
were  premonitory  symptoms  in  111  out  of  226  cases  collected  by  him. 
In  63  they  were  nervous,  in  8  there  was  profuse  diuresis,  and  in  14 
they  were  connected  with  the  digestive  system. 

The  attack  itself  usually  begins  during  sleep,  and  often  at  a  regular 
time.  It  may,  however,  begin  during  the  day,  and  at  a  certain  hour, 
independently  of  sleep.  The  onset  is  manifested  by  tightness  across 
the  chest  and  more  or  less  difficulty  in  breathing.  This  dyspnoea  in- 
creases rapidly  and  often  reaches  an  extreme  degree.  The  face  becomes 
pale  and  anxious,  and  may  be  covered  with  a  cold  perspiration  ;  the 
lips  are  dusky  from  insufficient  oxygenation  of  the  blood.  The  patient 
feels  smothered,  and  makes  frantic  efforts  to  get  his  breath,  rushing  to 
an  open  window,  no  matter  how  cold  the  weather,  or,  if  unable  to 
leave  the  bed,  sitting  up  with  the  hands  pressed  upon  the  bed  so  as  to 
give  purchase  to  the  accessory  muscles  of  respiration.  Notwithstand- 
ing that  great  respiratory  efforts  are  made,  the  chest  moves  but  little, 
because  the  lungs  are  already  distended  to  the  extent  of  a  full  inspira- 
tion. The  patient  is  unable  to  expel  the  contained  air,  owing  to  the 
spasm  of  the  bronchial  tubes. 

The  frequency  of  respiration  is  diminished,  sometimes  to  one-half 
the  normal ;  the  rhythm  is  also  altered,  inspiration  being  short  and 
gasping,  and  followed  without  pause  by  expiration,  which  is  much 
prolonged  and  accompanied  by  a  wheezing  sound  audible  to  bystanders. 

There  is  an  increased  amount  of  air  in  the  thorax,  and  inability  to 
remove  it.  The  chest  is  enlarged — barrel-shaped — the  movement  of 
the  chest  is  lessened  and  strikingly  out  of  proportion  to  the  muscular 
exertions.     The  diaphragm  is  lowered. 

The  physical  signs  are  hyper-resonance  on  percussion  ;  on  ausculta- 
tion, faint,  short  inspiration,  prolonged  expiration,  and  sibilant  and 
sonorous  rales,  more  marked  on  expiration. 

The  duration  of  an  attack  of  asthma  varies  from  half  an  hour  to  a 
day  or  two.  In  patients  with  chronic  bronchitis  it  may  be  prolonged 
for  a  week  or  two,  with  remissions  during  the  day.  It  may  subside 
abruptly  or  by  degrees. 


460  SPECIAL  DIAGNOSIS. 

Subsidence  of  an  attack  is  marked  by  expectoration,  the  sputa  having 
special  characteristics.  (See  under  Sputum.)  At  first  it  is  made  up  of 
rounded  gelatinous  masses,  which,  when  unfolded  in  water,  are  seen  to 
be  made  up  of  spirals.     Later  it  becomes  mucopurulent. 

Curshmann's  spirals  and  the  Charcot-Leyden  crystals  are  nearly 
always  found.  The  leucocytes  are  increased,  and  25  per  cent,  of  them 
are  eosinophils. 

The  causative  factors  in  asthma  are  various.  About  twice  as  many 
males  as  females  are  affected,  and  there  is  a  marked  hereditary  ten- 
dency in  some  families.  There  is  probably  some  special  peculiarity  in 
asthmatic  patients,  but  just  what  it  is  has  not  been  determined.  It  may 
reside  in  the  lungs,  and  may  be  part  of  a  general  constitutional  irrita- 
bility (Salter).  Bronchitis,  emphysema,  and  heart  disease  act  as  causes, 
and  so  do  syphilis,  malarial  poisoning,  and  chronic  Bright' s  disease. 

The  above  description  applies  to  that  form  of  dyspnoea  treated  of 
in  the  text-books  as  spasmodic  asthma,  a  respiratory  neurosis  winch 
for  lack  of  knowledge  is  classified  as  a  disease.  Up  to  this  time  the 
dyspnoea  is  paroxysmal.  Sooner  or  later  it  becomes  constant.  AVhen 
the  dyspnoea  associated  with  asthma  becomes  constant  other  changes 
have  taken  place  in  the  lungs.  First,  there  is  persistent  bronchitis  ; 
second,  the  presence  of  emphysema.  Indeed,  in  many  cases  it  is  diffi- 
cult to  ascertain  the  exact  sequence  of  affections.  In  emphysema  of 
the  lungs  dyspnoea  is  constant,  but,  on  exposure  to  cold  or  on  account 
of  an  attack  of  indigestion,  more  severe  paroxysms  may  occur,  as  well 
as  asthmatic  attacks,  although  the  patient  is  not  an  asthmatic.  On  the 
other  hand,  a  patient  may  have  had  asthma  for  a  number  of  years, 
during  which  attacks  of  dyspnoea  occurred  only  in  paroxysms.  As 
time  passes  the  paroxysms  become  more  and  more  frequent,  and 
emphysema  develops.  With  the  advent  of  emphysema  the  dyspnoea 
becomes  more  constant. 

Asthma,  as  above  described,  is  a  type  of  dyspnoea  of  nervous  origin. 
It  has  just  been  said  that  it  is  due  to  spasm  of  the  bronchial  tubes. 
This  may  occur  from  a  number  of  causes  :  (a)  It  may  be  of  central 
origin,  from  irritation  of  the  pneumogastric  centre  ;  (b)  it  is  just  possi- 
ble that  some  disturbance  of  the  trunk  of  the  pneumogastric  nerve  will 
also  cause  asthmatic  dyspnoea ;  but  what  concerns  us  most  is  (c)  the 
paroxysmal  dyspnoea  which  arises  renexly  from  irritation  of  the  ter- 
minal endings  of  the  pneumogastric  nerve,  or  of  nerves  intimately 
associated  with  the  pneumogastric,  in  the  medulla.  (1)  Disease  in  the 
upper  air-passages,  as  polyps,  or  a  hypertrophy  of  the  turbinated 
bones,  or  adenoid  growths,  are  the  most  frequent  source  of  paroxysmal 
dyspnoea.  Xot  only  in  permanent  disease  of  this  character  do  we  have 
such  dyspnoea,  but  temporary  irritants  applied  to  the  nares  likewise 
produce  it.  Various  odors,  the  irritation  of  micro-organisms,  or  of 
pollen,  or  emanations  from  vegetable  life,  provoke  attacks  of  nasal 
congestion  and  reflex  dyspnoea.  The  irritation  is  propagated  through 
the  ethmoidal  and  posterior  nasal  branches  of  the  nerve,  the  Vidian 
and  nasopalatine  nerves,  to  the  septum,  and  the  anterior  palatine  to 
the  middle  and  low  turbinates.  (2)  Irritation  in  the  fauces  and  larynx  is 
not  so  likely  to  cause  dyspnoea,  yet  there  is  no  doubt  that  the  presence 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  461 

of  a  constant  irritant  in  these  situations  tends  to  provoke,  or  keep  in  a 
state  of  excitability,  the  respiratory  tract,  so  that  asthma  is  more  likely 
to  persist.  (3)  To  this  class  of  cases  belongs  the  irritation  of  the  terminal 
branches  of  the  pneurnogastric  nerve  in  the  stomach.  Peptic  asthma, 
or  the  asthma  of  indigestion,  may  owe  its  origin  to  these  causes.  Often 
the  irritation  is  central,  due  to  the  irritating  influence  of  an  abnormal 
product  of  indigestion  upon  the  respiratory  centres  in  the  medulla. 
(4)  For  the  same  reason  we  have  asthma  due  to  other  poisonous  sub- 
stances circulating  in  the  blood,  as  the  poison  of  uraemia.  The  dysp- 
noea due  to  this  condition  usually  occurs  in  paroxysms,  but  may  become 
constant.  Sometimes  it  is  the  first  intimation  of  the  presence  of  renal 
disease.  The  dyspnoea  of  diabetic  coma  may  occur  from  the  same 
cause.  The  nature  of  both  is  recognized  more  particularly  by  their 
associate  symptoms.  The  condition  of  the  urine,  the  odor  of  the 
breath,  and  the  exhalations,  the  presence  of  hypertrophy  of  the  heart 
and  of  an  accentuated  second  sound,  point  to  a  ursemic  origin.  The 
history  and  symptoms  of  diabetes,  the  odor  of  acetone  on  the  breath, 
the  presence  of  sugar  in  the  urine,  the  absence  of  organic  pulmonary 
disease,  point  to  diabetes.  The  dyspnoea  of  uraemia  cannot  be  distin- 
guished from  other  forms  of  dyspnoea,  except  by  the  exclusion  of 
cardiac  and  lung  disease.  It  is  often  difficult  to  do  this,  because 
uraemia  so  frequently  develops  after  the  hypertrophied  heart  has  failed, 
so  that  the  physical  signs  of  dilatation  may  be  sufficient  to  explain  the 
dyspnoea.  The  dyspnoea  of  diabetic  coma,  known  as  {i  air-hunger,"  is 
characterized  by  slow  and  deep  respirations.  Cheyne-Stokes  respira- 
tion is  due  to  the  same  cause — namely,  irritation  in  the  medulla,  as  in 
other  forms  of  nervous  dyspnoea.  It  must  not  be  forgotten  that  the 
dyspnoea  of  uraemia  may  present  the  Cheyne-Stokes  phenomenon. 

Diminution  of  Air-space  from  Extrapulmonary  Causes. 
Anything  which  crowds  upon  the  thorax,  interfering  with  pulmonary 
expansion,  causes  dyspnoea.  This  is  notably  the  case  in  affections 
below  the  diaphragm.  Hence,  in  enlargements  of  the  various  organs 
of  the  abdomen,  as  the  liver,  spleen,  kidneys,  pancreas  (cystic  disease), 
and  uterus,  dyspnoea  always  occurs.  In  accumulations  of  gas  (flatu- 
lency), or  of  fluid  (ascites),  the  diaphragm  is  pressed  upward  and 
encroaches  on  the  thoracic  capacity.  In  abdominal  tumor,  as  of  the 
ovary,  the  omentum,  and  of  the  organs  above  mentioned,  dyspnoea  is 
a  distressing  feature. 

C.  Interference  with  the  Action  of  the  Muscles.  Practically 
any  derangement  of  the  action  of  the  respiratory  muscles  diminishes 
the  air-space,  as  expansion  of  the  lungs  is  interfered  with.  Neverthe- 
less, the  cause  of  the  dyspnoea  is  extrapulmonary.  It  is  due  to  weak- 
ness or  paralysis  of  the  muscles  concerned  in  breathing,  or  to  inhibi- 
tion of  their  action  on  account  of  pain,  or  to  interference  with  their 
action  on  account  of  obesity,  myxoedema,  or  oedema,  or  on  account  of 
actual  disease,  as  in  trichinosis  or  myositis. 

1.  Phrenic  dyspnoea  is  a  peculiar  form  due  to  paresis  of  the  phrenic 
nerve  and  consequently  to  interference  with  the  action  of  the  diaphragm. 
It  may  not  be  observed  as  long  as  the  patient  is  at  rest.  Upon  slight 
exertion  the  effort  distresses  him  and  causes  an  increase  in  frequency 


462  SPECIAL  DIAGNOSIS. 

of  the  respirations.  After  a  few  steps  a  sense  of  suffocation  ensues, 
or  upon  ascending  an  elevation  the  patient  must  stop  frequently  to 
take  breath. 

Other  physiological  processes  are  affected  in  phrenic  dyspnoea.  In 
the  act  of  sighing  the  patient  feels  as  though  the  abdominal  organs 
were  drawn  up  into  the  chest.  Any  straining  effort,  as  defecation,  is 
rendered  difficult.  The  voice  is  weak,  and  there  is  difficulty  in  cough- 
ing and  sneezing,  because  a  full  inspiration  cannot  be  taken.  A  slight 
attack  of  bronchitis  may  be  very  serious  on  this  account.  On  inspec- 
tion during  inspiration,  instead  of  the  natural  expansion  of  the  ribs  and 
chest,  the  epigastrium  and  the  hypochondriac  regions  are  drawn  in. 
During  expiration  they  are  pushed  forward.  The  thoracic  movements 
are  reversed.  The  abnormality  may  be  detected  on  palpation  with 
both  hands  below  the  cartilages  of  the  ribs,  even  better  than  by  inspec- 
tion. Unilateral  paralysis  of  the  diaphragm  causes  drawing  in  of  the 
corresponding  hypochondriac  region. 

In  progressive  muscular  atrophy,  in  general  lead-poisoning,  and  in 
multiple  neuritis  from  other  causes,  paralysis  of  the  diaphragm  may 
take  place.  It  is  said  to  occur  in  hysteria,  and  Walshe  states  that  he 
has  seen  it  after  diphtheria.  In  fatty  degeneration  of  the  diaphragm, 
on  account  of  inflammation  extending  from  the  peritoneum  to  the  pleura, 
the  same  phenomenon  has  been  seen.     It  may  occur  in  trichinosis. 

Paralysis  of  the  diaphragm  must  be  distinguished  from  inaction. 
If  during  the  act  of  inspiration  one  or  both  hypochondriac  regions  are 
drawn  in,  it  is  diagnostic  of  inaction  rather  than  of  paralysis  ;  whereas 
paralysis  of  the  diaphragm  is  always  accompanied  by  paralysis  of  other 
muscles. 

Dyspnoea  due  to  paralysis  of  other  respiratory  muscles  can  be  recog- 
nized on  careful  inspection  and  palpation.  The  atrophied  groups  of 
muscles  are  readily  observed.     Electricity  may  aid  in  the  diagnosis. 

2.  Pain  inhibits  muscular  action.  The  source  of  the  pain  may  be 
in  the  pleura,  the  muscles,  or  the  intercostal  nerves.  Frequently  it  is 
below  the  diaphragm,  as  in  peritonitis,  hepatitis,  etc.,  interfering  with 
the  action  of  that  muscle.  The  dyspnoea  that  occurs  from  pain,  as 
pleuritis,  or  inflammation  of  the  chest-wall,  is  recognized  by  the  posture 
which  is  taken  in  order  to  relieve  the  affected  side,  by  local  tender- 
ness, and  by  the  physical  signs  of  pleurisy  or  of  pleurodynia. 

Clinical  Varieties.  We  observe  whether  dyspnoea  is  (a)  influenced 
by  exertion ;  (b)  modified  by  the  frequency  of  respiration ;  or  (c)  by 
the  respiratory  rhythm ;  and  (d)  is  constant  or  paroxysmal. 

(a)  Influenced  by  Exertion.  1.  Shortness  of  breath  may  be 
apparent  on  exertion  only,  as  in  cases  of  simple  debility,  or  of  inter- 
ference with  respiratory  action  on  account  of  obesity.  It  is  the  form 
of  shortness  of  breath  seen  in  ansemia  and  in  moderate  cardiac  debility. 
It  may  not  be  observed  by  the  patient  unless  he  walks  hurriedly  or 
ascends  a  flight  of  stairs.  2.  Shortness  of  breath  independent  of  exer- 
tion is  of  more  serious  import,  and  is  due  to  a  number  of  causes.  It 
is  the  shortness  of  breath  that  is  seen  in  severe  cardiac  and  pulmonary 
disease.  To  the  latter  belong  asthma  and  emphysema,  bronchial  ob- 
struction, pulmonary  consolidation  and  compressions  (by  effusions). 


DISEASES  OF  THE  LUNGS  AND  PLEUBJE.  4(J3 

(b)  The  Frequency  of  Respiration.  Dyspnoea  varies  clinically 
in  the  frequency  of  the  respiration.  In  its  most  extreme  form  it  is 
known  as  orthopnoea,  when  the  upright  posture  of  the  trunk  is  assumed. 
(See  Posture.) 

1.  Respiration  Slow  or  Normal,  a.  Dyspnoea  may  be  characterized 
by  deep  inspirations,  the  frequency  of  respiration  being  less  than  nor- 
mal. This  is  one  of  the  forms  of  dyspnoea  seen  in  diabetic  coma — 
tl  breathlessness  without  dyspnoea."  It  is  most  characteristic,  and 
associated  with  nausea,  vomiting,  and  coma,  while  the  breath  and  urine 
smell  of  acetone,  b.  The  breathing  may  be  slow  and  stertorous.  Such 
breathing  is  likewise  associated  with  coma,  but  the  coma  is  of  central 
origin,  due  chiefly  to  apoplexy  or  tumor.  It  may  be  observed  that 
respirations  with  dyspnoea  are  usually  central  or  toxic. 

Toward  the  end  of  life  the  respirations,  even  though  hurried  before, 
become  slower  from  carbon  clioxid  intoxication. 

2.  Respirations  Increased.  The  respirations  may  be  hurried  and 
create  distress  in  simple  nervousness  alone,  and  hurried  respiration  is 
quite  common  in  cases  of  hysteria.  In  the  latter  affection  the  frequent 
breathing  is  often  attended  by  distress.  The  respirations  are  quick- 
ened, and  are  half  the  normal  pulse-rate  or  even  as  frequent  as  the 
pulse.  The  term  u  panting"  is  applied  to  such  respiration.  The  same 
character  of  breathing  is  seen  in  exophthalmic  goitre.  The  rate  of 
respiration  is  increased  in  all  forms  of  dyspnoea  upon  exertion  (see 
above),  and  in  all  forms  due  to  heart  or  lung  disease. 

(c)  The  Rhythm.  Alternately  slower  and  shallower  breathing,  and 
then  quicker  as  well  as  deeper,  is  seen  in  the  peculiar  form  of  breath- 
ing known  as  Cheyne-Stokes  respiration.  It  includes  a  period  of 
apnoea,  with  simultaneous  alterations  in  the  size  of  the  pupils.  (See 
Uraemia  and  Diseases  of  the  Brain.) 

(d)  Dyspnoea  may  further  be  divided  clinically  into  constant  and 
paroxysmal  dyspnoea.  Constant  dyspnoea  implies  a  persistence  of  the 
cause.  Paroxysmal  dyspnoea  does  not  include  the  form  that  is  in- 
creased by  exertion — a  form  which  in  one  sense  may  be  paroxysmal. 
It  is  seen  in  its  most  typical  form  in  asthma.  It  is  often  of  cardiac 
origin,  but  may  be  due  to  central  or  reflex  causes.  It  occurs  usually 
at  night.  Constant  dyspnoea  is  frequently  subject  to  aggravations 
paroxysmal  in  occurrence.  Asthma  is  the  type  of  true  paroxysmal 
dyspnoea. 

Diagnosis.  While  dyspnoea  is  usually  easy  of  recognition,  it  must 
not  be  forgotten  that  attacks  of  acute  indigestion,  with  thoracic  symp- 
toms of  oppression,  may  simulate  the  oppression  of  dyspnoea.  This 
form  of  dyspnoea  is  temporary,  however,  and  not  associated  with  in- 
creased rapidity  of  respiration.  Dyspnoea  is  recognized  by  increase  in 
rapidity  of  chest-movement,  with  increased  action  of  all  the  muscles 
of  respiration,  both  the  essential  and  the  auxiliary  muscles.  At  the 
same  time  the  expression  is  characteristic.  The  alse  nasi  move,  the 
eyes  and  countenance  are  indicative  of  more  or  less  agony,  the  pupils 
are  dilated.  As  the  dyspnoea  continues  cyanosis  develops,  and  fre- 
quently a  cold  sweat  breaks  out.  This  may  be  limited  to  the  forehead 
and  face  and  to  the  extremities,  or  may  become  general.     The  hands 


464  SPECIAL  DIAGNOSIS. 

and  feet  become  cold.  Stupor  sets  in,  carpo-pedal  spasni  or  general 
convulsions  follow,  the  respirations  become  slower,  and  death  takes 
place  in  coma  or  from  heart-failure  (asystole). 

The  dyspnoea  of  emphysema  is  characteristic  ;  it  is  due  to  inability 
to  empty  the  chest  of  air  {expiratory  dyspnoea).  The  inspiration  is 
short  and  quick  ;  the  expiration  is  prolonged,  and  all  the  auxiliary 
muscles  are  called  upon  to  complete  the  act.  The  powerful  abdominal 
muscles  are  seen  to  contract  vigorously,  and  thus  aid  in  pressing  up 
the  diaphragm.  The  quadratus  lumborum  and  serratus  posticus  supe- 
rior et  inferior  draw  down  the  ribs.  The  scaleni  are  strongly  con- 
tracted, the  serratus  magnus,  latissimus  dorsi,  and  the  pectorales  all 
aid  in  elevating  the  ribs.  Knowledge  of  the  processes  involved  in 
forced  expiration  renders  the  diagnosis  comparatively  easy.  The  con- 
traction of  the  broad  abdominal  muscles  confirms  the  diagnosis. 

Cough  in  Pulmonary  Affections.  (See  Larynx.)  Coughing  is  a 
reflex  act.  A  deep  inspiration  is  taken,  followed  by  closure  of  the 
glottis,  succeeded  immediately  by  a  sudden  expiratory  effort,  during 
which  the  glottis  is  opened,  causing  a  loud  sound  with  the  forcible 
passage  of  air  outward,  along  with  any  substances  in  the  air-vessels. 

Causes.  The  pulmonic  irritation,  on  account  of  which  the  act  takes 
place,  usually  begins  in  the  respiratory  mucous  membrane.  The  cough 
is  then  used  to  expel  accumulations  of  mucus  or  pus,  or  foreign  sub- 
stance. It  occurs  in  all  forms  of  bronchitis  and  in  the  lung  affections 
generally  in  which  bronchitis  is  associated.  The  cough  of  phthisis,  if 
not  laryngeal,  is  due  to  a  localized  bronchial  catarrh.  Modules  outside 
of  the  bronchi,  situated  in  the  lung  substance,  do  not  provoke  the  act 
of  coughing,  as  we  see  in  the  calcareous  and  fibrous  nodules  of  healed 
tuberculosis.  The  irritation  is  not  limited  to  the  mucous  membrane 
of  the  bronchial  tubes,  but  occurs  in  the  mucous  membrane  of  any  por- 
tion of  the  respiratory  tract.  A  foreign  body  of  any  kind  in  the 
bronchus  sets  up  cough.  It  is  notably  present  in  pharyngeal  and 
laryngeal  diseases.  The  cough  of  the  latter  is  of  peculiar  character, 
which  renders  it  easily  distinguished  from  cough  due  to  other  causes. 

It  must  not  be  forgotten  that  the  presence  of  an  irritant  does  not 
always  excite  cough.  Thus,  when  the  sensibilities  are  obtunded,  as 
in  typhoid  fever,  in  disease  of  the  brain,  or  in  the  last  stages  of  any 
disease,  the  presence  of  mucus  will  not  excite  cough,  and  yet  it  is 
known  to  be  in  the  trachea,  on  account  of  the  rattling  which  takes 
place.  In  cases  of  phthisis  sudden  checking  of  the  cough  and  expecto- 
ration, on  account  of  weakness,  is  of  bad  prognosis  and  denotes  ap- 
proaching death.     It  is  also  a  bad  sign  in  pneumonia. 

Central,  axd  Reflex-cough.  Cough  may  also  occur  from 
causes  outside  of  the  air-passages.  It  may  be  of  centric  origin.  Kohts 
has  found  by  experiment  that  irritation  of  the  floor  of  the  fourth  ven- 
tricle, above  the  centre  for  respiration,  excites  a  cough.  This  centric 
origin  may  possibly  explain  the  cough  of  hysteria,  and  the  short,  bark- 
ing cough'  which  arises  in  hysterical  or  nervous  states,  when  the  patient 
is  afflicted  with  the  idea  that  he  is  about  to  have  hydrophobia.  Irrita- 
tion of  nerves  which  are  in  anatomical  relation  with  the  pneumogastric 
also  excites  cough. 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  465 

Ear-cough.  The  most  characteristic  cough  of  this  form  is  that 
due  to  the  presence  of  a  foreign  body  in  the  meatus  of  the  ear,  or  to 
disease  of  that  organ.  It  is  sometimes  difficult  to  examine  the  exter- 
nal auditory  meatus,  because  coughing  is  excited.  The  afferent  nerve 
which  receives  the  irritation  is  the  auriculo-temporal  branch  of  the 
fifth  nerve,  according  to  Dr.  Fox,  and  not  the  minute  auricular  twig 
of  the  vagus. 

Tooth-cough.  The  same  authority  points  out  the  occurrence  of 
cough  from  the  irritation  of  the  stump  of  a  tooth,  and  refers  to  cough 
in  infants  during  the  first  dentition. 

Stomach-cough.  The  popular  opinion  that  cough  is  very  fre- 
quently due  to  the  stomach  is  not  substantiated  by  the  experiments 
of  Kohts.  Nevertheless,  we  frequently  observe  cough  in  patients  who 
are  suffering  from  mild  gastric  catarrh,  the  treatment  of  which  relieves 
the  cough.  This  is  in  all  probability  due  to  the  fact  that  with  the  gas- 
tritis there  is  a  secondary  pharyngitis,  and,  as  the  former  is  relieved, 
the  latter,  which  causes  the  cough,  disappears  entirely. 

It  will  be  seen,  therefore,  that  when  investigating  the  cause  of  a 
cough  in  diseases  in  which  this  symptom  is  prominent,  it  is  necessary 
not  only  to  make  examination  of  the  respiratory  tract  throughout  its 
course,  but  also  to  examine  the  condition  of  the  ears  and  the  teeth, 
and  to  bear  in  mind  its  possible  centric  origin. 

Clinical  Characteristics.  The  cough  may  be  dry  or  moist.  A 
dry  cough  occurs  when  there  is  an  irremovable  source  of  irritation 
(see  dry  cough  of  laryngeal  disease).  It  is  seen  in  the  first  stage  of 
bronchitis.  It  occurs  in  the  earlier  stages  of  phthisis.  As  a  short, 
hacking,  suppressed  cough  it  occurs  in  pleurisy  in  the  first  stage.  In 
the  second  stage  it  is  superficial,  as  if  the  sound-waves  were  checked. 
It  is  characteristic  and  most  familiar,  although  described  with  diffi- 
culty. It  is  the  best  type  of  cough  due  to  irritation  outside  of  the 
respiratory  tract.  The  ear-cough  and  tooth-cough  partake  of  this  char- 
acter. In  cases  of  emphysema  the  cough  may  be  dry  and  unproduc- 
tive for  a  long  time,  and  only  be  relieved  after  a  small  pellet  of  tough 
mucus  is  discharged.  In  the  same  category  belong  the  nervous  cough, 
which  is  nothing  but  a  bad  habit;  the  cough  of  hysteria,  and  the  cough 
of  a  peculiar  barking  character  that  occurs  at  puberty,  which  Sir 
Andrew  Clark  has  described. 

The  moist  cough  is  attended  by  expectoration  of  a  mucus,  muco- 
purulent, purulent,  or  bloody  character,  which  is  comparatively  easily 
removed. 

Dry  and  moist  or  loose  cough  may  be  either  constant  or  paroxysmal, 
or  both.  Constant  cough  implies  a  persistence  of  the  cause,  which  is 
strictly  pulmonary,  as  in  pleurisy,  phthisis,  bronchitis,  and  consolida- 
tions generally  ;  paroxysmal,  a  recurrence  of  cause  when  pulmonary, 
or  a  reflex  or  central  cause. 

Under  some  circumstances  the  cough  is  almost  constant.  The  irri- 
tation is  constantly  present.  A  large  amount  of  secretion  is  rapidly 
poured  out,  keeping  up  a  constant  cough.  This  is  seen  in  bronchorrhcea 
and  bronchial  dilatation  and  in  the  later  stages  of  tuberculosis.  In 
these  affections  the  moist  cough   may  occur  three  or  four  times    in 

30 


466  SPECIAL  DIAGNOSIS. 

twenty-four  hours,  during  which  time  an  enormous  amount  of  sputum 
is  thrown  off.  The  cavity  is  thereby  emptied,  the  accumulation  of 
matter  in  which  excites  coughing  only  after  a  certain  level  is  reached. 
In  this  affection  the  cough  is  further  characterized  by  aggravation  on 
change  of  position. 

The  moist  cough  may  occur  in  paroxysms  only,  each  paroxysm  being 
relieved  by  the  removal  of  the  irritation,  the  subsequent  paroxysm 
not  taking  place  until  the  irritating  secretion  has  reaccumulated.  In 
cases  of  bronchitis  of  the  second  stage  paroxysms  of  cough  may  occur 
every  few  hours,  or  the  cough  may  take  place  once  in  the  twenty-four 
hours,  usually  in  the  morning  on  arising.  The  accumulated  secretions 
of  the  night  are  disposed  of,  and  then  the  patient  remains  free  from 
annoyance.  Paroxysmal  coughs  occur  in  cases  of  cavities,  either  of  the 
lung  or  of  the  pleura  opening  into  the  lung.  Cough  is  excited  when- 
ever the  cavity  fills  with  secretion.  The  paroxysm  may  occur  daily 
or  several  times  a  day.  The  association  with  retching  and  vomiting 
is  of  some  diagnostic  significance.  It  is  seen  not  only  in  whooping- 
cough,  but  also  in  phthisis.  In  pertussis  the  character  of  the'  cough  is 
of  special  diagnostic  significance ;  it  occurs  in  paroxysms.  The  expira- 
tory efforts  are  frequent  and  rapid,  followed  by  a  noisy,  prolonged 
inspiration,  during  which  the  characteristic  whoop  is  created.  At  the 
same  time  the  appearance  of  the  countenance  is  marked.  The  face  is 
cyanosed,  the  eyes  stare,  the  appearance  of  distress  is  most  striking. 
The  labored  efforts  at  coughing  frequently  terminate  in  an  attack  of 
retching  or  vomiting. 

The  diagnostic  significance  of  cough  is  estimated  by  the  character ; 
by  the  sound  ;  whether  constant  or  paroxysmal ;  by  the  frequency  of 
the  paroxysm  ;  by  its  development  at  particular  times  or  under  partic- 
ular circumstances,  as  on  arising  in  the  morning,  or  change  to  a  cold 
atmosphere,  or  speaking,  or  upon  movement,  as  in  phthisis.  By  the 
sound,  laryngeal  and  bronchial,  coughs  are  distinguished.  The  diag- 
nostic value  of  cough  further  depends  on  a  knowledge  of  its  duration 
and  the  character  of  the  expectoration.     (See  Sputum.) 

The  Sound.  The  character  of  the  cough  sound,  however,  is  usually 
modified  by  the  condition  of  the  larynx,  for  which  consult  the  section 
on  Laryngeal  Diseases. 

Hemorrhage.  Hemorrhage  of  the  lungs  occurs  from  disease  or 
from  rupture  of  adjacent  bloodvessels  into  the  air-passages.  It  is  not 
in  itself  a  symptom  of  lung  disease.  A  hemorrhage  may  be  small  in 
amount  and  continue  over  a  considerable  period  of  time,  or  it  may  be 
characterized  by  a  sudden  profuse  discharge,  which  at  once  terminates 
the  life  of  the  patient. 

Cause.     A.  Affections  of  the  lungs. 

1.  Congestion  of  the  lungs  will  lead  to  hemorrhage.  The  amount  of 
blood  is  small ;  it  may  be  limited  to  streaking  of  the  expectoration,  or 
a  few  niouthfuls  may  be  discharged.  In  (a)  organic  heart  disease  this 
form  of  hemorrhage  is  seen.  It  is  also  a  characteristic  feature  of 
the  first  stage  of  (6)  croupous  pneumonia.  The  rusty-colored  sputum 
is  due  to  the  rupture  of  the  capillaries.     In  (c)  hemorrhagic  infarcts 


DISEASES  OF  THE  LUNGS  AND  PLEUBJE.  467 

hemorrhage  occurs,  and  is  diagnostic  if  attended  by  the  sudden  forma- 
tion of  a  consolidated  area  in  the  lung.  In  (d)  phthisis  it  also  occurs 
(see  below). 

2.  Tuberculosis.  In  tuberculosis  hemorrhage  may  occur  either  (a) 
as  the  first  symptom  of  the  disease,  on  account  of  collateral  conges- 
tion around  infiltrated  areas,  or  (6)  later,  on  account  of  ulceration  of 
an  artery  when  excavation  of  the  lung  has  taken  place.  In  the  early 
stages  the  hemorrhage  is  usually  profuse,  but  not  fatal.  It  may 
occur  repeatedly  during  a  series  of  weeks,  excited,  no  doubt,  by  the 
violent  non-productive  cough  which  attends  the  earlier  stages  of  this 
disease.  In  the  later  stages,  when  the  vessels  are  ulcerated,  the  patient 
may  have  repeated  hemorrhages,  varying  from  a  few  ounces  to  half  a 
pint  or  a  pint.  They  may  occur  daily,  or  be  repeated  at  intervals  of 
a  week  or  more  for  a  long  period  of  time.  After  the  hemorrhages  that 
occur  at  long  intervals  the  patient  experiences  much  relief.  Indeed, 
the  dyspnoea,  cough,  and  chest  oppression  subside  in  a  remarkable 
degree,  and  the  occurrence  of  another  hemorrhage  is  often  predicted 
by  a  gradual  recurrence  of  these  symptoms.  Death  does  not  usually 
ensue  on  account  of  the  large  hemorrhage  from  phthisical  ulceration, 
and  yet  it  may  possibly  take  place.  The  writer  has  seen  four  instances 
of  hemorrhage  into  a  large  cavity,  three  with  external  hemorrhage, 
which  caused  death  instantly.  Hemorrhage  with  the  expectoration  of 
calcareous  masses  recurs  (c)  frequently  in  patients  with  healed  or  qui- 
escent tubercle. 

3.  Cancer.  Hemorrhage  recurring  frequently  is  significant  of  can- 
cer of  the  lungs,  in  the  absence  of  other  causes. 

4.  Plastic  Bronchitis.  It  is  of  common  occurrence  in  plastic  bron- 
cliitis,  when  large  bronchial  casts  are  expelled. 

5.  Gangrene.  In  gangrene  of  the  lung  it  frequently  occurs,  often 
causing  death.  The  odor  and  sputum  indicate  the  true  nature  of  the 
primary  lesion. 

B.  Disease  outside  of  the  respiratory  tract.  (1)  Aneurismal  disease 
of  the  bloodvessels,  which  are  in  intimate  relation  with  the  trachea  and 
bronchus,  frequently  causes  ulceration  into  these  tubes,  with  hemor- 
rhage. The  hemorrhage  is  usually  profuse  and  often  induces  sudden 
death.  Sometimes  the  profuse  hemorrhage  may  be  preceded  for  days 
by  small  hemorrhages.  The  physical  signs  of  aneurism  are  sufficient 
to  explain  the  cause.  The  bleeding  can  sometimes  be  seen  in  the 
trachea,  when  an  aneurism  of  the  innominate  artery  or  the  aorta  presses 
upon  that  tube.  (2)  In  diseases  of  the  heart  it  does  not  usually  take 
place  until  the  later  stages  of  the  disease,  and  is  associated  with  second- 
ary congestion  of  the  lungs.  It  may,  however,  be  an  early  symptom 
in  mitral  stenosis.  The  hemorrhages  mav  amount  <>nlv  to  staining  of 
the  sputum,  or  several  times  during  the  day  an  ounce  or  more  of  blood 
may  be  expectorated. 

C.  Affections  of  the  blood  or  bloodvessels,  with  hemorrhages  in 
other  portions  of  the  body.  Thus,  it  may  occur  in  haemophilia,  in 
purpura,  in  scurvy,  and  in  anaemia.  It  occurs  in  jaundice  with  hemor- 
rhages in  other  situations. 


468  SPECIAL  DIAGNOSIS. 

D.  Gouty  endarteritis.  In  the  aged  of  both  sexes,  hemorrhages 
take  place  independently  of  disease  of  the  heart  or  of  the  parenchyma 
of  the  lungs.  Sir  Andrew  Clark  and  others  have  spoken  of  these 
hemorrhages  and  attributed  them  to  gouty  changes  in  the  vessels  as 
well  as  to  degenerations  of  lung-tissue,  on  account  of  which  the  rap- 
ture took  place. 

E.  Without  known  cause.  In  certain  instances  pulmonary  hemor- 
rhages occur  in  which  it  is  quite  difficult  to  find  any  cause  for  the  dis- 
charge. It  is  quite  common  to  see  hemorrhage  occur  in  females  :  some- 
times at  the  menopause,  in  other  cases  during  menstruation,  or,  again, 
perhaps  vicariously,  when  menstruation  does  not  occur.  A  number  of 
cases  that  have  come  under  the  writer's  observation  have  had  this  ten- 
dency for  years  without  the  development  of  pulmonary  disease,  and, 
apparently,  without  much  influence  on  the  general  health.  Indeed,  it 
may  be  said  that  recurrent  hemorrhage  from  the  lungs  in  women,  in 
the  absence  of  organic  disease,  is  not  of  grave  significance. 

The  Symptoms.  The  only  symptom  may  be  the  presence  of  blood 
hi  the  expectoration,  or  the  discharge  of  a  small  amount  of  blood  with 
slight  cough.  In  either  instance,  unless  the  patient's  mental  condition 
is  rendered  obtuse  by  disease,  the  hemorrhage  is  alarming  to  him.  He 
is  much  perturbed,  and  there  may  be  palpitation  of  the  heart,  besides 
other  nervous  phenomena.  Apart  from  the  nervousness  excited  by 
the  sight  of  blood,  small  hemorrhages,  and  even  hemorrhages  of  mod- 
erate amount,  do  not  cause  any  other  symptoms. 

The  symptoms  of  a  large  hemorrhage  depend  upon  the  amount  of 
blood  that  is  lost.  They  may  amount  to  faintness  and  giddiness  only, 
with  or  without  pallor.  If  more  pronounced,  syncope  may  take  place  ; 
extreme  pallor  develops ;  the  pulse  becomes  rapid,  small,  and  feeble ; 
the  extremities  are  cold,  and  the  face  bathed  in  perspiration.  If  the 
patient  recovers  from  the  syncope,  he  is  extremely  restless,  sighing  and 
breathing  hurriedly.  There  may  be  some  nausea.  Moderate  delirium 
and  mild  febrile  symptoms  often  follow  the  restlessness.  If  the  hem- 
orrhages do  not  recur  and  the  patient's  fears  are  calmed,  the  color  will 
gradually  return  and  the  heart's  action  become  stronger  and  slower. 
These  symptoms  occur  whether  the  hemorrhage  is  due  to  disease  of  the 
lungs  or  to  aneurism  rupturing  into  the  bronchus.  If  the  hemorrhages 
are  large,  they  differ  somewhat  in  the  two  conditions.  If  a  large  aneu- 
rism ruptures,  the  blood  rapidly  wells  up  into  the  throat  and  pours  out 
through  the  nostrils  and  mouth  with  great  rapidity.  With  such  hem- 
orrhage the  end  may  come  in  a  few  minutes.  In  pulmonary  hemor- 
rhages the  discharge  is  not  so  profuse,  and  is  attended  by  coughing. 
With  each  cough  blood  is  raised  to  the  amount  of  a  full  mouthful  at  a 
time.  The  blood  discharged  from  the  lungs  is  bright  in  color,  very 
frothy,  being  mixed  with  air.  There  are  no  clots  in  the  discharged 
fluid.  The  blood  from  an  aneurism  is  also  bright  red,  but  is  not  frothy, 
unless  the  discharge  is  very  slow,  and  becomes  mingled  with  air  in  the 
vessels.  In  rare  cases  of  pulmonary  hemorrhage  an  abundant  stream 
pours  out,  which  is  dark  in  color,  free  from  clots,  and  not  mixed  with 
air  (large  cavity). 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  469 

Diagnosis.  Hemorrhage  from  the  lungs  must  be  distinguished  from 
hemorrhage  from  the  upper  air-passages,  the  mouth,  the  stomach,  and 
oesophagus.  Thus  a  discharge  of  blood  from  the  mouth  may  occur 
from  cracks  in  the  pharynx,  or  varicose  veins.  It  is  not  abundant, 
and  the  hemorrhage  is  mingled  with  mucus,  which  is  streaked  with 
blood.  Hemorrhage  from  the  gums  may  be  taken  for  pulmonary  hem- 
orrhage, unless  there  is  stomatitis,  or  inflammation  of  the  gums  from 
scorbutus  or  ptyalism.  In  stomatitis  its  color  is  somewhat  different.  It 
is  thin,  fluid  blood,  often  offensive,  of  cherry-juice  color.  Hemorrhage 
from  the  lungs  is  distinguished  from  hemorrhage  from  the  stomach  by 
the  difference  in  the  way  in  which  it  is  discharged,  and  the  difference 
in  the  character  of  the  blood.  If  from  the  stomach  the  blood  is  vom- 
ited. It  is  mixed  with  particles  of  food  or  other  gastric  contents.  It 
is  dark  in  color,  often  of  the  appearance  of  coffee-grounds ;  it  is  not 
mixed  with  air,  and  hence  is  not  frothy.  The  rapid  hemorrhage  from 
ulceration  of  an  aneurism  into  the  oesophagus,  or  rupture  of  varicose 
veins  at  the  lower  end  of  the  oesophagus,  cannot  be  distinguished  by 
the  appearance  from  the  hemorrhage  of  an  aneurism  which  may  have 
ruptured  into  a  bronchus.  The  recognition  is  dependent  upon  the 
physical  signs  and  the  previous  history  of  the  patient's  illness. 

Pain.  Pain  is  rarely  a  symptom  of  disease  of  the  lungs  unless  the 
pleura  is  involved.  In  a  case  of  bronchitis  there  may  be  some  sore- 
ness and  oppression  behind  the  sternum,  but  otherwise  pain  is  absent. 

In  pleurisy  pain  occurs  before  the  exudation.  It  is  sharp  and  lanci- 
nating, and  so  severe  as  to  impede  respiration  and  cause  the  cough  to 
be  short  and  catchy.  It  is  usually  seated  at  the  base  of  the  chest,  in 
the  lateral  or  anterior  region.  It  occurs  when  the  patient  attempts  to 
take  a  full  breath.  Before  the  inspiratory  excursion  is  half  completed 
it  is  checked  involuntarily,  on  account  of  the  pain.  The  patient's  hand 
is  placed  upon  the  affected  part  and  he  involuntarily  leans  to  that  side. 
The  pain  of  pleurisy  may  be  increased  by  local  pressure,  but  general 
pressure,  as  from  the  whole  hand,  a  broad  bandage,  or  a  large  strap  of 
adhesive  plaster,  always  gives  relief.  In  the  pleurisy  that  attends 
phthisis  pain  is  quite  common.  It  is  of  the  same  character  as  the  pain 
of  acute  plastic  pleurisy,  but  varies  in  situation  and  in  degree.  The 
pain  occurs  in  paroxysms.  It  follows  a  slight  exposure  to  cold,  undue 
exertion,  or  fatigue.  It  may  continue  for  twenty-four  hours,  and  dis- 
appear until  a  repetition  of  the  cause  brings  it  on  again.  It  must  be 
distinguished  from  the  myalgia  of  phthisis  due  to  cough  and  exposure. 
In  myalgia  the  muscles  and  fascia?  at  the  bony  attachments  are  very 
tender. 

The  pain  of  pleurisy  must  be  distinguished  from  pleurodynia,  from 
intercostal  neuralgia,  and  from  the  pain  due  to  the  disease  of  the  ribs. 
In  pleurodynia  the  muscles  are  sensitive  if  pressed  between  the  fingers 
or  palpated.  An  enlarged  area  is  affected,  but  physical  signs  of  pleu- 
risy or  pneumonia  cannot  be  elicited.  Cough  is  absent,  and  so,  usu- 
ally, is  fever.  It  is  associated  with  pain  in  other  muscular  or  fibrous 
structures.  There  may  be  a  previous  history  of  exposure  to  cold  and 
dampness.     Usually  there  is  a  history  of  lithaemia  or  frequent  myalgia. 


470  SPECIAL  DIAGNOSIS. 

Intercostal  neuralgia  is  sometimes  difficult  to  distinguish.  The  pain 
is  sharp,  localized,  and  may  modify  the  movements  of  the  chest.  Gen- 
eral pressure  relieves  it ;  local  pressure  at  the  points  where  the  termi- 
nal filaments  of  the  nerve  come  to  the  surface  may  increase  it.  The 
so-called  Valleix's  tender  points  are,  however,  not  always  present  in 
cases  of  intercostal  neuralgia.  The  patient  is  usually  anaemic,  often 
the  subject  of  uterine  or  other  exhausting  disease,  and  may  suffer  from 
neuralgia  in  other  situations.  Cough  and  physical  signs  are  absent. 
Fracture  of  the  rib,  or  caries  of  the  rib,  may  be  recognized  by  the  local 
tenderness  and  by  the  signs  of  these  conditions.  Localized  pleurisy 
may  attend  both,  however — indicated  by  more  severe  pain  on  cough 
or  full  breathing.  Caries  or  fracture  is  determined  by  pressure  upon 
the  diseased  rib,  which  elicits  the  crepitus  of  fracture.  An  empyema 
that  is  about  to  point  will  cause  pain  in  some  area  of  the  chest.  The 
pain  is  usually  seated  at  the  points  of  election  for  the  discharge  of  the 
empyema,  and  is  soon  followed  by  swelling,  with  heat  and  redness  of 
the  skin,  and  the  occurrence  of  oedema. 

More  or  less  constant  pain  at  the  apices,  undoubtedly  independent 
of  affections  of  the  muscles,  is  a  suspicious  sign  of  tuberculous  disease 
in  that  situation.     It  may  be  aggravated  by  pressure. 

The  Data  Obtained  by  Observation. 

The  Objective  Symptoms.  By  physical  examination  of  the  lungs 
we  ascertain  (1)  their  degree  of  activity  (movement) ;  (2)  the  physical 
condition  of  their  parts  subjected  to  examination  ;  but  the  disease  is  not 
diagnosticated.  If  abnormal  signs  are  detected,  they  simply  indicate 
an  abnormal  condition  of  the  part,  which  condition  may  be  due  to  any 
number  of  diseases.  As  the  lungs  in  health  contain  air,  any  physical 
change  that  takes  place  causes  either  an  increase  or  a  diminution  in  the 
amount  of  air.  This  may  be  general  (bilateral),  or  limited  to  one  side 
(unilateral),  or  to  a  smaller  area  (local).  In  examining  the  lungs  we 
might  be  content  to  answer  the  question,  Is  there  an  increased  or  a 
diminished  amount  of  air  in  the  parts  suspected  to  be  the  seat  of  dis- 
ease ?  A  correct  answer  to  this  question,  and  to  an  inquiry  as  to  the 
case  of  the  increase  or  diminution,  would  explain  any  abnormal  phys- 
ical condition.  The  answer  is  determined  by  percussion.  Fortunately, 
however,  we  have  as  adjuncts  the  phenomena  that  can  be  elicited  by 
means  of  inspection,  palpation,  and  auscultation.  These  methods  of 
examination  depend  upon  the  movements  of  the  lungs  and  the  sounds 
produced  in  breathing  and  speaking. 

Value  of  Inspection  and  Palpation.  Too  much  emphasis  has 
been  laid  in  the  past  on  auscultation  and  percussion  in  the  study  of 
lung  diseases.  It  is  the  habit  to  rely  too  much  on  these  methods,  to 
the  exclusion  of  the  simpler  and  quite  as  valuable  methods — inspection 
and  palpation.  The  latter  have  been  employed  for  a  long  time  in  the 
study  of  the  objective  phenomena  of  disease.  The  former  are  com- 
paratively modern  methods,  and  have  required  special  cultivation  of 
senses  not  usually  employed  in  observation,  in  addition  to  exhaustive 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  471 

comparative  research,  to  put  the  findings  on  an  accurate  basis. 
Naturally,  they  have  been  given  undue  prominence  as  methods  of 
diagnosis.  The  pernicious  habit  of  examining  the  patient  without 
removing  the  clothing,  either  from  haste  upon  the  part  of  the  physician 
or  false  modesty  upon  the  part  of  the  patient,  has  unfortunately  also 
led  to  the  neglect  of  inspection  and  palpation.  It  is  proper  to 
insist  that  the  data  obtained  by  inspection  and  palpation  are  as 
important  and  valuable  as  those  obtained  by  other  means.  They  are 
even  more  suggestive  or  diagnostic  of  physical  conditions.  The  phe- 
nomena observed  are  more  positive  and  surrounded  by  fewer  qualifica- 
tions. 

The  Regions  of  the  Chest.  For  the  purpose  of  bearing  in  mind 
the  relations  of  the  organs  to  the  surface  of  the  chest,  and  the  localiza- 
tion and  proper  recording  of  the  seat  of  the  disease,  the  chest  is  divided 
into  regions.  The  regions  correspond  to  anatomical  points  on  the  sur- 
face of  the  chest,  and  are  subdivided  by  transverse  and  vertical  lines. 
Knowledge  of  the  landmarks  which  indicate  on  the  surface  the  position 
of  the  parts  underneath  is  of  great  importance  in  diagnosis.  The 
regions  in  the  anterior  portions  of  the  chest  are  :  The  supraclavicular 
region,  above  the  clavicle ;  the  infraclavicular  region,  below  the  clavi- 
cle, extending  to  the  third  rib  ;  the  mammary  region,  from  the  third 
to  the  sixth  rib.  In  the  axilla  two  regions  suffice— the  upper  and 
lower — the  position  of  the  disease  being  more  definitely  determined  by 
association  with  ribs  and  interspaces.  Posteriorly  the  regions  are 
the  suprascapular,  above  the  scapula  ;  the  scapular  region,  and  the 
infrascapular  region  ;  the  region  between  the  scapula  and  the  spine  is 
known  as  the  interscapular  region.  The  vertical  lines  are  to  the 
right  and  left  of  the  median  line  :  (1)  The  parasternal  line,  which  is 
drawn  downward  midway  between  the  edge  of  the  sternum  and 
the  second  line,  which  is  (2)  the  mid-clavicular  line,  drawn  from  the 
middle  of  the  clavicle,  generally  passing  through  the  nipple  in  males  ; 
(3)  the  anterior  axillary  line,  drawn  from  the  anterior  fold  of  the 
axilla  ;  (4)  the  mid-axillary  line,  from  the  centre  of  the  axilla ;  (5) 
the  posterior  axillary  line,  from  the  posterior  fold  of  the  axilla.  In 
the  back  one  line  is  sufficient — the  scapular  line,  drawn  through  the 
angle  of  the  scapula  when  the  arm  is  at  rest  at  the  side  of  the  patient. 
For  transverse  lines  the  ribs  and  interspaces  are  used.  In  this  way 
the  exact  location  of  a  diseased  area  can  be  indicated.  In  order  that 
accuracy  may  attend  its  localization,  knowledge  of  the  methods  of 
determining  the  landmarks,  and  especially  of  counting  the  ribs,  is 
essential. 

The  Angles  of  the  Thorax.  The  costal  angle  is  the  angle  of 
the  rib.  It  varies  during  the  act  of  respiration.  In  inspiration  the 
rib  rises  as  the  sternum  projects,  and  apparently  elongates  ;  the  angles 
become  more  obtuse  ;  in  expiration  the  sternum  falls,  the  ribs  become 
more  slanting,  and  the  angle  is  more  acute. 

The  epigastric  angle.  This  angle  is  formed  by  the  convergence  of 
the  ribs  of  both  sides  to  the  xiphoid  cartilage  of  the  sternum.  On  in- 
spiration it  is  obtuse,  increasing  as  the  ribs  rise  ;  in  expiration  it  is 
more  acute. 


472  SPECIAL  DIAGNOSIS. 

Method  of  Counting  Ribs  and  Inteespaces.  The  first  rib 
corresponds  to  the  clavicle ;  the  first  interspace  is  the  region  between 
the  clavicle,  or  first  rib,  and  the  second  rib  ;  the  subsequent  number 
of  an  interspace  corresponds  to  the  number  of  the  rib  above  it.  The 
following,  from  Holden,  is  of  great  importance  to  remember,  particu- 
larly when  the  ribs  of  fat  persons  are  counted  : 

a.  The  finger  passed  down  from  the  top  of  the  sternum  soon  comes 
to  a  transverse  projection,  slight,  but  always  to  be  felt,  at  the  junction 
of  the  first  with  the  second  bone  of  the  sternum.  This  corresponds 
with  the  middle  of  the  cartilage  of  the  second  rib. 

6.  The  nipple  of  the  male  is  placed  in  the  great  majority  of  cases 
between  the  fourth  and  fifth  ribs,  about  three-quarters  of  an  inch  ex- 
ternal to  their  cartilages. 

c.  The  lower  external  border  of  the  pectoralis  major  corresponds 
with  the  direction  of  the  fifth  rib. 

d.  A  line  drawn  horizontally  from  the  nipple  round  the  chest  cuts 
the  sixth  intercostal  space  midway  between  the  sternum  and  the  spine. 

This  is  a  useful  rule  for  localization  in  tapping  the  chest. 

e.  When  the  arm  is  raised  the  highest  visible  digitation  of  the  serra- 
tus  magnus  corresponds  with  the  sixth  rib.  The  digitations  below 
this  correspond  respectively  with  the  seventh  and  eighth  ribs. 

/.  The  scapula  lies  on  the  ribs  from  the  second  to  the  seventh,  inclu- 
sive. 

g.  The  eleventh  and  twelfth  ribs  can  be  felt,  even  in  corpulent 
persons,  outside  the  erector  spina?,  sloping  downward. 

h.  One  should  remember  the  fact  that  the  sternal  end  of  each  rib  is 
on  a  lower  level  than  its  corresponding  vertebra.  For  instance,  a  line 
drawn  horizontally  backward  from  the  middle  of  the  third  costal  car- 
tilage, at  its  junction  with  the  sternum,  to  the  spine,  would  touch  the 
body,  not  of  the  third  dorsal  vertebra  but  of  the  sixth.  Again,  the 
end  of  the  sternum  would  be  at  about  the  level  of  the  tenth  dorsal 
vertebra.  Much  latitude  must  be  allowed  here  for  variations  in  the 
length  of  the  sternum,  especially  in  women. 

It  is  important  to  recognize  the  relation  of  the  ribs  to  the  vertebrae. 
The  first  rib  articulates  with  the  first  dorsal  vertebra,  which  can  be 
located  by  the  position  of  the  prominent  spine  of  the  seventh  cervical 
vertebra  ;  even  in  very  fat  people  this  prominence  can  be  recognized. 
The  remaining  ribs,  except  the  tenth,  eleventh,  and  twelfth,  have 
facets  of  articulation  on  two  vertebra? ;  as  the  second  rib,  with  the 
first  and  second  thoracic  vertebra?.  The  eleventh  and  twelfth  articu- 
late with  the  eleventh  and  twelfth  thoracic  vertebra?. 

Topographical  Anatomy.  The  following  anatomical  points  are 
worthy  of  remembrance  : 

The  top  of  the  sternum  is  on  a  plane  with  the  lower  border  of  the 
second  dorsal  vertebra  behind.  The  junction  of  the  first  and  second 
portions  of  the  sternum  is  known  as  the  angle  of  Ludwig.  It  is  oppo- 
site the  middle  of  the  second  rib,  and  is  on  a  plane  with  the  lower 
border  of  the  fourth  dorsal  vertebra.  The  junction  of  the  body  of  the 
sternum  to  the  xiphoid  cartilage  is  on  a  plane  with  the  lower  border  of 
the  eighth  dorsal  vertebra. 


PLATE    XIII. 


Ficj.   1.     Anterior  Aspect. 


Fig.  2.     Posterior  Aspect. 


Situation    of   the    Viscera. 

i  )utlines  of  heart  and  vessels — broad  red  lines.     Margins  of  lungs  and  ot  individual  lobes — dotted  green  lines. 

Limits  of  pleural  sacs— solid  green  lines.     Liver — red  shading.     Stomach— green  shading. 

(In  part  after   His-Spalteholz  and   Luschka.) 


PLATE    XIV. 


Fig.  1.     Right  Lateral  Aspect. 


Fig.  2.     Left  Lateral  Aspect. 


Situation    of   the    Viscera. 


Margins  of  lungs  and  of  individual  lobes— dotted  green  lines.      Limits  of  pleural  sacs— solid  green  lines. 

Liver  and  spleen— solid  red  lines.     Diaphram  —  dotted  red  lines.     Stomach  (portion  not 

covered  by  lung)  — green  shading.     (In  part  after  Luschka.) 


DISEASES  OF  THE  LUNGS  AND  PLEURJE.  473 

The  apex  of  the  diaphragm  is  on  a  level  with  the  eighth  dorsal  ver- 
tebra. 

The  trachea  bifurcates  at  the  plane  which  includes  the  angle  of  Lud- 
wig  and  the  fourth  dorsal  vertebra. 

Purulent  effusions  in  the  left  pleural  sac  frequently  point  at  the 
fifth  interspace,  beneath  the  nipple,  because  this  is  the  weakest  point 
of  the  chest-covering.  A  little  external  to  the  inferior  angle  of  the 
scapula  and  the  eighth  and  ninth  interspaces  a  similar  weak  point  is 
found. 

Limits  of  the  Lungs.  The  apices  of  the  lungs  reach  three  to 
seven  centimetres  (one  and  one-fifth  to  two  and  three-quarter  inches) 
above  the  clavicles  in  front ;  behind  they  rise  as  high  as  a  line  drawn 
transversely  through  the  spinous  process  of  the  seventh  cervical  verte- 
bra. The  lower  anterior  margin  of  the  -right  lung,  when  the  chest  is 
passive,  commences  at  the  insertion  of  the  sixth  rib  into  the  sternum, 
and  runs  parallel  with  the  upper  border  of  the  sixth  rib  to  the  axillary 
line.  At  this  point  it  descends  to  the  upper  margin  of  the  seventh  rib. 
On  the  left  side  the  lower  limit  extends  as  far  downward  as  the  right. 
Posteriorly  both  lungs  reach  to  the  tenth  rib.  With  full  inspiration 
the  lungs  descend  both  in  front  and  behind  almost  the  extent  of  one 
interspace,  while  in  deepest  expiration  they  are  elevated  almost  to  the 
original  position.  The  "  complemental  space  "  of  Gerhardt  is  the  space 
at  the  lower  margin  of  the  lung,  and  at  the  point  at  which  the  left  lung 
overlaps  the  heart,  in  which,  during  expiration,  the  surfaces  of  the 
visceral  and  parietal  pleura  come  together.  In  inspiration  the  thin 
layer  of  the  lung  in  both  situations  insinuates  itself  into  this  space. 
The  heart  interferes  with  the  extension  of  the  left  lung.  The  space 
is  triangular  in  shape,  extending  in  the  median  line  from  the  fourth  to 
the  sixth  rib.  The  left  edge  of  the  triangular  area  corresponds  to  the 
edge  of  the  left  lung,  which,  notched  for  the  heart,  diverges  from  the 
median  line  and  runs  along  the  cartilage  of  the  fourth  rib. 

Position  of  the  Lobes.  Plates  XIII.  and  XIV.  illustrate  the 
position  of  the  lobes  of  the  lungs.  In  the  right  lung  the  upper  lobe 
in  front  extends  to  the  fourth  rib,  in  inspiration  laterally  to  the  third, 
and  behind  to  the  spine  of  the  scapula.  The  lower  lobe  begins  with 
the  spine  of  the  scapula  and  extends  to  the  tenth  rib  behind,  and  from 
the  fourth  to  the  tenth  ribs,  when  fully  expanded,  in  the  axillary 
region.  The  middle  lobe  is  not  seen  behind  ;  it  extends  between  the 
third  and  fourth  ribs  in  the  axillary  region  in  inspiration.  In  front  it 
extends  from  the  lower  margin  of  the  upper  lobe  to  the  sixth  rib. 

The  upper  lobe  of  the  left  lung  extends  to  the  sixth  rib  in  front  and 
to  the  fourth  interspace  at  the  side.  Behind,  a  small  portion  extends 
above  the  spine  of  the  scapula,  while  the  lower  lobe  extends  from  the 
spine  of  the  scapula  to  the  base  of  the  lung  behind.  At  the  sides  it 
extends  from  the  lowest  limit  of  the  upper  lobe  to  the  level  of  the 
eighth  rib. 

Inspection.  By  inspection  we  learn  (1)  the  appearance  of  the  ex- 
ternal surface,  (2)  the  shape  and  size,  and  (3)  the  movements  of  the 
chest.     The  second    indicates  the  capacity  of  the  lungs  ;  the  last,  the 


474 


SPECIAL  DIAGNOSIS. 


degree  of  functional  activity.  The  X-rays  are  also  employed  to  con- 
duct inspection. 

Methods.  The  patient  must  be  seated,  if  possible,  in  an  easy 
position,  with  the  light  falling  directly  on  the  part  or  from  the  side. 
He  should  be  viewed  by  the  observer  standing,  first  in  front,  then  be- 
hind, and  also  from  the  side.  To  observe  the  anterior  portion  it  is 
often  well  to  stand  behind  the  patient  and  look  downward  over  the 
shoulders.  The  arms  should  fall  by  the  side  ;  the  breathing  should  be 
quiet  and  undisturbed  by  talking  or  unusual  movements. 

The  Skin  and  Subcutaneous  Tissue.  In  health  the  normal 
covering  should  be  supple,  elastic,  and  of  the  color  previously  described. 
It  is  pale  in  ansemia  and  wasting  diseases  ;  yellow  in  jaundice  ;  pig- 
mented generally  or  locally  from  causes  previously  mentioned.  It  is 
the  particular  seat  for  the  parasitic  disease,  tinea  versicolor,  and  is  the 
seat  of  sudamina  as  well  as  other  non-specific  eruptions.  The  veins 
over  the  surface  of  the  chest  should  not  be  very  distinct.  They  are 
distinct  when  there  is  interference  with  the  circulation  in  the  mediasti- 
num from  the  pressure  of  an  aneurism  or  morbid  growths  obstructing 
the  veins.  They,  along  with  the  cervical  veins,  may  also  be  enlarged 
in  dilatation  of  the  right  heart.  The  capillaries  along  the  base  of  the 
chest  are  often  enlarged  or  more  distinct  than  usual,  and  arranged  in  a 
bow  corresponding  to  the  attachment  of  the  diaphragm.  This  bow 
is  frequently  seen  in  intrathoracic  obstruction.  (Edema,  or  subcutane- 
ous emphysema  occurs  as  indicated  under  general  inspection.  If  there 
is  too  much  fat  over  the  surface  of  the  chest,  the  muscles  may  be  want- 
ing in  tone,  and  an  estimation,  therefore,  of  respiratory  capacity  cannot 
be  made.  Wasting  of  the  fat  and  muscles  is  seen  in  phthisis,  carci- 
noma, diabetes,  muscular  atrophy,  and  paralysis.     The  degree  of  sqft- 

FrG.  121. 


Transverse  section  of  healthy  adult  chest  upon  level  of  sterno-xiphoid  articulation. 
Circumference  =  89  centimetres. 


ness  of  the  ribs  can  be  estimated  in  a  measure  by  the  undue  depression 
of  the  ribs  at  the  costo-cartilasnnous  articulations,  and  at  the  base  of 


DISEASES  OF  THE  LUNGS  AND  PLEURA. 


475 


the  chest  (about  the  sixth  rib),  during  the  act  of  inspiration.  It  is  an 
indication  of  rickets.  Rigidity  of  the  thorax,  equal  to  the  senile  fixa- 
tion, occurs  in  some  adults  in  middle  life,  and  Roberts  points  out  that 
in  young  subjects  it  may  be  due  to  congenital  syphilis. 

The  Shape  and  Size  of  the  Chest.     We  appreciate  the  shape  of 
the  chest  in  health  by  an  estimation  of  the  relations  of  the  antero-pos- 


FlG.  122. 


Transverse  section  of  healthy  male  adult  chest.     Semi-circumference,  right  side,  16%  inches  ; 
left  side,  16%  inches  ;  expansion,  3%  inches.    (Ward  6,  Philadelphia  Hospital.) 

terior  and  the  transverse  diameters  and  by  the  shape  of  the  transverse 
section  of  the  chest.     The  latter  is  an  ellipse,  and  has  been  described 

Fig.  123. 


Transverse  section  of  an  infant's  chest,  aged  nine  months.     A  circle  within  shows  the  similarity. 


as  reniform  (see  Fig.  121).     The  antero-posterior  diameter  is  about 
one-fourth  less  than  the  transverse.     Measurement  with  the  cvrtometer 


476  SPECIAL  DIAGNOSIS. 

(see  Mensuration)  verifies  the  result  of  inspection  with  mathematical 
precision.  In  children  the  transverse  section  is  different.  It  is  more 
circular,  and  the  antero-posterior  and  transverse  diameters  are  almost 
equal.  (See  Fig.  123.)  Marked  deviations  from  such  section,  or  in 
the  relations  of  the  diameters,  are  seen  in  abnormal  types  of  chest. 

It  is  difficult  to  describe  the  shape  of  the  chest  in  health.  By  re- 
peated practice  we  readily  form  a  judgment  of  the  true  shape.  No 
rule  has  been  applied  to  the  relation  of  the  length  of  the  chest  to  the 
length  of  the  body,  but  it  would  seem  that  there  is  some  such  propor- 
tion. (See  Mensuration.)  In  health  the  chest  should  be  symmetrical, 
the  right  side  probably  a  little  larger  than  the  left.  In  the  ideal  chest 
the  muscles  of  respiration  should  be  well  developed  and  there  should 
be  a  moderate  amount  of  subcutaneous  fat.  The  sternmn  should  pro- 
ject forward  from  above  downward,  and  the  portion  joining  the  manu- 
brium and  the  gladiolus  should  be  a  little  more  prominent  than  the 
other  part.  It  is  not  unusual  to  see  a  clearly  marked  demarcation 
between  the  upper  and  middle  portions  of  the  sternum,  or  an  undue 
projection  of  one  or  more  of  the  upper  ribs,  and  some  striking  changes 
about  the  xiphoid  cartilage,  none  of  which  are  indications  of  disease. 
The  xiphoid  may  be  depressed,  on  account  of  which  a  crater  form  or 
funnel-shaped  depression  is  seen  (occupation).  The  tip  of  the  cartilage 
is  sometimes  drawn  inward,  but  more  frequently  the  reverse  is  noted. 

The  Movements  of  the  Chest.  The  frequency,  the  rhythm,  the 
degree  of  expansion,  and  the  so-called  diaphragm-phenomena  are 
studied.  A  complete  respiratory  act  consists  of  two  events,  inspiration 
and  expiration.  Inspiration  is  active  ;  expiration  passive.  The  latter 
act  is  a  trifle  longer  than  the  former,  as  may  be  illustrated  by  the 
following  proportion — Insp.  :  Exp.  :  :  5  :  6.  A  pause  follows  the  act 
of  expiration.  The  chest  increases  in  circumference  and  in  vertical 
length  (descent  of  diaphragm)  in  inspiration  as  the  lung  expands  with 
air.  The  term  expansion  is  applied  to  the  result  of  inspiration  ;  its 
degree  varies. 

The  frequency  and  character  of  the  movements  in  health  vary  in  the 
two  sexes.  The  respirations  are  from  16  to  24  in  the  minute  in  a 
healthy  adult.  In  the  female  they  may  be  20  to  22.  In  children  the 
frequency  of  respiration  is  much  greater — under  one  year,  44  per 
minute,  and  at  five  years  26.  They  are  increased  in  frequency  in  the 
standing  position.  They  are  lessened  in  the  horizontal  position,  in- 
creased during  bodily  exertion,  with  increased  temperature  of  the  air, 
and  during  digestion.  The  hand  placed  on  the  epigastrium  facilitates 
counting  of  the  respirations. 

The  movements  of  the  chest  in  quiet  breathing  are  more  marked  in 
the  lower  half  in  male  adults,  and  thus  the  costo-abdominal  or  dia- 
phragmatie  type  of  breathing  is  seen.  The  sternum  rises,  the  ribs  are 
elevated,  and  at  the  same  time  are  drawn  forward  and  outward.  The 
antero-posterior  and  vertical  diameters  increase.  The  costal  angle  and 
epigastric  angle  become  more  obtuse.  The  diaphragm  acts  conjointly 
with  the  external  muscles  of  the  thorax,  and,  as  it  descends,  the  epi- 
gastric region  swells  with  each  inspiratory  effort.     In  expiration  the 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  477 

sternum  falls,  the  ribs  become  more  slanting  instead  of  horizontal,  the 
epigastrium  retracts,  the  angles  become  acute.  The  antero-posterior 
and  transverse  diameters  lessen.  The  upper  half  of  the  chest  moves 
more  actively  in  women,  and  hence  the  costal  or  upper  thoracic  type  of 
breathing  is  seen.  The  areas  below  the  clavicles  and  the  upper  por- 
tion above  the  sternum  swell  more  distinctly  during  inspiration.  The 
movements  of  the  lower  portion,  and  especially  of  the  diaphragm,  are 
limited. 

The  costal  type  occurs  most  frequently  in  children.  The  type  of 
breathing  is  costal  in  both  sexes  during  sleep  ;  the  same  type  is  ob- 
served during  deep  respiration. 

The  Diaphragm-phenomena  (Litten).  The  diaphragm  and  walls  of. 
the  thorax  approach  each  other  during  expiration,  and  come  in  apposi- 
tion at  the  end  of  this  act.  During  inspiration  they  become  separated. 
In  persons  whose  chest-walls  are  not  too  thick  the  movements  of  the 
diaphragm  are  indicated  on  the  surface  by  the  rise  and  fall  of  a 
shadowy  line.  The  patient  must  lie  on  his  back  with  his  face  from 
the  light  and  head  slightly  elevated.  The  light  should  fall  from 
behind.  The  observer  stands  a  distance  of  three  or  four  feet  with  his 
back  to  the  light.  The  chest  is  scanned  at  an  angle  of  about  forty- 
five  degrees.  In  the  act  of  inspiration  a  horizontal  shadow  or  undula- 
tion is  seen  to  start  on  either  side  about  the  sixth  interspace  and 
passes  downward  during  inspiration  over  a  distance  of  two  or  more 
interspaces,  and  even  to  the  margin  of  the  ribs.  In  expiration  the 
shadow  begins  below  and  moves  upward  to  the  starting-point. 

Absence  of  the  phenomena  is  noted  when  there  is  fluid  or  air  in  the 
pleural  cavity,  when  the  pleural  cavity  is  obliterated  by  adhesions, 
when  there  is  pneumonia  of  the  lower  lobe ;  and  in  emphysema  of  the 
lungs,  and  intrathoracic  tumors  low  down  in  the  chest.  Tumors  or 
fluid  accumulations  below  the  diaphragm  do  not  lessen  the  phe- 
nomena. 

By  this  phenomena  the  volume  or  vital  capacity  of  the  lungs  can  be 
estimated.  In  normal  individuals  the  shadow  should  move  more  than 
two  and  a  half  inches.  If  there  is  lessening  of  the  extent  of  move- 
ment the  respiratory  capacity  is  diminished.  In  this  manner  tubercu- 
losis may  be  suspected.  Limitation  of  the  excursion  of  the  diaphragm 
— X-ray  investigations  have  forcibly  taught  us — is  one  of  the  earliest 
signs  of  tuberculosis.  This  limited  excursion  can  be  detected  in  proper 
subjects  by  Litten's  method,  although  it  must  be  remembered  that 
general  debility  and  emphysema  lessen  the  excursion  on  both  sides. 
In  splenic  and  hepatic  enlargements  the  normal  shadow  continues,  but 
in  a  large  collection  of  ascitic  fluid  it  may  be  detected  with  difficulty, 
or  may  be  absent. 

The  Shape  and  Size  of  the  Chest  in  Disease.  The  chest  may 
be  enlarged  or  diminished  in  size.  Such  change  may  be  general  or 
bilateral,  unilateral  or  local. 

General   or   Bilateral   Changes   in   Shape.     Enlargement.     The 

"  barrel-shaped  "  chest,  the  type  of  bilateral  enlargement  of  the  chest, 

is  seen  in  health  when  it  is  in  the  state  of  full  inspiration.     All  the 


478 


SPECIAL  DIAGNOSIS. 


diameters  are  increased,  particularly  the  anteroposterior  ;  the  length 
is  shortened.  The  diameters  are  almost  equal,  and  the  transverse  sec- 
tion approaches  a  circle.  This  occurs  because  in  all  figures  of  fixed 
length,  in  order  that  the  area  may  be  increased,  a  change  to  a  circular 
form  must  take  place.  (See  Figs.  125  and  126.)  The  ribs  are  ele- 
vated and  almost  horizontal,  the  epigastric  angle  is  obtuse.  The  ster- 
num and  the  spine  are  arched  ;  the  former  at  the  angle  of  Ludwig. 
The  shoulders  are  rounded  and  elevated,  and  the  scapulae  lie  flat  against 
the  thorax.     All  the  muscles  of  respiration  stand  out  prominently,  the 


Fig.  124. 


<A 


Emphysema  with  enlargement  of  the  chest.    The  antero-posterior  diameter  is  much  increased. 
(Ward  6,  Philadelphia  Hospital.) 


neck  and  upper  trunk  muscles  particularly.  The  individual  with 
bilateral  enlargement  of  the  chest  presents  a  striking  appearance.  The 
neck  is  short,  the  arms  are  short ;  there  is  undue  fulness  above  the 


DISEASES  OF  THE  LUNGS  AND  PLEURAE. 


479 


clavicles.     As  this  enlargement  is  attended  with  dyspnoea,  the  face  is 
drawn  and  anxious,  and  the  lips  usually  faintly  livid,  or  purple. 


Fig.  125. 


Bilateral  enlargement  of  emphysema. 
Inner  line  =  emphysematous  chest. 
Outer  line  =  a  circle  drawn  to  show  how  nearly  the  emphysematous 

approaches  the  circular  shape. 
Dotted  line  =  natural  adult  chest. 

Actual  measurement  in  centimetres. 


Circumference       =  natural  89.0 
Transverse  =       "        29.6 

Antero-posterior    =       "        22.25 


emphysematous,  87.75. 
27.25. 
25.4. 


— (Dr.  Gee.) 


The  movement  of  the  chest  in  bilateral  enlargement.  Expansion  is 
lessened.  The  respiratory  capacity  is  diminished.  The  chest  is  in  a 
state  of  full  inspiration,  and  the  attendant  dyspnoea  is  known  as  expi- 
ratory dyspnoea.  The  respirations  are  hurried,  the  inspirations  short, 
followed  by  prolonged  expiration.  While  the  expansion  of  the  chest 
in  health  extends  over  an  area  of  three  or  four  inches,  when  the  chest 
is  bilaterally  enlarged  it  may  be  lessened  to  one  and  a  half  inches,  or 
even  be  as  low  as  half  an  inch.  Both  the  costal  and  the  diaphragmatic 
types  of  breathing  are  seen  in  a  state  of  exaggeration.  In  men  the 
diaphragm  acts  very  vigorously  at  times.  Expiration  is  three  or  four 
times  as  long  as  inspiration. 

Cause.  The  increase  in  size  is  due  to  enlargement  of  the  normal 
contents  of  the  chest  or  to  the  presence  of  abnormal  contents.  In 
nearly  all  cases  it  is  due  to  an  increased  amount  of  air  within  the 
thorax  (normal  contents),  as  in  emphysema.  In  a  few  instances  en- 
largement of  both  sides  is  seen  in  cases  of  bilateral  pleural  effusion  ;  but, 
as  considerable  effusion  would  be  incompatible  with  life,  the  enlarge- 
ment from  this  cause  is  never  very  great.  It  is  said  that  such  enlarge- 
ment may  occur  in  rapidly  growing  cancer  of  the  lungs. 


480 


SPECIAL  DIAGNOSIS. 


It  mast  be  remembered  that  emphysema  can  exist  without  bilateral 
enlargement  of  the  chest. 

Bilateral  Diminution  in  Size.  The  type  is  seen  in  the  so-called 
phthisical  or  tuberculous  chest.  The  chest  is  long,  the  antero-posterior 
diameter  small  (see  Fig.  126),  the  transverse  relatively  very  much  in- 
creased.    The  angles  are  acute,  the  ribs  are  slanting,  the  epigastric 


Fig.  126. 


15  c 


The  flat  or  phthisical  chest,  short  antero-posterior,  long  transverse  diameter.    (Gee  ) 


angle  is  particularly  sharp.  The  shoulders  fall,  and  hence  the  scapula? 
are  prominent — so  marked  in  many  cases  that  the  term  alar  or 
"winged"  chest  has  been  given  to  it.  The  anterior  plane  is  often 
flattened,  and  hence  the  term  ' '  flat  "  chest  is  employed.  This  change 
occurs  because  the  curve  in  the  cartilage  of  the  true  ribs  becomes 
straight.  The  movement  or  expansion  is  lessened  just  as  the  respiratory 
capacity  is  diminished. 

With  this  type  of  chest  we  see  the  neck  long,  the  larynx  (Adam's 
apple)  very  prominent,  the  arms  long.  The  patient  is  loosely  put 
together  ;  the  length  of  the  long  bones  is  increased. 

It  is  known  as  the  phthisical,  phthisinoid,  or  tuberculous  chest.  (See 
Figs.  126  and  127.)  Although  the  term  tuberculous  is  applied  to  the 
chest  of  this  description,  it  does  not  necessarily  imply  that  an  individual 
with  such  a  chest  has,  or  will  have,  tuberculosis.  It  is  true  that  in 
individuals  with  such  type  of  chest  the  vulnerability  to  the  action  of 
the  tubercle  bacillus  is  more  marked,  and  they  are  more  liable  to  have 
the  disease.  Nevertheless  a  very  large  number  of  individuals  go 
through  life  with  such  chests  and  die  of  other  diseases.  If  they  are 
not  exposed  to  the  infection,  they  will  certainly  escape  the  disease. 

Cause.  Bilateral  diminution  means  diminution  of  contents.  The 
extent  of  air-surface  is  lessened. 

The  Chest  of  Rhachitis.  Another  type  of  diminished  size  of 
chest  is  constantly  referred  to.  It  is  known  as  the  chest  of  rhachitis 
(see  Fig.  129),  and  arises  in  infancy,  on  account  of  this  disease  of 
the  bones.  Many  other  shapes  are  seen,  to  which  various  names  have 
been   given.      Among  the  more   common   is  what   is   known   as  the 


DISEASES  OF  THE  LUNGS  AND  PLEURJE. 


481 


"  pigeon-breast."  (See  Rhachitis,  and  The  Head.)  The  chest  is 
usually  shortened,  the  sternum  is  much  more  prominent  than  in  health, 
the  lower  portion  projecting  to  an  unusual  degree.  The  portion  of 
the  chest  at  the  junction  of  the  cartilages  and  the  ribs  is  depressed. 
This  tends  to  throw  the  sternum  further  outward.  The  transverse 
section  of  such  chest  resembles  a  triangle  with  the  portions  where  the 
base-line  joins  the  ribs  rounded.     (See  Fig.  131.)     The  sternum  is  de- 


FlG.  127. 


Fig.  128. 


The  phthisical  chest.    (Full-blooded  Indian,  Philadelphia  Hospital  ) 


pressed  and  the  osteo-cartilaginous  articulations  are  more  prominent  in 
some  forms  of  rickety  chest.  In  others  the  ribs  and  sternum  from 
above  to  the  fifth  rib  are  prominent,  and  from  thence  downward  to  the 
base  are  drawn  in.  In  the  chest  of  rhachitis  the  costal  angle  is  usually 
very  acute.  (See  Fig.  130.)  It  often  looks  as  if  pressure,  as  by  the 
hands,  had  been  applied  to  the  sides  of  the  chest  about  the  anterior 

31 


482 


SPECIAL  DIAGNOSIS. 


axillary  line,  causing  the  anterolateral  portion  to  sink  inward,  while 
the  antero-inedian  portion  is  projected  forward. 


Fig.  129. 


Transverse  section  of  a  rhachitic  chest  at  level  of  sixth  thoracic  vertebra.    Circumference, 
32%  inches ;  right  half,  16%  inches ;  expansion,  2  inches. 

The  chest  of  rickets  is  attended  by  enlargement  of  the  articulations 
of  the  cartilaginous  and  bony  portions  of  the  rib — the  rhachitic  rosary 
— and  by  changes  in  the  other  bones. 


Fig.  130. 


Fig.  131. 


Chest  of  rhachitis.    (Eichhorst  ) 


Circumference  =  42.75  centimetres. 
Rickety  chest.    Dotted  line  indicates  the  shape  ot 
chest  in  an  infant  about  the  same  age.    (Gee.) 


The  rhachitic  chest  must  not  be  confounded  with  similar  changes  in 
shape  due  to  abnormal  conditions  of  the  upper  respiratory  apparatus 
in  early  childhood.     In  cases  of  adenoid  disease  of  the  pharynx  (see 


DISEASES  OF  THE  LUNGS  AND  PLEURjE. 


483 


Diseases  of  the  Pharynx)  the  change  in  shape  of  the  chest  has  been 
noted. 

The  Transverse  Groove.  This  is  a  depression  observed  in  many 
individuals.  It  extends  from  the  median  line  along  the  base  of  the 
thorax  to  the  axilla  ;  its  upper  limit  is  on  a  level  with  the  xiphoid 
cartilage.  It  slopes  downward  toward  the  axilla.  It  is  caused  in  early 
life  by  the  pressure  of  the  external  columns  of  air  on  the  soft  bony 
thorax  when  the  lungs  are  not  completely  filled  with  air.  Hence,  it 
indicates  nasal,  faucial,  or  bronchial  obstruction  in  early  life,  from 
adenoid  disease,  bronchial  catarrh,  or  other  causes.  It  may  mark  the 
upper  limit  of  the  liver  on  the  right  side  as  it  was  in  infancy. 


Fig.  132. 


.--30 


Unilateral  enlargement  of  chest  (right  side),  artificially  produced  by  injecting  air  into  the  right 
pleural  cavity.  Unbroken  line  :  outline  before  injection.  Broken  line  :  outline  after  moderate 
distention.  Dotted  line :  outline  after  extreme  distention.  Figures  at  bottom  of  vertical  line 
indicate  the  antero-posterior  diameter;  along  horizontal  line,  transverse  semi-diameter ;  remain- 
ing figures,  right  and  left  semi-circumferences.    (Gfe.) 


The  shape  of  the  chest  just  described  (rhachitic)  does  not  indicate 
any  disease  of  the  lungs  ;  it  does  indicate  deficient  respiratory  capacity, 
and  is,  of  course,  the  tell-tale  by  which  rhachitis  of  early  life  or  early 
laryngeal  and  nasal  obstruction  are  recognized. 

Deformities.  The  rhachitic  chest  must  not  be  confounded  with 
deformities  of  the  chest  which  may  be  congenital  in  origin,  the  result 
of  occupation  (shoemaking),  or  of  vertebral  disease  (Pott's  disease). 
The  funnel-breast  (trichterbrust)  is  congenital  and  often  seen  in  several 
members  of  a  family  (Warthin).  It  is  associated  with  other  stigmata 
of  degeneration.  The  lower  sternum  forms  a  deep  concavity.  (See 
Fig.  133.) 

Unilateral  Changes  in  Shape.  Unilateral  Enlargement.  This 
can  usually  be  seen  more  prominently  at  the  base.  The  length  is  in- 
creased. The  ribs  are  elevated,  the  side  more  rounded,  the  costal 
angle  more  obtuse.  The  interspaces  are  frequently  effaced,  or  fuller 
than  on  the  corresponding  side.     The  movement  may  be  increased  or 


484 


SPECIAL  DIAGNOSIS. 


diminished,  depending  upon  the  cause.  The  nipple  is  diplaced  out- 
ward. The  scapula  of  the  affected  side  is  also  displaced  outward,  and 
hence  the  distance  from  it  to  the  spine  is  greater  than  on  the  opposite 
side.     (See  Fig.  132.) 


Funnel-breast  (trichterbrust). 

Cause.  Enlargement  of  one  side  means  enlargement  of  contents. 
It  may  -be  due  "(1)  to  increase  of  the  normal  contents,  as  in  compensa- 
tory emphysema,  in  which  there  is  an  increased  amount  of  air  in  the 
lung,  or  (2)  to  the  presence  besides  of  abnormal  contents,  as  fluid  or 
air  in  the  pleural  sac.  It  is  the  most  characteristic  sign  of  pleural 
effusion.  AVhen  the  normal  contents  are  increased  the  movement  is 
increased  ;  when  the  pleural  cavity  is  filled  it  is  diminished. 

Unilateral  Contraction  or  Diminution  in  Size.  The  costal 
angles  are  sharper,  the  plane  of  the  anterior  or  posterior  portion,  or  of 
both,  is  depressed,  and  approaches  the  transverse  median  plane  of  the 
chest.  (See  Fig.  134.)  The  affected  side  looks  flat  before  and  behind. 
The  semi-circumference  is  lessened,  as  well  as  the  diameter  through 
the  nipple  or  any  fixed  point.  The  interspaces  are  lessened  in  width 
and  may  be  drawn  in.  The  ribs  are  closer  together,  and  may  almost 
overlap.     The  movement  of  the  side  is  lessened. 

Cause.  Any  diminution  of  contents  will  cause  diminution  of  the 
affected  side.  This  may  occur  from  obstruction  or  compression  of  the 
bronchi  of  that  side  lessening  the  amount  of  air  in  that  portion  of  the 


DISEASES  OF  THE  LUNGS  AND  PLEURAE. 


485 


thorax.  Theoretically,  it  may  occur  in  a  case  in  which  there  is  com- 
plete occlusion  of  the  main  bronchus.  The  condition  is  rare,  and  is 
accompanied  by  marked  associate  emphysema  of  the  other  lung.  The 
unilateral  change  is  most  frequently  seen  in  cases  of  chronic  pleurisy 
and  fibroid  phthisis.  A  large  portion  or  even  the  whole  of  the  lung 
may  be  bound  down  and  compressed  by  thickened  adhesions.  The 
pleural  cavity  of  the  side  thus  affected,  save  where  encroached  upon 
by  the  heart  or  by  invasion  of  an  emphysematous  portion  of  the  lung 
of  the  corresponding  side,  is  completely  obliterated. 


Fig.  134. 


Unilateral  retraction  of  chest,  consequent  upon  cirrhosis  of  left  lung,  in  a  girl  of  fourteen  years. 
The  figures  indicate  antero-posterior  and  transverse  diameters  and  semi-circumferences  of  right 
and  left  half  of  chest.    (Gee.) 

Local  Changes  in  Size  and  Shape.  Enlargement  and  diminution 
are  also  seen. 

Local  Enlargement  is  particularly  noted  in  the  region  of  the 
heart  and  great  vessels,  and  will  be  considered  when  this  division  of 
the  subject  is  discussed.  A  local  enlargement  in  the  lower  anterior  or 
lateral  region  of  the  chest  may  occur  in  cases  of  empyema,  in  which 
the  pus  tends  to  be  evacuated,  or  in  pulsating  pleurisy.  Enlargement 
in  diseases  of  the  mediastinum  is  usually  seen  in  the  region  of  the  heart 
and  vessels,  to  which  reference  must  also  be  made. 

Local  Contraction.  This  may  be  seen  either  at  the  apex  or  the 
base.  At  the  apex  the  local  contraction  or  diminution  in  size  is  seen 
above  and  below  the  clavicle.  The  term  flattening  is  applied  to  this 
condition.  The  interspace  is  sunken  and  the  ribs  depressed.  It  may 
be  more  readily  seen  when  looked  at  from  behind.  Flattening  may 
also  be  either  in  the  lateral  or  posterior  region  at  the  base.  The  an- 
terior and  lateral,  or  the  lateral  and  posterior,  region  is  combined  in  the 
local  contraction. 

Cause.  The  physical  condition  is  the  same  as  in  unilateral  or  gen- 
eral contraction — contraction  or  diminution  in  size  of  the  structures 
underneath.  Anything  which  lessens  the  amount  of  air  will  cause 
local  diminution  in  size,  or  flattening  of  the  surface.     This  is  notably 


436  SPECIAL  DIAGNOSIS. 

seen  in  tuberculosis,  in  which  affection  three  processes,  alone  or  in  com- 
bination, lessen  the  amount  of  air :  First,  occlusion  of  the  bronchioles 
by  tubercles  and  by  inflammatory  products,  causing  collapse  of  the 
alveoli ;  second,  the  overgrowth  of  connective  tissue  which  attends  the 
more  chronic  forms  of  tuberculosis  ;  third,  a  localized  pleurisy.  Local 
pleurisy,  with  organization  and  contraction  of  the  inflammatory  exudate, 
also  causes  diminution  of  the  amount  of  air  underneath  the  part,  or 
diminution  of  the  contents  from  compression  of  the  adjacent  lung 
structure.  In  local  contractions  movement  of  the  part  is  generally 
diminished. 

General  Review.  It  must  not  be  forgotten  that  the  element  of 
time  is  necessary  to  produce  changes  in  shape  and  size  of  the  chest, 
with  the  exception  of  unilateral  enlargement.  In  emphysema  the 
change  in  shape  takes  a  long  time  to  develop.  The  unilateral  and  local 
contractions  are  of  slow  progress,  and  hence,  it  must  follow,  require 
more  or  less  chronic  disease  for  their  development.  The  occurrence  of 
pleural  effusion  may  cause  unilateral  enlargement  very  rapidly. 

The  Movements  of  the  Chest  in  Disease.  Bilateral  Changes. 
Frequency.  The  movements  are  increased  in  nearly  all  forms  of 
dyspnoea.  (See  Dyspnoea.)  The  frequency  of  movement  varies  in  many 
affections.  They  are  more  markedly  increased  in  the  acute  lung  affec- 
tions attended  by  fever,  and  are  especially  more  rapid  in  children. 
Increased  frequency  of  respiration  does  not  necessarily  indicate  pulmo- 
nary disease.  It  is  always  seen  in  fever,  and  is  a  marked  phenomenon 
of  hysteria.  Conditions  outside  of  the  chest  increase  the  frequency,  as 
enlargement  of  the  abdomen  from  any  cause  encroaching  upon  the 
capacity  of  the  chest.  The  respirations  are  lessened  in  frequency  in 
cases  of  disease  of  the  medulla  in  which  there  is  pressure  upon  the 
respiratory  centre,  and  in  some  forms  of  poisoning,  as  that  due  to 
opium. 

Alterations  in  the  Rhythm  of  Movement.  Alterations  in 
the  character  and  rhythm  of  the  movement  are  observed  by  inspection. 
(See  Dyspnoea.)  The  movements  may  be  (1)  slow,  and  either  shallow  or 
deep  ;  (2)  rapid  and  shallow  or  deep  ;  (3)  irregular  in  rhythm.  The 
relations  of  the  act  of  inspiration  to  that  of  expiration  in  health  are  as 
5  to  6  ;  in  women,  children,  and  the  aged,  6  to  8.  The  expiration  is 
longer.  The  expiration  may  be  prolonged,  so  that  it  is  far  greater  in 
length  than  inspiration.  Length  of  inspiration  increased.  The  degree 
of  expansion  and  the  duration  of  inspiration  are  increased  when  there 
is  obstruction  in  the  trachea  or  larynx.  Such  increased  expansion  of 
the  upper  chest  is  usually  associated  with  retraction  of  the  soft  parts 
of  the  thorax,  especially  at  the  base.  The  ribs  and  the  tissues  along 
the  margins  of  the  thorax  are  drawn  in  with  each  inspiration.  The 
space  occupied  by  the  lung  above  the  clavicle  may  also  be  retracted. 
The  transverse  groove  is  more  pronounced.  If  the  difficulty  in  breath- 
ing continues,  the  indrawing  becomes  very  marked,  and,  if  the  ribs 
are  soft,  permanent.  Expiration  prolonged.  Inspiration  is  short  and 
quick  in  cases  of  emphysema.  The  expiration  is  correspondingly  pro- 
longed, and  the  muscles  of  expiration  are  seen  to  be  brought  into  full 
action. 


DISEASES  OF  THE  LUNGS  AND  PLEURJE.  487 

In  the  consideration  of  dyspnoea  we  shall  describe  the  appearance 
and  posture  of  the  patient  and  the  action  of  the  muscles  of  respiration. 
(See  Subjective  Symptoms.) 

Irregular  Rhythm.  By  inspection  the  Cheyne-Stokes  type  of 
breathing  can  be  noted.  "  Respiratory  pauses  "  of  half  to  three-quar- 
ters of  a  minute  alternate  with  a  short  period  of  increased  activity,  dur- 
ing which  time  twenty  to  thirty  respirations  occur.  The  respirations 
constituting  this  series  are  shallow  at  first,  but  gradually  they  become 
deeper  and  more  dyspnceic,  and  finally  become  shallow  or  superficial 
again.  The  acts  of  respiration  are  carried  on  by  an  alternation  of 
pauses  and  periods  of  modified  or  "  tidal "  breathing.  Sometimes  con- 
sciousness is  abolished  during  the  pause.  Often  the  pupils  are  con- 
tracted and  inactive.     When  the  respirations  begin  they  dilate. 

Unilateral  Changes  in  Movement.  Increased  movement  of 
one  side  is  seen  when  the  lung  of  that  side  is  acting  vigorously  from 
compensation,  the  other  lung  being  disabled  by  disease.  The  whole 
side  moves  more  rapidly  and  vigorously.  The  increased  movement  is 
associated  with  enlargement  of  the  affected  side  and  hyper-resonance 
on  percussion.  Unilateral  diminution  in  movement  occurs  when  there 
is  diminution  of  the  respiratory  surface,  occlusion  of  the  bronchial 
tubes,  or  from  causes  outside  of  the  lung.  The  air-space  is  lessened  in 
cases  of  pneumonia,  tuberculosis,  or  any  affection  which  fills  bronchi- 
oles and  alveoli  with  inflammatory  exudation  or  fluid.  The  air-space 
is  particularly  lessened  by  the  compression  of  effusions  in  the  pleura, 
of  contracted  and  thickened  exudations,  and  of  adhesions. 

Impaired  motion  due  to  pleural  effusion  is  almost  always  unilateral, 
develops  gradually,  following  an  attack  of  acute  pleurisy,  is  unattended 
by  pain  on  respiration,  but  is  attended  frequently  by  great  embarrass- 
ment of  the  respiration,  and  sometimes  by  orthopncea.  Fever  is  usu- 
ally moderate  in  uncomplicated  cases.  It  is  to  be  recognized  by  the 
clinical  signs  mentioned  and  by  the  physical  signs  of  fluid  in  the 
pleura. 

Impaired  motion  from  chronic  pleurisy  is  of  long  standing  and 
gradual  development.  The  chest-wall  upon  the  affected  side  is  re- 
tracted, and  may  be  very  markedly  sunken.  In  the  absence  of  accom- 
panying lung  trouble  there  is  no  pain  and  no  fever.  It  is  to  be  dis- 
tinguished from  other  types  of  impaired  motion  by  the  sinking  in  of 
the  affected  side,  in  sharp  contrast  with  the  hypertrophy  of  the  other 
side  ;  by  the  absence  of  fever  and  pain  ;  by  its  chronicity  ;  and  by  the 
physical  signs  of  thickened  pleura  and  compressed  lung.  Impaired 
motion  from  'pneumothorax  develops  suddenly,  generally  in  a  person 
with  tuberculosis  of  the  lungs.  Its  appearance  is  usually  precipitated 
by  coughing,  and  its  sudden  development  is  marked  by  intense  pain, 
distention  of  the  affected  side,  great  difficulty  in  breathing,  and  a  very 
anxious  expression  of  countenance.  The  escape  of  air  into  the  pleural 
cavity  is  followed  by  the  development  of  pleurisy  with  effusion,  so  that 
the  affection  presents  the  physical  signs  of  air  and  fluid  in  the  pleural 
cavity. 

The  motion  of  the  affected  side  is  sometimes  impaired  in  pneumonia, 
when  a  large  portion  or  the  whole  of  one  lung  is  involved,  and  the  air- 


488  SPECIAL  DIAGNOSIS. 

vesicles  are  so  occluded  that  very  little  air  can  get  in.  The  physical 
signs  in  these  cases  resemble  those  of  pleurisy  with  effusion  very 
closely,  but  the  diagnosis  can  be  made  by  noting  the  acute  onset  of 
the  disease,  with  high  temperature  and  frequent  respiration,  without 
antecedent  pleurisy,  and  by  the  presence  of  cough  with  expectoration 
containing  the  pneumococcus. 

Occlusion  of  the  bronchus,  with  diminution  of  the  movement  of  the 
corresponding  side,  is  seen  in  rare  cases  in  which  a  foreign  body  fills 
the  lumen  of  the  tube,  or  in  more  common  cases  of  pressure  externally 
upon  the  bronchus  by  an  aneurism  or  mediastinal  tumor. 

Impaired  motion  from  pressure  on  a  bronchus  by  an  aneurism  or 
enlarged  lymph-gland  produces  the  physical  signs  of  collapse  of  the 
lung,  coupled  with  those  peculiar  to  the  cause  of  the  occlusion  of  the 
bronchus.  It  develops  gradually,  the  patient  having  no  pain  in  the 
lung. 

Outside  of  the  lung  lessened  movement  is  caused  by  (1)  interference 
with  the  muscular  activity  of  that  side  from  rheumatism  of  the  inter- 
costal or  respiratory  muscles  ;  (2)  pain  seated  either  in  the  ribs  or  in 
the  pleura.  It  may  be  due  to  acute  pleurisy,  the  patient  checking  the 
motion  of  the  affected  side  as  much  as  possible,  and  breathing  with  the 
abdominal  muscles,  because  chest  respiration  causes  acute  pain.  Im- 
paired motion  from  this  cause  or  from  pleurodynia  may  be  suspected 
when  it  has  come  on  suddenly,  and  when  respiration  causes  acute  suffer- 
ing, usually  depicted  in  the  face.  Pleurodynia  and  pleurisy  are  to  be 
distinguished  from  each  other  by  the  presence  in  the  one  case  of  tender 
muscles,  a  more  constant  and  less  stabbing  pain,  and  absence  of  fever, 
cough,  and  rales;  and,  in  the  case  of  pleurisy,  by  the  occurrence- of 
stabbing  pain  in  respiration,  absence  of  local  tenderness,  and  presence 
of  fine,  dry,  or  coarse  rales  on  inspiration,  with  cough  and  fever. 

Local  diminution  of  the  movement  or  deficient  expansion  occurs 
under  the  same  conditions  that  produce  flattened  and  local  contraction, 
and  for  the  same  reason.  Hence  deficient  expansion  is  observed  in  the 
early  stages  of  phthisis,  or  in  local  pleurisies. 

Impaired  motion,  due  to  consolidation  of  the  lung  in  tuberculosis,  is 
usually  limited  to  one  of  the  apices,  and  is  accompanied  by  flatten- 
ing of  the  affected  apex  and  emaciation.  The  condition  is  of  gradual 
development,  and  presents  the  usual  signs  of  tubercular  consolidation 
of  the  lungs  (q.  v.). 

Sometimes  the  impaired  motion  and  flattening  are  due  to  a  super- 
ficial cavity  from  tuberculosis  or  abscess,  and  when  the  walls  are  very 
thin  they  may  be  seen  to  flap  feebly  with  respiration. 

Rarer  causes  of  impaired  motion  of  the  lung  are  cancer  and  hydatid 
cyst  (q.  v.). 

Fluoroscopic  or  X-ray  Examination.  Through  the  efforts 
of  Williams,  Leonard  and  others  the  X-ray  has  become  an  aid  to  the 
diagnosis  of  pulmonary  affections.  F.  H.  Williams  has  paid  especial 
attention  to  thoracic  diseases.  I  quote  from  some  of  his  brilliant  studies 
the  results  secured  by  such  examination  of  the  lungs  : 

"  In  health  the  lungs  are  readily  traversed  by  the  ray  ;  they  appear 
in  the  fluoroscope  as  light  areas  on  either  side  of  the  backbone  and 


DISEASES  OF  THE  LUNGS  AND  PLEUBJE.  489 

the  heart,  The  lower  portions  of  the  lungs,  bounded  by  the  dia- 
phragm, are  seen  to  move  up  and  down  through  a  distance  of  about  half 
an  inch  during  quiet  breathing,  and  to  descend  during  full  inspiration 
to  a  point  about  two  and  one-half  inches  below  its  level  in  expiration. 
The  pulmonary  is  lighter  in  deep  inspiration  than  during  expiration. 
There  are  three  principal  ways  in  which  the  fluoroscope  may  lead  us 
to  suspect  disease  in  the  chest :  (1)  The  appearance  of  the  dark  areas 
which  occur  in  tuberculosis,  pneumonia,  carcinoma,  diaphragmatic 
hernia,  gangrene  of  the  lungs,  and  in  echinococcus  cyst,  infarction, 
pleurisy,  empyema,  etc.,  due  to  the  increase  in  density,  which,  by  ob- 
structing the  passage  of  the  ray,  diminishes  the  normal  brightness  in 
the  chest  or  changes  its  normal  outlines  ;  (2)  the  occurrence  of  abnor- 
mal brightness  which  is  found  in  emphysema  and  pneumothorax  con- 
sequent upon  decrease  in  density,  which  makes  the  lung  area  appear 
lighter  than  in  health  as  seen  in  the  fluoroscope  ;  (3)  the  restriction  of 
the  maximum  excursion  of  the  diaphragm  and  its  altered  position  and 
curve  from  that  observed  in  health." 

In  tuberculosis  the  consolidated  portion  of  the  lung  appears  darker 
than  normal  in  the  fluoroscope.  The  expansion  of  the  lung  is  reduced. 
The  excursion  of  the  diaphragm  downward  is  diminished  during  full 
inspiration,  but  this  muscle  is  carried  up  into  the  thorax  as  high,  or  it 
may  be  even  higher  than  in  health.  From  time  to  time  the  fluoro- 
scopic pictures  show  the  apex  of  one  lung  darker,  as  already  stated  ; 
the  clavicle  and  upper  ribs  less  marked  on  the  diseased  than  on  the 
normal  side  ;  the  darker  area  extending  more  and  more  as  the  disease 
progresses.  Then  the  apex  of  the  other  lung  begins  to  darken  and  this 
area  continues  to  extend.  The  diminishing  excursion  of  the  dia- 
phragm, which  is  also  a  characteristic  feature  of  this  disease,  may  like- 
wise be  observed,  and  sometimes  may  be  the  earliest  sign. 

In  pneumonia  the  affected  areas  are  easily  recognized  in  the  fluoro- 
scope, and  in  a  central  pneumonia  may  be  seen  when  auscultation  and 
percussion  do  not  reveal  them.  The  excursion  of  the  diaphragm  is 
also  restricted,  and  the  heart  may  be  much  displaced  to  the  right,  if 
the  pneumonia  is  only  on  the  left  side.  A  secondary  empyema,  fol- 
lowing pneumonia,  can  be  seen  by  the  X-ray.  The  pleuritic  effusion 
which  sometimes  accompanies  pneumonia  may  be  proved  to  exist  if  a 
dark  area  and  the  outline  of  the  diaphragm  below  the  dark  pneumonic 
portion  is  not  visible  in  the  fluoroscope. 

In  both  these  affections  the  outlines  of  the  lower  part  of  the  chest 
are  dulled  or  obliterated,  especially  the  diaphragm  line.  If  the  effusion 
is  large  the  whole  chest  is  dark,  and  the  heart  and  mediastinum  are 
displaced.  In  a  circumscribed  pleurisy  or  empyema  an  exploring 
needle  may  fail  to  reach  the  desired  spot,  but  we  may  sometimes,  by 
means  of  the  fluoroscope,  exactly  outline  the  limits  of  the  fluid. 

Lungs  that  are  less  dense  than  normal,  as  in  emphysema,  give  a 
brighter  area  than  in  health,  and  the  distended  lung  reaches  lower  in 
the  chest  than  normal.  The  maximum  excursion  of  the  diaphragm  is 
much  less  than  in  health,  as  this  muscle  does  not  rise  so  high  in  expi- 
ration. These  two  signs  are  characteristic  of  emphysema.  The  en- 
larged ventricles  and  also  the  dilated  right  auricle  are  seen  in  late 


490  SPECIAL  DIAGNOSIS. 

stages  ;  the  heart  also  lies  in  a  more  vertical  direction,  and  its  position 
is  not  much  changed  by  a  deep  inspiration. 

In  pneumothorax  the  diaphragm  is  very  low,  loses  its  normal  curve 
and  movement  on  the  affected  side,  and  the  heart  and  mediastinum 
are  seen  to  be  displaced  to  the  healthy  side. 

Palpation.  By  palpation  the  results  of  inspection  are  confirmed, 
the  character  and  consistence  of  tumors  ascertained,  the  vocal  fremitus 
determined,  and  fluctuation  detected. 

Method.  The  surface  should  be  bared,  although  the  fremitus  can 
be  detected  through  a  thin  layer  of  linen  or  gauze.  To  detect  the 
fremitus  in  front,  it  is  often  well  to  stand  behind  the  patient,  with  the 
palms  of  the  hands  placed  over  the  surface  of  the  chest  in  front.  The 
opposite  position  is  taken  to  detect  the  fremitus  behind.  The  axillary 
region  must  also  be  investigated.  The  hands  should  be  warmed  and 
applied  evenly  to  the  surface.  The  two  sides  must  constantly  be  com- 
pared, either  by  simultaneous  application  of  the  hands  on  the  two 
sides,  or  by  applying  the  hand  first  on  one  side,  then  on  the  other. 

The  Vocal  Fremitus.  Cause.  The  columns  of  air  in  the  bronchial 
tubes  are  thrown  into  vibration  during  the  act  of  speaking.  The  vibra- 
tions are  transmitted  to  the  hand  on  the  surface  of  the  chest.  They 
are  known  as  the  vocal  fremitus.  In  infants  the  cry  must  be  relied 
upon  instead  of  the  spoken  voice. 

The  fremitus  on  the  right  side  at  the  apex  is  stronger  than  on  the 
left,  because  the  right  bronchus  is  larger  than  the  left,  its  angle  with 
the  trachea  is  more  acute,  and  the  bronchus  going  to  the  right  upper 
lobe  is  two  and  one-half  inches  nearer  the  larynx  than  the  left  (Cary, 
Ewart).  The  fremitus  is  stronger  in  persons  with  deep,  low-pitched 
voices,  because  the  vibrations  are  not  so  rapid.  It  is  more  distinct, 
therefore,  in  males  than  in  females,  and  in  individuals  with  a  bass 
voice.  The  vocal  fremitus  is  felt  more  distinctly  in  persons  with  thin 
chest-walls.  Thick  chest- walls  and  large  mammarv  glands  interfere 
with  the  transmission  of  fremitus.  The  fremitus  is  not  disthict  in 
children  because  the  vibrations  are  too  rapid. 

It  is  well  to  become  familiar  with  the  vibrations  produced  by  fixed 
monotones,  in  order  to  appreciate  the  fremitus.  The  patient  is  asked 
to  count  one,  two,  three,  or  to  repeat  ninety-nine. three  or  four  times. 
It  is  well  to  observe  a  fixed  rule  as  to  the  words  used,  in  order  to  have 
definitely  in  the  mind  the  character  of  the  vibrations  in  health,  and 
the  departures  from  the  normal  in  disease. 

Vocal  Fremitus  in  Disease.  The  vocal  fremitus  may  be  increased, 
may  be  diminished,  or  may  be  absent. 

Vocal  Fremitus  Increased.  When  the  lung  is  consolidated, 
vibrations  are  transmitted  to  the  hand  with  greater  force.  Fremitus 
is  increased  in  all  consolidations,  as  in  pneumonia,  tuberculosis,  and 
hemorrhagic  infarct.  (See  Fig.  135.)  The  fremitus  may  be  absent 
in  rare  cases  of  pneumonia,  in  which  the  large  tubes  are  occluded  by 
exudate.  The  fremitus  is  increased  in  the  later  stages  of  tuberculosis, 
when  cavities  have  formed,  if  the  walls  are  dense. 

Vocal  Fremitus  Diminished.  Anything  intervening  between 
the  lung  and  the  surface  of  the  chest  which  interferes  with  the  conduc- 


DISEASES  OF  THE  LUNGS  AND  PLEURJE. 


491 


tion  of  the  vibrations  diminishes  the  fremitus.  The  fremitus  is  dimin- 
ished in  cases  of  thickened  pleura,  and  in  thin  layers  of  pleural  effu- 
sion. The  fremitus  is  lessened  if  the  columns  of  air  in  the  bronchi 
are  smaller  on  account  of  diminution  in  the  calibre,  as  in  bronchitis  or 
in  emphysema  and  asthma.  The  fremitus  is  lessened  in  cavities  filled 
with  fluid,  or  when  the  bronchus  is  occluded. 

Vocal  Fremitus  Absent.  1.  The  vocal  fremitus  is  absent  when 
the  columns  of  air  are  obstructed  entirely  by  occlusion  of  the  bronchus, 
as  by  the  external  pressure  of  a  tumor,  aneurism,  or  enlarged  gland.  2. 
The  fremitus  is  absent  in  accumulations  in  the  pleura  of  air  or  of  fluid, 
causing  interference  with  the  vibrations.  (See  Fig.  136.)  The  well- 
known  illustration  of  striking  a  stone  underneath  the  surface  of  the 
Avater  implies.  If  the  ear  of  the  listener  is  above  the  water,  the  sound 
cannot  be  heard.  If'  the  ear  is  underneath  the  water,  the  sound  is 
heard  a  long  distance  from  its  origin.  Vocal  fremitus  is  absent  in 
pneumothorax,  in  hydrothorax,  in  pyothorax,  and  in  hemothorax. 
The  same  physical  condition  is  present  when  the  pleura  is  greatly 
thickened,  and  hence  the  fremitus  is  also  absent. 


Fig.  135. 


Fig.  136. 


Consolidation :  Pneumonia.    Vocal  fremitus 
increased.    (Gibson  and  Russell.) 


Pleural  effusion.    Vocal  fremitus  absent 
at  a.    (Gibson  and  Russell.) 


The  vibrations  produced  by  the  passage  of  air  through  mucus  or 
fluid  in  the  bronchial  tubes  are  transmitted  to  the  hand  when  it  is  laid 
on  the  surface  of  the  chest.  It  is  known  as  the  rhoTichicd  fremitus. 
They  are  felt  during  inspiration.  They  may  be  felt  all  over  the  chest 
in  bronchitis,  or  in  asthma,  as  distinct  vibrations,  sometimes  coarse,  or 
again  fine,  indicating  rapidity  of  movement.  The  vibrations  may  be 
transmitted  over  a  Realized  area  in  phthisis,  due  to  air  passing  through 
fluid  in  the  cavity.  They  are  distinct  in  children  in  cases  of  bron- 
chitis, and  are  often  the  source  of  much  alarm  to  the  parents. 

Friction-fremitus.  An  exudation  of  lymph  on  the  surface  of  the 
pleura  often  causes  a  vibration  which  may  be  transmitted  to  the  hand. 


492  SPECIAL  DIAGNOSIS. 

It  is  known  as  a  friction-freinitus,  and  is  felt  in  inspiration.  It  is 
usually  felt  at  the  base  of  the  chest,  in  front,  laterally,  or  posteriorly. 
It  is  not  modified  by  coughing,  and  is  increased  by  full  breathing. 
The  rhonchi,  on  the  other  hand,  are  influenced  by  cough  and  breathing. 

Fluctuation  is  detected  by  palpation  in  some  cases  of  effusion, 
particularly  if  the  intercostal  spaces  are  swollen  and  tense,  or  if  an 
empyema  is  about  to  point.  In  rare  instances  it  may  be  detected  by 
striking  the  chest  opposite  the  palpating  hand. 

Percussion.  By  percussion,  (1)  sounds  are  elicited,  (2)  the  degree 
of  resistance  to  the  percussing-finger  estimated.  When  a  part  is  per- 
cussed the  sounds  produced  are  noises  or  tones.  If  a  tone,  the  vibra- 
tions are  uniform  and  will  be  in  unison  with  a  tuning-fork  ;  if  a  noise, 
the  vibrations  produced  are  without  uniformity.  We  speak  of  the 
pitch,  the  volume,  the  duration,  and  the  quality  of  the  sound.  The 
pitch  depends  upon  the  rapidity  of  vibrations,  the  number  that  occur 
in  a  definite  period  of  time.  It  may,  therefore,  be  high  or  low.  In 
sounds  that  are  high  in  pitch  the  vibrations  are  rapid.  In  sounds 
that  are  low  in  pitch  the  vibrations  are  correspondingly  slower  in  the 
same  period  of  time.  The  volume  or  intensity  of  the  sound  depends 
upon  the  amplitude  of  the  vibrations,  and  varies  directly  as  the  square 
of  the  amplitude.  It  is  modified  by  the  degree  of  force  used  in  the 
production  of  the  sound.  ' '  Duration  "  explains  itself.  These  charac- 
teristics bear  certain  relationships.  Sounds  that  are  high  in  pitch  are 
of  diminished  volume  or  intensity,  and  of  short  duration.  The  accom- 
panying diagram  shows  the  relation  of  the  characters  of  the  sound. 
(See  Fig.  137.)     On  the  other  hand,  sounds  that  are  low  in  pitch  have 

Fig.  137. 


Dull  tone. 

Tracheal  or  tubular  tone. 


Resonant  tone. 

Tympanitic  tone. 


Volume  and  duration. 
Diagrammatic  sketch  of  the  relations  of  the  character  of  tone.    The  perpendicular 
line  represents  the  pitch.    The  transverse  line  the  volume  and  duration. 

correspondingly  greater  volume  or  intensity  and  longer  duration.  The 
three  characteristics  determine  the  quality  of  the  sound.  The  term 
' '  clearness  "  is  applied  to  sounds  which  have  the  character  of  tones. 
They  are  low  in  pitch,  of  good  volume,  and  long  duration.  Sounds 
that  are  high  in  pitch,  of  small  volume,  and  short  duration  are  of  a 
dull  quality.  Xoises,  highest  in  pitch  and  least  in  volume  and  dura- 
tion, are  absolutely  dull  or  flat.  The  former  are  indicative  of  the  pres- 
ence of  air ;  the  latter,  of  the  absence  of  air.  The  tones,  or  clear 
sounds,  are  naturally  produced  over  structures  containing  air.     The 


DISEASES  OF  THE  LUNGS  AND  PLEUBJS.  493 

production  of  a  tone  implies  the  presence  of  air  in  a  sac.  Structures 
in  which  the  proportion  of  air  to  solid  material  varies  yield  sounds 
which  vary  between  clearness  and  muffling,  to  absence  of  tone  or  dul- 
ness.  Resonance  and  tympany  are  clear  sounds  which  will  be  ex- 
plained later. 

Method  of  Procedure.  Due  attention  should  be  paid  to  the 
presence  or  absence  of  tenderness,  which  necessarily  modifies  the  results 
obtained  by  this  method  of  exploration.  Definite  information  can  be 
secured  by  light  percussion,  even  when  there  is  a  good  deal  of  tender- 
ness. In  children  percussion  should  be  the  final  step  in  the  examina- 
tion. 

Immediate  Percussion.  The  chest  may  be  tapped  by  the  finger 
or  hand  directly.  This  was  the  original  method  of  percussing  the 
chest.  It  is  known  as  the  immediate  method.  When  the  fingers  are 
employed  it  is  known  as  palpatory  percussion.  One  finger  is  sufficient. 
The  pulp,  as  most  sensitive,  may  give  the  blow.  Or  the  tip,  the  finger 
bent  at  a  right  angle,  may  be  used.  By  this  method  the  sense  of  resist- 
ance is  better  appreciated. 

Mediate  Percussion.  The  method  now  employed  is  that  in  which 
a  medium  is  placed  between  the  chest- wall  and  the  instrument  used  for 
percussing.  This  medium  is  called  a  pleximeter.  It  may  be  a  small 
plate  of  ivory  of  suitable  size  to  place  between  the  ribs,  or,  better  still, 
the  fingers  of  the  hand  not  used  in  tapping.  The  plessor  is  used  to 
create  the  sound.  It  may  be  a  small  hammer.  The  one  usually  selected 
is  of  moderate  weight,  has  a  firm,  light,  slightly  flexible  handle  and 
metal  head,  the  poles  of  which  are  tipped  with  rubber.  For  purposes 
of  class  demonstration  a  plessor  of  this  character,  with  an  ivory  plex- 
imeter, is  of  value  ;  but  for  bedside-work  the  fingers  of  the  physician 
are  better. 

The  Use  of  the  Pleximeter.  The  pleximeter  must  be  placed 
in  close  contact  with  the  surface  of  the  chest  in  performing  percussion. 
If  the  finger  is  used  as  a  pleximeter,  in  percussing  the  anterior  portion 
of  the  chest,  for  instance,  it  must  be  placed  parallel  with  the  ribs.  It 
must  not  cross  them.  If  it  is  not  in  close  contact  with  the  chest,  the 
cushions  of  air  between  the  two  will  modify  the  sound,  so  that  accurate 
data  are  not  obtained.  Interspace  after  interspace  should  be  percussed 
in  this  mauner  from  above  downward.  At  the  same  time,  if  neces- 
sary, the  pleximeter  may  be  placed  over  the  corresponding  ribs,  but 
parallel  with  them.  With  a  little  practice  the  method  of  applying  the 
pleximeter  can  soon  be  acquired. 

The  Use  of  the  Plessor.  This  requires  considerable  practice  on 
the  part  of  the  student.  If  a  metal  instrument  is  used,  care  should  be 
taken  to  acquire  the  habit  of  percussing  under  all  circumstances  with 
the  same  degree  of  force.  If  the  finger  of  the  operator  is  employed  as 
a  plessor,  several  points  in  the  procedure  must  be  remembered.  It  is 
better  to  use  one  finger,  preferably  the  middle  finger.  Some  operators 
use  more  than  one  finger,  but  with  a  little  practice  a  sufficient  degree 
of  force  can  be  given  with  one  to  elicit  the  sounds  essential  for  distinc- 
tion. The  finger  should  be  bent  at  right  angles  and  kept  in  a  fixed 
position.     It  must  be  made  to  strike  the  pleximeter  perpendicularly 


494  SPECIAL  DIAGNOSIS. 

to  its  plane.  If  the  blow  is  given  at  any  other  angle  to  the  part  per- 
cussed, a  true  sound  cannot  be  obtained.  The  blows  must  be  regular 
and  the  force  even.  The  character  of  the  part  investigated  will  deter- 
mine the  degree  of  force  that  should  be  used.  (See  Method  of  Percus- 
sion, page  493.)  The  force  of  the  blow  is  to  come  from  the  wrist  alone, 
neither  the  arm  nor  the  forearm  must  come  into  play.  Beginning 
anteriorly  with  the  supraclavicular  fossse,  and  proceeding  downward 
an  interspace  at  a  time,  comparison  should  be  made  with  the  other  side 
at  each  step.  The  axillary  portions,  and  the  posterior  portions  from 
supraspinous  fossa?  to  base,  should  then  be  examined  in  the  same  way. 

Hearing  and  Feeling  Combined.  Another  excellent  plan  is  to  secure 
information  by  the  sense  of  touch,  as  well  as  by  the  sound.  The 
second,  third,  and  fourth  fingers  of  the  percussing  hand  are  flexed  at 
an  angle  of  45  degrees.  The  tips  are  brought  down  on  the  pleximeter 
finger  and  kept  there  for  a  few  seconds,  when  the  blow  may  be  re- 
peated. The  perpendicular  blow  is  not  used.  The  sound  produced 
is  not  loud.  It  is  most  useful  in  diseases  of  the  lungs,  spleen,  and 
liver,  and  where  strong  percussion  cannot  be  used,  as  in  perityphlitis 
and  cholecystitis. 

Position  of  the  Patient.  The  best  position  is  the  standing  one, 
with  the  arms  allowed  to  drop  loosely  at  the  sides,  the  head  straight, 
not  thrown  back,  and  the  shoulders  allowed  to  fall  a  little  forward  if 
they  are  inclined  to  do  so.  Any  position  which  throws  the  chest-mus- 
cles into  contraction  tends  to  defeat  the  object  of  the  examiner  who 
seeks  to  elicit  the  chest-sounds.  In  percussing  the  posterior  portions 
of  the  chest  it  is  desirable  to  have  the  patient  stoop  forward  with  arms 
folded.  While  this  renders  the  muscles  more  tense,  it  has  the  advan- 
tage of  exposing  a  larger  portion  of  the  chest. 

When  the  patient  is  confined  to  bed  he  should,  if  not  too  ill,  be 
allowed  to  sit  up  during  percussion,  as  contact  with  the  bed  or  with 
pillows  deadens  the  sounds  elicited.  This  fact  should  be  borne  in  mind 
when  from  any  cause  it  is  not  desirable  to  have  the  patient  sit  up. 

All  clothing  should  be  removed,  if  possible.  A  thin  undershirt  may 
be  permitted  from  motives  of  delicacy,  or  parts  oidy  of  the  chest  be 
exposed  at  one  time  if  there  be  danger  of  chill. 

The  Sounds  in  Health.  Four  types  of  sounds  can  be  produced  by 
percussing  over  the  trunk  for  the  purpose  of  study.  1.  Resonance 
over  the  lungs.  2.  Tympany  over  the  caecum.  3.  A  modified  tym- 
panitic or  so-called  tubular  or  tracheal  sound  over  the  trachea.  4. 
Dolness  over  the  heart.  Modifications  of  these  types  represent  all 
sounds  produced  under  every  variety  of.  circumstances.  They  will  be 
considered  in  the  order  of  their  importance.  The  term  resonance  is 
applied  to  the  clear  sound  that  is  produced  over  the  lungs  on  percus- 
sion. It  is  due  to  the  vibration  of  the  chest- walls  and  of  the  air  in 
the  bronchi.  ' :  Pulmonary  resonance  "  is  a  term  also  used  to  indicate 
the  same  sound.  While,  as  stated  above,  the  sound  produced  is  called 
a  tone,  yet  on  account  of  the  relation  of  the  air  to  the  solid  structure 
of  the  lung,  the  air  being  confined  in  innumerable  sacs,  a  true  tone  is 
not  produced — i.  e.,  the  sound  cannot  be  pitched  with  another  tone  or 
made  to  vibrate  in  unison  with  one.     For  practical  purposes,  however, 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  495 

the  term  ' '  tone  "  may  be  used  convertibly  with  ' '  clearness  "  and 
"  resonance."  Its  characteristics  cannot  be  denned  accurately,  and 
must  be  learned  by  repeated  practice. 

Modifications  in  Health.  The  degree  of  clearness  or  resonance 
differs  in  various  parts  of  the  thorax.  It  is  purer  in  the  upper  axil- 
lary region,  at  the  angle  of  the  scapula  behind,  and  on  the  anterior 
surface  of  the  chest,  in  the  second  interspace.  It  is  slightly  higher  in 
pitch  at  the  right  than  at  the  left  apex.  It  is  modified  by  the  condi- 
tion of  the  chest-walls.  Thick  chest-walls,  accumulations  of  fat,  the 
mammary  gland,  and  the  scapula?  impair  the  resonance  and  necessitate 
deep  percussion  to  bring  out  the  true  sounds.  In  persons  with  thin 
chest-walls  the  resonance  is  clear  and  more  pronounced.  The  elasticity 
of  the  chest-walls  also  modifies  it.  In  the  aged  it  is  less  clear  because 
of  rigid  chest-walls.  In  children,  in  whom  the  chest-walls  are  elastic, 
the  resonance  is  much  fuller  or  clearer,  and  approaches  more  nearly  the 
character  of  a  tone.  The  sounds  vary,  within  certain  limits,  in  different 
individuals  with  perfectly  healthy,  normal  chests,  as  may  be  seen  from 
the  above.  Moreover,  a  sound  normal  in  one  part  of  the  chest  may 
in  another  part  indicate  disease. 

It  follows  that  percussion-sounds  do  not  have  an  absolute  value ; 
their  significance  depends  upon  the  individual  and  upon  the  part  of  the 
chest  examined.  The  student  should  learn  from  the  outset  to  com- 
pare the  sounds  developed  by  percussion  of  symmetrical  portions  of 
the  chest,  and  thus  determine  the  normal  for  the  individual.  Below 
the  third  rib  on  the  left  side  the  dulness  of  the  heart  destroys  the  value 
of  comparative  percussion.  Significance :  Excess  of  clearness  or  reso- 
nance— hyper-resonance — means  excess  of  air,  as  in  vicarious  emphys- 
ema. Diminution  of  clearness  means  diminution  of  air — increase  of 
solid  structure. 

Abnormal  changes  in  resonance  caused  by  disease  will  be  considered 
later. 

Tympany.  When  a  single  cavity  with  smooth  walls,  containing 
air,  is  percussed,  the  sound  that  is  produced  is  a  tone  of  low  pitch,  of 
considerable  volume  or  intensity  and  of  long  duration.  The  term 
"tympany"  is  applied  to  this  sound.  In  health  it  can  be  elicited 
over  the  stomach  when  it  is  free  from  food,  over  the  large  intestine, 
and  at  times  over  the  small  intestine.  In  addition  to  the  low  pitch 
and  large  volume,  it  possesses  a  peculiar  metallic  quality  which  is 
characteristic.  It  may  be  said  to  be  a  "hollow"  sound.  It  is  a 
quality  of  sound  with  which  the  student  should  become  familiar,  for 
variations  are  characteristic  of  abnormal  physical  conditions  in  the 
lung  and  in  the  abdomen.  It  must  be  remembered  that  tympany  can 
be  developed  normally  over  the  posterior  portions  of  the  lungs  of  in- 
fants and  children.  The  relation  of  this  sound  to  resonance,  or  the 
sound  produced  on  percussing  the  healthy  lung,  and  to  dulness  pro- 
duced over  airless  structures,  may  be  appreciated  by  reference  to  the 
diagram  modified  from  Gee.  (See  Fig.  137.)  In  pitch,  in  volume,  and 
in  duration  it  is  lower  than  the  resonant  and  tracheal  tones.  The  latter 
stands  midway  between  tympany  and  dulness.  As  intimated  pre- 
viously, all  varieties  of  sounds  that  may  be  produced,  and  which  occupy 


496  SPECIAL  DIAGNOSIS. 

positions  between  the  extremes  noted  in  the  triangle,  are  dependent 
entirely  upon  the  proportion  of  air  to  solid  material. 

The  tracheal  tone  is  a  clear  tone  produced  over  the  trachea  when  the 
mouth  is  open  moderately.  It  is  clear,  higher  in  pitch  than  resonance, 
and  of  a  tympanite  or  tubular  quality. 

Dulness.  The  sound  over  the  heart  is  dull,  and  may  be  useful  to 
compare  with  dull  sounds  yielded  over  areas  usually  resonant.  If  a 
dull  sound  has  some  pitch  and  duration,  some  tone  is  mingled  with  it. 
If  dulness  is.  absolute,  it  is  without  pitch  and  is  a  noise.  The  signifi- 
cance of  dulness  has  been  described  ;  it  means  the  absence  of  air.  Ab- 
solute dulness  implies  that  the  airless  part  underneath  is  in  immediate 
contact  with  the  surface  of  the  chest.  Relative  dulness  implies  the  in- 
terposing of  air-containing  structures  between  the  airless  structure  and 
the  chest-wall.  The  portion  of  the  heart  or  liver  in  contact  with  the 
chest-wall  yields  absolute  dulness  when  percussed ;  the  portion  over- 
lapped by  lung  yields  relative  dulness.  Absolute  dulness  is  readily 
elicited,  and  with  ordinary  percussion  is  a  fixed  area.  All  observers 
will  usually  secure  the  same  size  of  absolute  cardiac  dulness,  for  in- 
stance. Relative  dulness  depends  so  much  upon  the  method  of  per- 
cussion, light  or  strong,  and  upon  the  ear  of  the  observer,  that  for  its 
extent  each  observer  will  have  a  different  opinion.  The  personal 
equation  is  a  disturbing  factor  in  the  estimation  of  its  extent.  It  must 
be  remembered  in  disease  of  the  lungs,  of  the  bloodvessels,  and  medi- 
astinum the  location  of  the  lesion  is  usually  made  out  by  the  detection 
of  relative  dulness,  or  of  changes  in  the  pitch,  quality,  and  duration  of 
the  sound,  indicating  less  air  in  the  part  percussed.  Such  changes  are 
more  diagnostic  if  the  effects  of  breathing  (respiratory  percussion),  of 
the  position  of  the  patient,  and  of  the  force  of  percussion  (light  or 
strong)  are  considered. 

The  Pitch.  The  estimation  of  the  pitch  of  the  sound  is  of  the 
highest  importance.  It  is  the  one  distinctive  attribute  or  characteristic 
which  is  of  special  diagnostic  significance  as  to  the  physical  condition 
of  the  part.     It  requires  considerable  practice  to  estimate  it  correctly. 

Its  significance  in  relation  to  dulness  and  tympany  has  been  men- 
tioned. Although  a  high-pitched  sound  may  be  considered  a  dull 
sound,  this  is  not  necessarily  so.  A  sound  of  high  pitch  need  not  be 
markedly  dull — indeed,  it  may  be  moderately  clear.  Under  the  right 
clavicle  in  health  the  pitch  is  higher  than  under  the  left,  but  not  dull 
in  character. 

The  student  may  become  familiar  with  the  pitch,  and  with  altera- 
tions in  it,  by  percussing  over  a  portion  of  the  lung  clearly  resonant, 
as  in  the  third  interspace  and  thence  downward  on  the  right  side.  As 
the  interspaces  in  apposition  with  the  liver  are  reached  the  pitch 
changes.  The  fulness  of  the  sound  is  lessened  ;  it  becomes  more 
shallow.  The  increase  in  rapidity  of  the  vibrations  can  almost  be 
appreciated,  and,  as  they  increase,  the  heightened  pitch  caused  by  them 
is  recognized.  This  normal  increase  in  pitch  is  due  to  a  thin  layer  of 
lung  backed  up  behind  by  the  solid  liver.  Change  in  pitch  makes  it 
possible  to  outline  organs  and  pursue  topographical  percussion. 

The  Degree  of  Resistance.  This  is  estimated  by  the  sense  of 
touch.     When  organisms  containing  air  are  percussed  the  resistance 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  497 

appreciated  by  the  finger  percussed  is  small,  or,  indeed,  may  be  said 
to  be  absent  entirely.  The  sensation  of  the  finger  is  as  if  the  parts 
underneath  bounded  away.  When  the  air  decreases  and  the  propor- 
tion of  solid  structure  increases  more  resistance  is  felt.  It  is  of  the 
greatest  importance  to  carefully  educate  the .  finger  in  this  sense  of 
resistance.  It  is  often  difficult  to  determine  the  pitch  exactly,  and  the 
sense  of  resistance  furnishes  an  additional  means  of  detecting  the  pres- 
ence or  absence  of  solid  structure.  Palpatory  percussion  indicates 
the  sense  of  resistance  to  a  better  degree  than  any  other  method. 

Superficial  and  Deep  Percussion.  In  superficial  percussion  the 
blows  are  directed  lightly  over  the  part  percussed,  so  as  to  bring  out 
the  sound  yielded  by  the  portion  directly  underneath  the  surface. 
Hence  superficial  percussion  is  applicable  over  the  thinner  portions  of 
the  lung.  It  enables  one  to  bring  out  areas  of  absolute  dulness. 
Light  percussion  is  necessary  in  children  and  in  patients  with  sore 
chest-walls,  or  when  they  have  just  had  a  hemorrhage.  In  deep  per- 
cussion the  blows  are  given  with  enough  force  to  influence  the  struc- 
tures situated  deeply  in  the  lung  or  overlapped  by  the  edges  of  the 
lung.  It  is  necessary,  therefore,  in  cases  of  deep-seated  consolidation, 
and  in  cases  of  aneurism  covered  by  lung,  in  order  to  define  its  limits. 
It  is  employed  to  determine  the  true  height  of  the  liver  and  the  relative 
area  of  dulness  of  the  heart. 

Auscultatory  or  Stethoscopic  Percussion.  This  is  a  valuable 
means  of  defining  the  exact  outline  of  a  dull  area,  as  an  aneurism  or 
tumor  within  the  chest,  or  of  determining  the  limits  of  organs  even 
of  similar  physical  structure.  The  stethoscope  is  placed  over  the  organ 
the  border  of  which  is  to  be  defined,  and  percussion  is  begun  some 
distance  from  it.  It  is  conducted  toward  the  stethoscope,  and  the  dull 
sound  of  the  non-resonant  structure  is  transmitted  to  the  ear  beyond 
limits  not  determined  by  ordinary  methods.  If  the  tympany  of  the 
stomach  is  to  be  distinguished  from  the  tympany  of  the  colon,  place 
the  stethoscope  over  either  one  of  the  organs.  Percuss  with  the  finger- 
tips directly  on  the  surface  by  immediate  percussion.  Begin  at  the 
stethoscope  and  percuss  from  it.  As  soon  as  the  limit  of  the  structure 
percussed  is  reached  a  difference  of  tone  or  pitch  is  observed  which 
cannot  be  detected  by  other  means.  In  this  manner  the  dulness  of  the 
liver  can  be  told  from  that  of  pulmonary  consolidation  or  pleural  effu- 
sion ;  the  dulness  of  an  effusion  from  a  consolidation  of  the  lung  which 
rises  higher  than  the  effusion,  as  in  pleuropneumonia.  Mediate  per- 
cussion may  also  be  employed. 

Respiratory  Percussion.  (Da  Costa.)  The  difference  in  the  sound 
elicited  in  full  inspiration  and  in  full  expiration  is  marked  in  health. 
In  general  it  may  be  said  the  sound  becomes  more  resonant  and  higher 
in  pitch  in  full  inspiration.  In  ordinary  bronchitis  the  same  change 
is  observed  as  in  health  ;  on  the  other  hand,  in  bronchitis  with  much 
secretion  and  in  bronchopneumonia  the  marked  difference  between  inspi- 
ration and  expiration  does  not  hold.  In  phthisis  the  difference  between 
the  two  sides  of  the  chest  can  be  made  more  plain  by  respiratory  per- 
cussion. By  the  varying  changes  in  pitch  and  duration,  cavities  are 
detected.     (Gerhardt's  sign.) 

32 


498  SPECIAL  DIAGNOSIS. 

Object  of  Percussion.  The  object  of  percussion  is  to  estimate 
the  proportion  of  air  to  the  solid  tissue  contained  in  the  chest.  We 
can  thus  determine  (1)  the  size  of  the  lungs  ;  (2)  the  presence  or 
absence  of  disease  causing  abnormal  physical  conditions  ;  (3)  the  size 
of  the  other  organs  in  the  thorax  (topographical  percussion),  and  (4) 
in  the  case  of  the  abdomen  the  position  and  size  of  its  organs  and  the 
presence  of  tumors  or  other  solid  structures. 

The  Size  of  the  Lungs.  Increase  in  size  :  The  boundaries  of  the 
lung  have  been  described.  If  the  resonance  extends  beyond  these 
boundaries,  it  may  be  said  that  the  lungs  are  enlarged.  This  is  seen 
in  emphysema.  The  area  of  resonance  in  this  affection  extends  above 
the  clavicles  to  a  greater  height  than  in  health.  It  encroaches  upon, 
and  may  altogether  displace,  the  normal  area  of  cardiac  dulness  ;  it 
extends  one  and  a  half  to  two  inches  beyond  the  lower  limits  of  the 
healthy  lung.  The  upper  border  of  liver-dulness  is,  therefore,  lower — 
instead  of  beginning  in  the  fifth  or  sixth  space  it  begins  an  inch  or  two 
below.  Diminution  in  size  :  Shrinkage  of  the  apices  (one  or  both) 
takes  place  in  phthisis,  hence  the  resonance  of  health  does  not  extend 
as  high  up  in  the  neck.  Shrinkage  or  contraction  may  take  place 
along  the  lateral  borders  or  lower  edges,  on  account  of  phthisis  or  re- 
tracting pleurisy,  causing  diminution  in  size  of  the  lung  and  spurious 
enlargement  of  the  heart  or  liver.  In  diseases  below  the  diaphragm, 
effusion  or  enlarged  liver,  the  size  of  the  lungs  varies.  (For  heart 
and  liver,  see  the  special  chapter  devoted  to  these  organs.) 

The  Sounds  in  Disease.  It  may  be  said  in  general  that  when  a 
sound  is  produced  in  the  thorax  which  varies  from  the  normal  resonant 
tone  it  indicates  an  abnormal  physical  condition,  or,  in  a  word,  disease. 
Exactly  corresponding  portions  of  the  two  sides  must  be  compared. 

Change  in  tone  may  be  general  or  local.  The  areas  over  both  lungs 
may  yield  a  different  percussion-note  from  the  normal  (bilateral);  the 
change  may  be  limited  to  one  side  (unilateral);  or  it  may  be  found  in 
small  areas  (local). 

Increased  Resonance  or  Tracheal  Tone.  The  resonance  may 
be  increased  or  diminished.  When  the  resonance  is  increased  the  sound 
is  abnormally  clear.  If  it  is  fuller  and  clearer  than  in  health,  without 
the  characteristics  of  the  tympanitic  note,  it  is  known  as  hyper-reso- 
nance or  exaggerated  resonance  or  a  tracheal  tone.  The  physical  con- 
dition which  causes  exaggerated  or  hyper-resonance  is  increase  in  the 
amount  of  air.  This  increased  amount  of  air  may  be  general,  unilat- 
eral, or  local.  When  general  (bilateral)  it  gives  the  characteristic  sound 
heard  in  emphysema.  In  this  affection  the  amount  of  air  is  so  great, 
and  the  tension  of  the  chest-Avails  so  exaggerated,  that  hyper-resonance 
and  sometimes  a  pure  tympanitic  sound  ("  band-box  "  resonance)  are 
produced  over  the  entire  thorax.  At  the  same  time  normally  dull 
areas  are  encroached  upon.  The  heart-dulness  is  effaced,  the  liver 
dulness  lowered.  The  same  increased  resonance  may  be  present  in 
acute  miliary  tuberculosis.  Unilateral  increase  in  resonance  or  tym- 
pany occurs  when  there  is  an  increased  amount  of  air  in  one  lung,  on 
account  of  compensatory  enlargement  (vicarious  or  compensatory  em- 
physema), or  on  account  of  an  increase  of  air  in  the  pleura.     Local 


DISEASES  OF  THE  LUNGS  AND  PLEURAE. 


499 


increase  of  resonance  occurs  when  a  local  area  of  the  lung  is  acting  in 
a  compensatory  manner.  This  is  seen  in  cases  of  phthisis  in  which  the 
alveoli  or  lobules  surrounding  small  areas  of  consolidation  are  very 
distended.  The  exaggerated  note  may  aid  in  the  recognition  of  a  deep 
consolidated  area.  The  same  note,  hyper-resonance,  or  skodaic  reso- 
nance, is  obtained  over  a  portion  of  the  lung  above  the  line  of  pleural 
effusion,  and  above  the  line  of  consolidation  in  pneumonia. 


Fig.  138. 


Fig.  139. 


Diagram  showing  at  x  moderate  dulness 
over  tubercular  infiltration.  (Gibson  and 
Russell.) 


Diagram  showing  heightening  of  pitch  an- 
teriorly at  x  from  consolidation  posteriorly 
(shaded  points).    (Gibson  and  Russell.) 


Diminished  or  Impaired  Resonance.  The  normal  tone  or  reso- 
nance is  impaired  or  muffled — that  is,  the  pitch  is  higher,  while  the 
volume  is  lessened  and  the  duration  shorter — in  cases  of  incipient  con- 
solidation of  the  lung,  and  in  small  pleural  effusions  when  a  thin  layer 
overlaps  the  lung.  It  is  the  first  change  toward  dulness.  It  is  par- 
ticularly noted  in  the  early  stages  of  phthisis,  when  the  lung  area, 
usually  the  apex,  is  the  seat  of  small  areas  of  tuberculous  infiltration. 
The  relative  amount  of  air  to  solid  structure  is  lessened.  Impaired 
resonance  is  the  result.  As  the  disease  advances  the  note  changes  grad- 
ually to  dulness. 

Pitch.  Gibson  and  Russell  have  pointed  out  the  change  in  quality 
of  sound  with  change  in  pitch.  (See  Fig.  139.)  If,  for  instance,  the 
apex  of  the  lung  is  percussed  in  front,  when  there  is  an  effusion  of  fluid 
behind,  or  a  consolidation  of  small  area  directly  on  the  opposite  surface 
of  the  lung,  the  pitch  is  higher,  compared  with  the  sound  in  the  oppo- 
site lung  at  the  corresponding  point,  although  the  quality  is  clear.  A 
clear  sound  of  heightened  pitch  is  diagnostic  of  airless  structure  behind 
air-containing  structure. 

Tympany  in  Disease.  Significance  :  If  a  tympanitic  note  is 
elicited  over  a  part  where  in  health  resonance  should  be  found,  it  is  an 
indication  of  disease.  It  signifies  (1)  that  air  is  confined  in  a  space 
(cavity),  or  that  there  is  an  excess  of  air  in  many  sacs,  as  in  the  lungs 
in  emphysema  ;  (2)  that  the  tension  of  the  lungs  is  less  than  normal — 
the  lung  is  relaxed,  as  it  is  above  the  limits  of  a  pleural  effusion.     A 


500 


SPECIAL  DIAGNOSIS. 


Fig.  140. 


tympanitic  sound  from  the  chest  occurs — 1.  Bilaterally,  in  cases  of 
emphysema.  2.  Unilaterally ,  in  cases  of  pneumothorax  and  compen- 
satory emphysema.  In  pneumothorax  the  pitch  may  be  raised  if  there 
is  much  tension  ;  it  is  then  known  as  a  dull  tympany.  3.  Locally, 
a.  It  is  limited  to  the  lobe  of  the  lung  in  some  cases  of  compensatory 
emphysema,  b.  It  may  occur  in  the  early  stages  of  pneumonia,  or  in 
the  later  stages  of  complete  consolidation.  In  the  former  it  is  due  to 
relaxed  tension  ;  in  the  latter,  to  the  air  in  the  bronchus,  the  lumen  of 
which  is  free.  c.  In  cases  of  pleural  effusion,  owing  to  alteration  in 
the  tension  of  the  lung,  a  tympanitic  note  is 
present  above  the  layer  of  fluid,  d.  In  phthisi- 
cal excavations  at  the  base  of  the  apex,  and  in 
bronchial  dilatation,  if  the  cavity  communicates 
with  the  air,  and  has  moderately  thin,  elastic 
walls,  and  is  at  the  same  time  empty,  a  tym- 
panitic note  is  produced.  The  musical  pitch 
of  the  note  depends  upon  the  volume  of  air, 
the  size  of  the  opening,  and  tension  of  the 
wall.  Large  volume  of  air,  low  pitch ;  large 
opening,  low  pitch  ;  greater  tension,  higher 
pitch.  Small  volume,  high  pitch  ;  small  open- 
ing, high  pitch  ;  less  tension,  low  pitch.  (For 
modifications  of  tympany,  see  Special  Sounds 
and  Cavities.) 

Dulxess  ix  Disease. 
pitch,  small  in  volume,  and  short  in  duration 
Absence  of  air,  or  a  relatively  small  amount 
in  proportion  to  solid  structure,  is  present.  The 
conditions  which  give  rise  to  it  are  all  forms 
of  consolidation  and  pleural  effusions.  The 
extent  and  the  degree  of  dulness  depend  upon 
the  proportionate  amount  of  solid  to  air-con- 
taiuing  material.  Moderate  dulness  is  seen  in 
tubercles;  below  exaggerated  tubercular  disease,  with  moderate  infiltration 
reem0physeCmafr0m  compensatory  of  the  lung  (see  Fig.  138),  and  in  small  patches 
of  catarrhal  pneumonia,  in  pulmonary  conges- 
tion, and  in  atelectasis  and  physical  conditions  in  which  there  is  solid 
material  in  greater  proportion  than  in  health.  Absolute  or  complete 
dulness  occurs  when  the  air  is  completely  absent,  as  in  the  stage  of 
hepatization  of  acute  pneumonia,  in  hemorrhagic  infarction,  in  con- 
densation from  pressure,  in  pleurisy  with  large  effusion,  or  great  thick- 
ness of  the  pleura,  and  in  tumors.  Flatness  is  applied  to  the  extreme 
degree  of  dulness.     (See  Fig.  141.) 

"We  have,  therefore,  all  gradations  of  the  dull  sound,  from  simple 
impaired  resonance  in  incipient  tuberculosis  of  an  apex  of  the  lung,  as 
determined  by  careful  comparison  of  the  two  apices,  to  absolute  flatne.-.- 
or  deadness. 

Method  of  Percussion  :  The  kind  of  percussion  necessary  to  bring 
out  the  dulness  will  depend  upon  the  extent  and  the  distance  from  the 
surface  of  the  disease.     When  the  consolidation  or  thickening  is  super- 


The  note  is  high  in 


At  the  apex  complete  dulness 
and  bronchial  breathing,  from 
tuberculous  consolidation ;  in 
the  middle  portion  impaired 
resonance,    from    disseminated 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  501 

ficial,  light  percussion  will  discover  it,  whereas  strong  percussion  would 
bring  out  the  resonance  of  the  deeper  healthy  lung-tissue  to  such  an 
extent  as  to  mask  completely  the  superficial  dulness.  On  the  other 
hand,  when  the  airless  consolidated  tissue  is  deep-seated  and  sur- 
rounded by  healthy  lung,  strong  percussion  is  required  to  discover  it. 


Fig.  141. 


Exaggerated  breath-sounds.    Skodaic  resonance 


Retracted  lung. 


Air.        Tympany.    Metallic    tinkling 
and  amphoric  breathing. 


Succussion  on  shaking. 

Fluid.  Flat  on  percussion.  Loss  ot 
vocal]  resonance  and  fremitus.  Ab- 
sent breath-sounds. 


Pneumothorax ;  resonance  over  retracted  lung.    Tympany  over  air.    Dulness  or 
flatness  over  fluid.    (Gibson  and  Russell.) 

Again,  when  the  airless  tissue  occupies  a  small  focus  and  is  sur- 
rounded by  healthy  lung,  as  in  pneumonia  beginning  centrally  ;  and 
when  there  are  small  airless  foci,  perhaps  surrounded  by  emphysema, 
as  occurs  sometimes  in  disseminated  tuberculosis,  percussion  is  often 
wholly  negative. 

Special  Sounds.  Special  percussion-sounds,  or  sounds  the  quality 
of  which  differs  from  the  ordinary  tympanitic  sound,  are  present  in 
some  physical  conditions.  Of  these  the  amphoric,  or  metallic,  and  the 
cracked-pot  percussion-sounds  are  most  familiar.  The  amphoric  sound 
is  tympanitic,  but  has  a  metallic  clang,  or  echo,  which  is  an  overtone. 
The  prolongation  of  the  sound  is  compared  to  an  echo.  It  is  like  the 
sonorous  ring  of  the  voice  when  one  utters  a  tone  hi  an  empty  hall. 
It  can  be  imitated  by  percussing  an  empty  vessel.  It  is  heard  best  in 
cases  of  pneumothorax  (see  Fig.  141)  and  in  phthisical  excavation 
when  the  cavity  is  large,  superficial,  with  smooth  walls,  and  when  it 
has  open  communication  with  a  bronchus.  The  cracked-pot  sownd,  as 
the  name  indicates,  resembles  that  produced  when  a  cracked  metal 
vessel  is  tapped  ;  it  is  simulated  by  clasping  the  hands  loosely  at  right- 
angles  t<»  each  other  and  striking  them  over  the  knee.  It  is  heard 
best  over  cavities  which  communicate  directly  with  a  bronchus,  espe- 
cially if  the  chest-wall  is  thin  and  yields  to  the  percussion-stroke. 
The  cavity  is  usually  at  the  apex.  In  order  to  elicit  the  sound  the 
patient  should  be  made  to  keep  the  mouth  open.  The  sound  should 
be  created  at  the  time  of  expiration,  and  the  percussing  finger  should 
be  retained  instead  of  elevated  after  striking  the  pleximeter. 


502  SPECIAL  DIAGNOSIS. 

In  some  rare  cases  this  sound  can  be  elicited  in  health.  It  may  be 
generated  if  the  chest  of  a  healthy  screaming  infant  is  percussed.  In 
this  instance  it  is  due  to  the  compressed  air  forcibly  throwing  the  vocal 
cords  into  vibration.  The  other  pathological  conditions  in  which  the 
sound  occurs  rarely  are  pleurisy,  when  the  chest  is  percussed  above  the 
effusion,  pneumonia  before  consolidation  has  taken  place,  and  pneumo- 
thorax if  there  is  a  free  communication  between  the  cavity  and  a 
bronchus.  In  the  latter  instance  the  sudden  rush  of  air  into  the  bron- 
chus produces  this  sound.  This  is  proved  by  the  fact  that  it  can  be 
created  when  the  chest  is  percussed  in  a  case  of  empyema,  after  the 
fluid  has  been  evacuated  by  a  free  incision.  It  is  to  be  noted  that, 
while  corroborative,  it  is  not  of  itself  positive  evidence  of  any  single 
condition. 

Auscultation.  Sounds  are  produced  in  the  act  of  breathing.  They 
are  heard  by  the  application  of  the  ear  directly  to  the  chest-wall  or 
through  some  medium.  They  are  created  both  in  inspiration  and  in 
expiration.     They  vary  in  character  in  accordance  with  the  situation. 

Method.  If  possible,  the  patient  should  sit  upright  in  an  easy,  un- 
restrained position.  For  auscultation  in  front,  the  arms  should  hang 
carelessly  by  the  side.  For  auscultation  behind,  the  patient  should  fold 
the  arms  and  lean  slightly  forward.  For  comparison  both  sides  should 
have  the  same  freedom  of  movement,  which  would  not  be  attained  if 
the  patient  assumed  a  lateral  or  side  posture  or  attitude.  Auscultation 
should  be  practised  in  quiet,  in  full  and  in  forced  inspiration  and  ex- 
piration. 

Auscultation  is  practised  by  two  methods  :  First,  the  ear  is  applied 
directly  to  the  chest,  a  thin  towel  or  napkin  free  from  starch  alone 
intervening.  This  is  known  as  the  immediate  or  direct  method.  It  is 
of  service  to  ascertain  the  general  character  of  the  sounds.  It  has  the 
disadvantage  of  imperfect  localization.  Second,  by  means  of  the  stetho- 
scope and  phonendoscope  the  mediate  or  indirect  method  is  practised ; 
but  it  is  disadvantageous  in  infants,  because  they  cannot  be  kept  quiet 
or  are  sensitive  to  its  pressure,  and  in  children  because  instruments 
are  alarming. 

The  advantages  of  the  stethoscope  over  direct  methods  of  ausculta- 
tion are  seen  when  it  is  necessary  to  localize  sounds.  The  definite 
localized  area  in  which  the  sound  is  produced  can  be  ascertained,  and 
sounds  in  close  proximity  differentiated.  Its  use  is  essential  in  the 
study  of  heart-sounds.  In  addition,  the  operator  is  more  likely  to 
escape  from  contagious  diseases  and  vermin.  Moreover,  on  the  score 
of  delicacy,  the  stethoscope  is  preferable. 

The  stethoscopes  used  are  single  and  double,  and  vary  in  form  with 
the  practice  of  the  operator.  It  should  be  an  absolute  rule  with 
the  student  to  become  familiar  with  and  use  one  form  of  stethoscope 
only.  The  single  stethoscope  is  very  good  to  localize  and  determine 
the  relation  of  sounds.  It  also  transmits  the  shock  of  an  aneurismal 
vessel  or  of  the  heart.  The  objection  to  it  is  that  the  weight  of  the 
head  causes  pain  if  the  chest  is  sore,  and  the  pressure  of  the  instrument 
may  modify  sounds  if  bloodvessels  are  auscultated,  or  sounds  in  close 
proximity  to  the  ear,  as  a  friction.     In  the  use  of  the  single  stetho- 


DISEASES  OF  THE  LUNGS  AND  PLEURJE.  503 

scope  the  student  should  be  particular,  first,  to  see  that  the  portion 
applied  to  the  chest  is  perpendicular  to  the  plane  of  the  area  over  which 
auscultation  is  practised.  Otherwise  slight  tilting  of  the  instrument 
will  take  place  and  outside  noises  he  transmitted  through  the  tube. 
The  operator  should  place  himself  in  an  unconstrained  position  and 
see  that  his  head  is  accommodated  to  the  position  of  the  instrument, 
not  the  latter  to  the  head.  If  the  parts  over  which  auscultation  is 
practised  are  covered  with  hair,  an  extraneous  sound  from  friction  is 
produced.  Oil  should  be  applied  to  obviate  this.  The  double  stetho- 
scope is  the  most  suitable  for  class  instruction.  It  can  even  be  applied 
over  parts  that  are  quite  tender.  The  rule  of  application  to  the  chest 
is  the  same  as  for  the  single  stethoscope.  The  ear-pieces  should  fit 
comfortably.     The  humming  sound  in  the  tube  is  confusing  at  first. 

The  Sounds  in  Health.  It  may  be  well  to  call  attention  to  the 
confusion  that  always  arises  when  the  student  is  examining  the  chest 
for  the  first  time.  The  probability  is  that  the  coincidence  of  heart- 
sounds  and  lung-sounds  in  the  chest  prevents  the  discrimination  of 
the  latter  sounds.  If  attention  is  paid  to  the  respiratory  rhythm 
they  can  be  distinctly  isolated.  When  the  student  is  ausculting  the 
lungs  he  should  place  his  hand  on  the  thorax  or  the  epigastrium  and 
fix  his  attention  upon  the  two  acts  of  respiration — inspiration  and  ex- 
piration. JNTote  the  occurrence  of  each  movement,  the  expansion  of 
inspiration  and  the  contraction  of  expiration  Then  analyze  carefully 
the  sounds  during  each  event  of  a  respiratory  act.  Having  fixed  the 
attention  on  respiration,  noted  its  divisions,  and  excluded  cardiac 
rhythm,  note  (1)  the  character  of  the  sound  in  inspiration  ;  (2)  the 
character  of  the  sound  in  expiration  ;  (3)  the  relative  length  of  the  two. 
By  this  means  the  sounds  of  respiration  are  accurately  ascertained,  and 
confusing  extraneous  sounds,  as  from  the  heart,  distinctly  eliminated. 

Bronchial  Breathing.  If  the  stethoscope  is  placed  over  the 
trachea  at  the  top  of  the  sternum,  a  sound  characterized  as  follows 
will  be  heard  :  First,  it  attends  inspiration  and  expiration  with  a  defi- 
nite pause  between  ;  second,  the  inspiration  and  expiration  are  nearly 
equal  in  length ;  third,  they  are  of  a  tubular,  blowing  character.  The 
expiration  is  perhaps  a  little  stronger  and  longer  than  the  inspiration. 
If  the  mouth  is  closed,  there  is  no  change  except  that  both  inspiration 
and  expiration  are  harsher  and  sharper.  Bronchial  breathing  is  the 
term  applied  to  the  sound  which  is  heard  in  this  situation.  It  is  one 
of  the  normal  sounds  of  the  chest.  It  may  be  heard  behind,  at  or  a 
little  below  the  seventh  cervical  vertebra,  feebler  in  quality  than  in 
the  trachea,  and  in  the  interscapular  space  over  the  large  bronchi  as 
they  leave  the  trachea.  A  sound  heard  in  these  areas,  bronchial  in 
character,  is  normal. 

Vesicular  Breathing,  or  the  Respiratory  Murmur.  If  the 
car  is  applied  over  the  anterior  portion  of  the  chest,  or,  better  still,  in 
the  upper  axilla  or  below  the  angle  of  the  scapula  behind,  a  sound  is 
heard  both  on  inspiration  and  expiration.  It  differs  from  bronchial 
breathing,  however,  in  that  inspiration  and  expiration  are  changed  in 
length.  The  sound  of  inspiration  is  twice  or  three  times  as  long  as 
the  sound  of  expiration.     The  sound  of  inspiration  is  soft,  breezy,  or 


504  SPECIAL  DIAGNOSIS. 

sighing  in  character,  increasing  in  intensity  to  the  end  of  full  inspira- 
tion. It  is  immediately  followed  by  expiration,  which  diminishes  in 
intensity  as  the  air  is  expelled,  and  terminates  when  one-half  or  two- 
thirds  of  the  expiratory  act  is  completed.  The  sounds  can  be  imitated 
by  breathing  with  the  lips  in  the  position  required  to  pronounce  "  f  " 
or  "  v." 

Cause  of  the  Sounds.  The  sound  is  caused  by  the  passage  of  air 
through  the  nares  into  the  wider  pharynx  when  the  mouth  is  closed. 
The  sounds  heard  over  the  bronchi,  the  terminal  bronchioles,  and  the 
vesicles  are  probably  created  in  the  upper  air-passages  and  transmitted 
to  the  ear  through  the  medium  of  the  bronchi.  Bronchial  breathing 
is  the  sound  unmodified,  transmitted  to  the  ear,  weakened  only  by  its 
distance  from  the  upper  air-passages.  The  vesicular  breath-sound  is 
the  same  sound  modified  on  account  of  the  intervention  of  the  air- 
vesicles  between  the  ear  and  the  larger  bronchi.  The  sound  is  thus 
smothered  or  dampened  down.  It  was  held  that  part  of  the  sound  of 
vesicular  breathing,  if  not  the  whole,  was  due  to  expansion  of  the  vesi- 
cles and  rush  of  air  through  the  bronchioles.  The  proof,  however, 
seems  to  be  in  favor  of  the  first  view  given,  chiefly  because,  when  the 
vesicular  tissue  is  removed,  as  in  pneumonia  or  other  consolidation, 
even  far  distant  from  the  trachea,  bronchial  breathing  is  produced. 

Modifications  of  the  Sounds  in  Health.  Exaggerated  Breath- 
sounds.  Bronchial  breathing  and.  vesicular  breathing  are  increased  in 
loudness  and  sharpness  by  strong,  rapid  breathing.  In  some  persons 
a  sound  is  heard  which  partakes  of  the  qualities  of  both  bronchial 
breathing  and  the  vesicular  sound.  It  is  noticed  in  the  interscapular 
region  about  the  level  of  the  spines  of  the  scapulae,  replacing  the  pure 
bronchial  breathing  which  is  heard  in  other  individuals.  Its  characters 
are,  first,  soft,  blowing  inspiration,  or  loud,  harsh  inspiration ;  second, 
slightly  prolonged  blowing  expiration,  more  exaggerated,  louder,  but 
not  harsher,  than  in  health.  The  term  broncho-vesicular  is  applied  to 
this  kind  of  breathing.  It  is  due  to  the  fact  that  the  sound  produced 
in  the  upper  air-passages  is  conducted  to  the  ear  less  dampened  down 
or  modified,  because  the  air-vesicles  which  surround  the  bronchus  are 
here  smaller  in  number  than  are  found  in  the  remainder  of  the  lung. 

The  sounds  are  increased  in  children,  in  whom  there  are  combined 
greater  elasticity  of  the  chest-wall  and  greater  friction  throughout  the 
smaller  bronchi,  which  are  relatively  larger.  So  distinct  and  charac- 
teristic is  the  sound  in  children  that  the  term  puerile  respiration  is 
applied  to  it.  The  sounds  of  inspiration  and  expiration  are  both  in- 
tensified or  sharper  than  in  healthy  adults  ;  the  latter  is  relatively  pro- 
longed. 

Feeble  Breath-sounds.  The  sounds  are  modified  by  the  condition 
of  the  chest-walls.  If  they  are  thick,  or  there  is  an  abundance  of  fat, 
the  sounds  are  fainter  or  lessened  in  intensity.  Feeble  respiratory 
power,  in  wasting  and  exhausting  diseases,  causes  feeble  breath-sounds. 
The  condition  of  the  upper  air-passages,  even  if  not  pathological,  mod- 
ifies the  sound.  If  the  glottis  is  small,  or  there  is  a  disturbed  relation- 
ship between  the  nose  and  pharynx,  the  ■  sounds  will  be  modified. 
They  are  usually  weakened. 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  505 

The  Sounds  in  Disease.  It  is  well  for  the  student  to  bear  in  mind 
that  sounds  heard  in  the  chest  which  are  departures  from  the  normal 
sounds  always  indicate  disease. 

Vesicular  Breathing  Exaggerated.  Bilateral.  The  vesicu- 
lar breathing  or  respiratory  murmur  is  increased,  first,  when  there 
is  increase  in  the  force  of  breathing — when  normal  respiration  is  in- 
creased and  the  patient  takes  full,  deep  breaths.  It  is  seen  in  some 
forms  of  dyspnoea,  as  at  the  acme  of  Cheyne-Stokes  breathing,  or  in 
the  dyspnoea  of  diabetic  coma.  It  may  be  increased  or  exaggerated 
in  certain  forms  of  bronchitis,  particularly  when  the  small  tubes  are 
narrowed  by  inflammatory  swelling. 

Unilateral  exaggeration  or  increase  of  vesicular  breathing  is  heard 
when  the  lung  is  acting  vigorously  or  in  a  compensatory  manner.  The 
strong  inspiration  followed  by  strong  and  relatively  prolonged  expira- 
tion of  an  actively  moving  lung  signifies  almost  certainly  disease  of  the 
lung  of  the  opposite  side. 

Local  exaggeration  of  vesicular  breathing,  the  inspiration  harsh,  is 
noted  in  cases  of  phthisis  in  its  earliest  stages.  It  should  be  compared 
with  the  sound  of  the  opposite  side,  when  the  difference  can  easily  be 
ascertained.  It  is  heard  over  the  apex,  in  pneumonia  or  pleurisy  of 
the  base,  and  vice  versa. 

Vesicular  Breathing,  Diminished  or  Absent.  Bilateral.  (1) 
It  is  lessened  in  all  cases  in  which  the  expansion  is  interfered  with.  In 
feeble  persons  the  respiratory  murmur  is  weak,  particularly  at  the 
bases  posteriorly.  If  the  muscles  of  respiration  are  paralyzed  or  en- 
feebled, the  murmur  is  also  lessened.  If  the  expansion  is  interfered 
with,  on  account  of  disease  of  the  diaphragm,  or  pressure  upward  by 
accumulations  in  the  abdomen,  it  is  weakened. 

(2)  Anything  which  lessens  the  amount  of  air  supplied  to  the  chest 
diminishes  the  vesicular  breathing.  It  is,  therefore,  lessened  in  cases 
of  occlusion  or  obstruction  of  the  nares,  the  pharynx,  or  the  larynx. 

(3)  Thickened  chest- walls  that  occur  from  disease,  as  oedema,  weaken 
the  respiratory  sound. 

(4)  The  vesicular  breathing  is  weakened  throughout  the  entire  extent 
of  the  lung  in  emphysema.  The  enfeebled  respiratory  forces  and  the 
short  act  of  inspiration  in  this  affection  cause  less  air  to  enter  the  already 
overfilled  chest.  Moreover,  in  the  bronchitis  that  attends  emphysema 
the  bronchioles  are  all  more  or  less  occluded,  and  hence  the  air-supply 
is  diminished.  These  conditions  lead  to  feeble  respiratory  murmur 
except  at  the  anterior  margins  of  the  lungs. 

Unilateral  diminution  of  breath-sounds  occurs  (1)  when  there  is  nar- 
rowing of  the  bronchus,  as  in  cases  of  aneurism  or  mediastinal  tumor ; 
(2)  when  there  is  pleural  effusion,  which  («)  lessens  the  amount  of  air- 
pressure  by  compression  of  the  lung  and  (6)  interferes  as  a  different 
conducting  medium.  (See  Fig.  136.)  If  pain  in  pleurisy,  pleurodynia, 
or  neuralgia  is  present  on  one  side,  the  breath-sounds  of  the  affected 
side  will  be  lessened.  Not  only  in  pleural  effusions  from  serum,  blood, 
pus,  or  air,  but  also  in  thickened  pleura  there  is  weakness  or  faintness 
of  the  respiratory  murmur.  It  should  not  be  forgotten  that  effusions 
and  thickenings  of  the  pleura  rarely  take  place  bilaterally  ;  when  they 


506  SPECIAL  DIAGNOSIS. 

do  occur  the  breath-sounds  are  weakened,  but  not  to  the  same  extent 
as  when  an  effusion  is  limited  to  one  side. 

Local  diminution  of  breath-sounds  occurs  in  the  early  stages  of  phthisis 
or  in  the  earliest  stages  of  pneumonia. 

Alteration  of  the  Rhythm.  We  take  cognizance  of  the  rhythm 
of  the  sounds.  In  health  the  movement  of  inspiration  and  that  of 
expiration  are  almost  equal,  but,  as  previously  noted,  the  sound  of  in- 
spiration is  heard  during  the  entire  act,  while  that  of  expiration  occu- 
pies the  first  third  or  so  of  the  act.  The  sound  produced  during 
expiration  may  even  be  less  than  half  the  length  of  that  produced 
during  inspiration.  The  following  proportion  represents  relative 
lengths — Ins.  :  Exp.  :  :  3  : 1. 

Expiration  Prolonged.  The  first  notable  change  in  the  rhythm 
of  respiration  may  be  prolongation  of  expiration.  When  the  expira- 
tion is  prolonged  it  equals  inspiration,  or  may  even  be  longer.  This 
is  due  to  the  difficulty  of  getting  the  air  out  of  the  chest — expiratory 
dyspncea,  a  physical  condition  which  enables  the  sound  of  expiration 
to  reach  the  ear.  Hence,  prolongation  of  expiration  all  over  the' chest 
is  seen  in  emphysema  and  asthma.  In  this  condition  the  inspiration 
is  short,  the  expiration  prolonged.  Although  distinct  throughout  the 
chest,  it  is  more  pronounced  above  the  clavicles  and  along  the  free 
margins  of  the  lung  anteriorly.  It  is  prolonged  in  bilateral  broncho- 
vesicular  breathing  (q.  v.). 

Local  prolongation  of  the  expiration  is  of  great  diagnostic  significance. 
It  occurs  when  areas  of  the  lung  are  partially  consolidated  and  the 
elasticity  thereby  impaired.  The  respiratory  murmur  is  harsh,  or 
puerile,  or  it  may  be  weak.  This  condition  obtains  in  tuberculosis, 
and  is  one  of  the  first  physical  signs  of  this  affection. 

Jerking  or  Interrupted  Inspiration.  Instead  of  the  smooth, 
even,  sighing,  or  breezy  inspiration  the  sound  is  created  in  puffs  or 
jerks,  so  that  during  the  act  of  inspiration,  as  the  chest  expands,  a 
number  of  successive  vesicular  sounds  are  heard  until  the  act  is  com- 
pleted. The  physical  condition  which  causes  jerking  inspiration,  or 
cog-wheel  breathing,  is  found  in  the  earlier  stages  of  tuberculosis, 
when  the  various  bronchioles  are  more  or  less  occluded  by  outgrowths 
of  tubercle.  ^  The  air,  therefore,  enters  different  lobules  at  different 
periods  of  time,  thereby  giving  rise  to  this  peculiar  broken  sound.  It 
must  not  be  confounded  with  the  same  character  of  breathing  that  is 
heard  adjacent  to  the  heart,  due  to  the  pressure  of  that  organ,  or  of 
structures  in  intimate  relation  therewith,  upon  portions  of  the  lung,  on 
account  of  which  air  enters  various  areas  in  puffs.  On  the  other  kind, 
jerking  inspiration  sometimes  occurs  in  health.  It  is  simulated  by  the 
jerky  act  of  inspiration  in  nervous  patients.  It  is  of  no  significance 
unless  attended  by  other  physical  signs. 

In  cases  of  adhesion  at  the  apex,  particularly  of  the  left  lung,  the 
same  puffing  or  jerking  inspiration  is  often  heard.  It  is  also  present 
in  aneurism,  or  disease  of  the  aorta,  pressing  upon  a  bronchus,  causing 
the  air  to  enter  the  part  in  an  intermittent  manner.  When  pathologi- 
cal jerking  breathing  is  present,  the  expiration  is  prolonged,  and,  if  the 
case  is  under  observation  a  sufficiently  I0112;  time,  bronchial  breathing 


DISEASES  OF  THE  LUNGS  AND  PLEURjE. 


507 


will  usually  replace  the  jerky  respiratory  murmur  in  progressive  con- 
solidations. Small,  moist  rales,  excited  by  coughing  or  a  full  breath, 
usually  attend  jerking  breathing  when  it  is  pathological. 

Bronchial  Breathing.  The  normal  situation  of  bronchial  breath- 
ing in  health  has  been  indicated.  If  the  same  kind  of  breathing  is 
heard  in  any  other  portion  of  the  lung  it  is  pathological.  It  is  gener- 
ally indicative  of  the  presence  of  consolidation.  The  spongy  lung- 
tissue  is  replaced  by  solid  conducting  material,  by  which  the  bronchial 
sound  is  conducted  to  the  ear.  It  is  heard,  therefore,  in  all  pathologi- 
cal conditions  in  which  consolidation  takes  place.  It  is  the  typical 
form  of  breathing  heard  in  pneumonia,  in  consolidation  of  the  lung  due 
to  tuberculosis  (see  Fig.  142),  in  hemorrhagic  infarcts,  and  in  lung 
syphilis.  It  must  not  be  forgotten,  however,  that  cases  of  pneumonia 
do  exist  without  this  type  of  breathing.  This  is  the  case  when  the 
large  bronchus  supplying  the  hmgs,  or  the  bronchioles,  are  occluded  by 
inflammatory  exudate.  In  tuberculous  consolidation  it  may  be  absent 
for  similar  reasons.  In  central  pneumonia,  where  consolidation  is  deep- 
seated  and  surrounded  by  lung-tissue,  bronchial  breathing  may  not  be 
heard,  or  it  may  be  postponed  until  the  third  or  fourth  day  of  the  disease, 
by  which  time  consolidation  will  have  reached  the  surface  of  the  lung. 


Fig.  142. 


Consolidated  area. 

Fremitus  increased. 
Vocal  resonance  increased. 

Dulness  on  percussion. 
Bronchial  breathing. 


Increased  vocal  resonance 
and  fremitus.    Dulness. 

Cavity     with      cavernous 
breathing  and  gurgling 
rales.    Pectoriloquy. 

Hyper-resonance  on  per- 
cussion. 

Consolidation  —  bronchial 
breathing.  Increased 
fremitus  and  resonance. 
Dulness  on  percussion. 


Tubercular  infiltration. 
Impaired  resonance  on 
percussion. 

Congestion— crepitant  and 
subcrepitant  rales. 


Showing  phthisis  at  various  stages.    (Gibson  and  Russell. 


In  certain  cases  of  pleurisy  with  effusion  bronchial  breathing  exists. 
The  accumulation  is  not  great  enough  to  compress  the  lung  completely. 
The  bronchial  tubes  remain  patent,  while  the  vesicular  structure  is 
compressed.  Low-pitched  bronchial  breathing  is  heard  under  .these 
circumstances.  It  is  more  pronounced  at  the  upper  layer  of  the  effu- 
sion. It  is  always  heard  close  to  the  spine  posteriorly,  where  the  lung 
is  compressed.  Sometimes  it  is  heard  above  the  limit  of  the  effusion, 
in  all  probability  because  of  relaxed  tension  of  the  lung. 

Varieties  of  Bronchial  Breathing.  Its  special  characteristics 
must  be  borne  in  mind.     (See  p.  503.)     It  must  not  be  forgotten  that 


508  SPECIAL  DIAGNOSIS. 

bronchial  breathing  is  not  represented  accurately  in  every  instance  by 
the  sounds  heard  over  the  trachea.  Its  character  may  be  modified  and 
yet  approach  that  type  of  breathing.  The  modification  occurs  in  one 
or  both  of  the  two  portions  that  go  to  make  up  the  sound  :  (1)  The 
blowing  element  may  not  be  as  distinct  in  inspiration  as  in  expiration ; 
(2)  in  rare  cases,  the  characteristic  blowing  sound  may  not  continue  so 
long  during  expiration  as  to  equal  the  inspiratory  sound.  On  the  other 
hand,  (3)  the  bronchial  breathing  may  vary  in  pitch.  At  times  it  is 
(a)  high  in  pitch,  both  in  inspiration  and  expiration,  but  with  a  pure 
blowing  quality  (harsh)  attending  each.  It  may  be  (b)  soft  and  low  in 
pitch  attending  both  acts.  The  strong,  high-pitched  sound  emitted 
by  breathing  deepty  when  the  lips  and  tongue  are  placed  in  position 
to  pronounce  "ch"  is  termed  tubular  breathing.  It  is  the  characteristic 
sound  of  croupous  pneumonia.  (4)  The  loudness  of  the  sound  may 
also  vary.  This  depends  largely  upon  physical  peculiarities  of  the 
individual.  The  condition  of  the  chest-walls  and  the  force  of  breathing 
determine  it. 

When  pleurisy  with  effusion  coexists  with  pneumonia,  the  bronchial 
breathing,  which  should  be  audible,  is  feeble  and  distant.  Under  the 
same  circumstances  a  bleating  sound  replaces  bronchophony.  (See 
^Egophony.) 

Mode  of  Determination.  Breathing  which  may,  during  very 
quiet  respiration,  appear  to  be  normal,  is  sometimes  discovered  to 
be  bronchial  when  the  patient  has  a  spell  of  coughing  and  then  takes 
several  deeper  breaths  than  usual  in  rather  quick  succession.  Some- 
times the  noise  made  in  nasal  respiration  obscures  the  pulmonary 
sounds.  The  patient  should  be  instructed  to  breathe  with  the  mouth 
open,  to  take  somewhat  deeper  breaths  than  usual,  and  to  let  expiration 
follow  at  once  upon  the  close  of  inspiration.  Many  patients  when  told 
to  take  deep  breaths  expand  their  lungs  to  the  utmost,  and  then  hold 
the  air  in  a  while,  and  allow  it  to  pass  out  slowly.  Such  a  method 
usually  defeats  the  purpose  of  the  examiner,  which  is  first  to  note  the 
relative  length  of  inspiration  and  expiration,  and  then  the  quality  of 
the  two  sounds,  first,  as  compared  with  each  other,  and,  secondly,  as 
compared  with  the  normal.  In  listening  for  bronchial  breathing  the 
attention  should  be  fixed  more  upon  the  length  and  quality  of  the  expi- 
ratory sound,  and  it  is,  therefore,  important  that  the  patient  breathe  so 
as  to  bring  out  its  characteristics  more  clearly  ;  this  he  can  do  by 
taking  several  moderately  deep  breaths  in  quick  succession  and  with 
the  mouth  open. 

Modifications  of  Bronchial  Breathing.  If  a  case  of  tubercu- 
lous consolidation  is  watched,  it  will  be  found  after  a  time  that  the 
bronchial  breathing  becomes  lower  in  pitch.  It  is  heard  in  inspiration 
and  expiration,  but  a  more  hollow  quality  attends  the  sound.  From 
the  hollowness  of  the  tone  the  word  cavernous  has  been  applied  to  the 
breath-sound  ;  it  is  due  to  the  formation  of  a  cavity  in  the  consolida- 
tion, or  to  a  dilated  bronchus.  It  is  a  sign  of  a  cavity.  (See  Fig.  142.) 
Cavernous  breathing  may  have  a  metallic  quality,  and  is  then  called 
amphoric.  It  is  analogous  to  the  sound  produced  by  blowing  across 
the  open  mouth  of  a  jar.     A  large  cavity  with  smooth  walls  that  com- 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  509 

municates  with  the  air  is  the  cause  of  the  development  of  such  sound. 
It  is  heard  also  in  pneumothorax,  when  such  communication  exists. 
The  metallic  tone  is  analogous  to  the  metallic  percussion-sound.  It 
occurs  under  the  same  physical  circumstances.  The  physical  condition 
which  causes  it  may  be  so  marked  that  the  same  character  of  tone  is 
imparted  to  rales  produced  in  the  cavity,  or  to  the  heart-sounds  which 
are  transmitted  by  the  solidified  area  surrounding  the  excavation. 

Bronchovesicular  Breathing  in  Disease.  The  physical  con- 
dition is  more  or  less  consolidation  surrounded  by  vesicular  structure, 
as  in  the  early  stages  of  tuberculosis.  It  is  found  midway  in  the 
change  from  respiratory  murmur  to  bronchial  breathing  in  progressive 
consolidations.  The  inspiration  is  higher  in  pitch ;  the  expiration 
prolonged,  harsh,  and  blowing ;  or  the  former  may  be  bronchial  or 
tubular,  the  latter  absent.  It  may,  however,  be  indistinct  or  masked 
by  rales.  It  is  sometimes  heard  in  the  earlier  stages  of  pneumonia, 
and  is  the  modified  bronchial  breathing  heard  over  small  consolidated 
areas  in  capillary  bronchitis  and  catarrhal  pneumonia,  with  collapse  of 
lobules.  The  term  "transition  breathing"  has  been  applied  to  this 
character  of  breath-sounds. 

New  Sounds.  The  foregoing  sounds  are  modifications  of  the  nor- 
mal sounds  heard  during  the  act  of  breathing.  New  sounds  or  adven- 
titious sounds  are  created  in  the  lungs  or  in  the  pleura.  In  the  lungs 
the  term  rales  is  applied  to  them,  and  in  the  pleura  they  are  known  as 
friction-sounds.  Under  the  same  head  may  be  classified  the  succussion- 
sound  and  metallic  tinkling. 

Kales.  Rales  are  sounds  created  in  the  bronchi,  bronchioles,  and 
air-vesicles,  or  in  pathological  excavations  (cavities).  They  are  due 
(1)  to  the  passage  of  air  through  bronchial  tubes  which  are  narrowed, 
either  on  account  of  swelling  of  the  mucous  membrane  or  on  account  of 
spasm  ;  or  (2)  the  passage  of  air  through  fluid  (mucus,  serum,  pus, 
blood).  The  former  are  called  "  dry  rales  ;"  the  latter  moist  rales,  or 
crepitation.  When  the  dry  rales  are  continuous — i.  e.,  heard  during 
both  the  acts  of  inspiration  and  expiration — they  are  known  as  rhonchi. 
Dry  rales  are  musical ;  moist  rales  are  not.  When  heard  over  con- 
solidated areas,  the  latter  are,  however,  usually  accompanied  by  over- 
tones (resonance  transmitted  from  the  bronchi),  and  are  then  clear  and 
sharp — "  consonirende  Rasselgerausche,"  Skoda. 

Dry  Rales  are  divided  into  (a)  sonorous  and  (6)  sibilant.  The 
former  are  large  rales,  the  character  of  which  is  indicated  by  the  name. 
They  are  created  in  the  large  bronchial  tubes.  They  are  coarse,  low- 
pitched  musical  sounds.  Sibilant  rales  are  created  in  small  tubes,  and 
arc  high-pitched,  whistling  sounds.  Both  are  heard  only  over  the 
areas  of  their  creation,  although  the  sonorous  rale  may  be  transmitted 
all  over  the  chest.  They  may  be  heard  at  the  same  time.  The  dry 
rales  are  heard  in  the  early  stages  of  bronchitis,  when  the  mucous 
membrane  is  swollen  and  thickened,  but  has  not  begun  to  secrete 
mucus  or  mucopurulent  matter.  They  are  also  heard  in  asthma 
in  which  there  is  spasm  of  the  bronchial  tubes,  and  in  the  chronic 
bronchitis  of  emphysema.  In  the  latter  the  smaller  rales  are  more 
common. 


510  SPECIAL  DIAGNOSIS. 

Moist  Rales,  or  Crepitatiox.  They  may  be  divided  into  large 
or  small  rales  ;  the  latter  are  also  called  subcrepitant.  (See  Fig.  142.) 
The  crepitant  rale  is  a  fine  rale,  said  to  be  created  in  the  alveoli,  due 
to  inflation  of  the  cells,  the  walls  of  which  have  been  held  together  by 
exudation  or  fluid  (cedenia).  It  is  a  fine  rale  distinctly  localized,  resem- 
bling the  sound  produced  by  rubbing  a  lock  of  hair  between  the  fingers 
or  by  putting  salt  on  a  hot  plate.  In  the  early  stages  of  pneumonia 
and  in  oedema  of  the  lungs  it  is  said  to  be  pathognomonic.  It  may, 
however,  be  heard  whenever  there  is  a  small  amount  of  fluid  in  the 
alveoli  and  feeble  respiratory  action.  The  small,  moist  or  subcrepitant 
redes  are  created  in  the  smaller  bronchioles  and  the  alveoli.  They  may 
be  general  or  local.  If  general,  they  are  due  to  bronchitis  in  the 
second  stage.  There  is  an  abundance  of  secretion  in  the  terminal  air- 
passages  which  is  thrown  into  vibration  by  the  current  of  air  during 
the  act  of  breathing.  The  element  of  moisture  is  pronounced  and 
gives  to  them  their  quality,  to  which  the  term  "  crackling  "  is  some- 
times applied.  They  are  found  in  congestion  with  outpouring  and 
stagnation  of  secretion  ;  in  oedema  ;  and  whenever  fluid  is  drawn  into 
the  bronchi,  as  when  there  has  been  a  hemorrhage  in  the  upper  pas- 
sages. Small  moist  rales  in  local  areas  are  found  in  phthisis,  partic- 
ularly at  the  end  of  the  first  stage,  on  account  of  the  local  bronchial 
catarrh,  and  in  the  second  stage  for  the  same  reason.  They  occur  in 
the  early  stage  of  pneumonia,  particularly  in  the  area  of  the  lung  which 
is  the  seat  of  collateral  oedema  adjacent  to  the  consolidation.  They 
are  also  heard  in  the  later  stages  of  pneumonia  when  resolution  has 
taken  place.  If  this  is  reached,  however,  they  may  be  replaced  by 
large  rales.  They  may  be  heard  around  any  consolidation  because  of 
congestion,  oedema,  or  catarrh.  It  must  not  be  forgotten  that  cough 
or  forced  inspiration  must  be  excited  before  rales  can  be  definitely  ex- 
cluded. 

Large  moist  rales,  or  mucous  rales,  occur  in  the  larger  bronchial  tubes, 
or  in  cavities,  from  the  same  causes  that  produce  small  rales.  The 
fluid,  however,  is  larger  in  amount,  the  air-current  stronger,  and  the 
space  for  vibration  is  greater.  While  sometimes  present  in  bronchitis, 
they  are  heard  in  their  most  marked  form  in  the  third  stage  of  phthisis. 
They  are  described  as  bubbling  and  gargling  rales,  and  are  very  char- 
acteristic after  a  full  breath  or  a  cough.     (See  Fig.  142.) 

Rales  are  to  be  distinguished  from  other  adventitious  sounds. 
Although  in  some  instances,  as  when  rales  are  heard  over  the  bases  of 
the  lungs,  it  is  almost  impossible  to  distinguish  them  from  friction 
sounds,  they  have  nevertheless  certain  marked  characteristics.  We 
recognize  rales,  first,  by  the  qualities  previously  mentioned.  Second, 
by  their  location;  if  the  adventitious  sounds  are  general,  they  are  due 
to  rales.  Third,  rales  are  modified  by  cough  or  breathing.  They  may 
be  intensified  by  either  act,  or,  after  the  completion  of  the  act,  may 
disappear  entirely.  On  quiet  breathing,  in  the  early  stages  of  tuber- 
culosis, for  instance,  they  may  not  be  heard  at  all.  It  is  absolutely 
necessary,  before  excluding  them,  to  have  the  patient  cough  and  then 
take  a  full  breath.  Fourth,  they  vary  in  position.  This  may  occur  from 
hour  to  hour.     If  the  chest  is  examined  in  the  morning,  they  may 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  51] 

be  more  pronounced,  for  instance,  at  the  base.  At  another  time  in  the 
twenty-four  hours  they  are  distinct  at  the  apex.  They  are  more  likely 
to  be  present  at  the  base  if  the  patient  is  kept  in  the  recumbent  posture. 
Fifth,  they  vary  in  character.  At  one  time  small,  moist  rales  are 
heard  ;  in  a  short  time  they  are  replaced  by  larger  rales.  Dry  rales 
are  regularly  followed  by  moist  rales  in  the  course  of  bronchitis.  In 
a  case  of  bronchial  asthma  all  sorts  of  rales  may  be  heard  in  a  few 
hours.  Sixth,  they  are  distant.  They  seem  to  be  further  away  from 
the  listening  ear  than  are  friction-sounds. 

Rales  in  the  bronchi  must  not  be  confounded  with  the  crepitant  or 
fine  crackling  sound  which  is  heard  at  the  base  of  the  lung  in  patients 
who  have  been  ill  with  the  exhaustive  fevers  and  who  have  not  taken 
full  breaths  for  some  time.  They  disappear  after  the  patient  has  in- 
spired deeply  half  a  dozen  times. 

Rales  throughout  the  lung  are  not,  in  themselves,  diagnostic  of  any 
affection  save  bronchitis,  in  which,  with  the  absence  of  other  physical 
signs,  their  occurrence  all  over  the  chest  is  significant.  In  the  absence 
of  this  affection  rales  at  the  base  of  both  lungs  are  due  to  congestion. 
Rales  at  one  apex,  with  failing  health,  point  to  the  onset  of  tubercu- 
losis. 

Friction-sound.  In  health  the  two  surfaces  of  the  pleura  rub 
together  without  making  any  sound.  If  they  are  inflamed,  the  sur- 
faces are  roughened,  as  swelling  and  dilatation  of  the  capillaries  pro- 
duce a  more  or  less  granular  surface,  or  because  of  transudation  of  fluid 
or  lymph.  Under  these  circumstances  rubbing  together  of  the  two 
surfaces  creates  a  sound,  to  which  the  term  friction  is  applied.  It  is 
heard  at  the  end  of  inspiration,  and  may  continue  during  expiration. 
It  is  a  localized  sound,  usually  at  the  seat  of  pain  ;  it  is  near  the  ear, 
and  is  not  modified  by  cough  or  full  breathing,  except  occasionallv 
by  the  latter  when  repeated.  It  occurs  in  "  nests  "  or  "  bunches." 
It  may  be  increased  by  the  pressure  of  the  stethoscope.  Moreover,  it 
is  a  fixed  sound,  in  that  it  does  not  disappear  until  effusion  takes  place. 
It  may  reappear  again  when  the  fluid  subsides.  The  above  character- 
istics distinguish  it  from  rales.  Both,  however,  may  occur  together. 
Although  almost  always  of  respiratory  rhythm,  when  the  pleurisy  is 
in  the  neighborhood  of  the  heart,  the  friction  may  be  of  cardiac 
rhythm.  Under  these  circumstances  it  is  more  distinct  during  the  act 
of  inspiration.  It  is  heard  as  a  systolic  rubbing,  often  of  respiratory 
rhythm,  along  the  borders  of  the  heart. 

We  not  only  distinguish  the  friction-sound  by  the  characters  just 
indicated,  but  also  by  the  presence  of  pain,  which  renders  its  existence 
more  probable.  Usually  it  is  heard  at  the  base,  in  the  nipple-line  in 
front,  or  at  the  angle  of  the  scapula  behind,  and  frequently  in  the 
axillary  region. 

In  addition  to  the  friction-sound  of  acute  pleurisy,  dry  creaking 
sounds,  not  unlike  the  sounds  produced  when  an  old  door  is  swung  on 
rusty  hinges,  or  when  new  leather  is  bent,  are  heard  in  cases  of  old 
pleurisy.  Other  physical  signs  of  pleural  adhesions  are  present,  and  a 
friction-fremitus  is  often  transmitted  to  the  hand.  An  old  or  dry  fric- 
tion is  often  heard  at  the  apex,  in  the  neighborhood  of  old  cavities.     It 


512  SPECIAL  DIAGNOSIS. 

attends  both  inspiration  and  expiration,  is  not  modified .  by  cough,  nor 
has  it  any  of  the  elements  of  the  moisture  that  attends  moist  rales. 
The  patient  may  be  cognizant  of  the  grating  or  rubbing  sensation,  and 
be  able  to  describe  the  sensation  during  each  breath.  It  may  continue 
a  long  time  after  an  acute  pleural  effusion  has  disappeared,  and  is 
sometimes  the  source  of  anxiety  upon  the  part  of  the  patient. 

Pysemic  deposits  in  the  lungs,  infarction,  bronchiectasis  with  reactive 
pneumonia,  and  pleurisy  with  emphysema,  are  first  revealed  by  pleu- 
ritic frictions  (Vierordt).  At  the  base  of  the  right  lung  they  may 
be  the  first  indication,  or  at  least  an  early  one,  of  hepatic  abscess 
(Clark).  The  pleural  friction  in  the  hepatic  region  must  not  be  con- 
founded with  peritoneal  friction  of  respiratory  rhythm.  In  a  case 
of  secondary  cancer  of  the  liver  a  friction-sound  was  heard  in  the 
seventh  interspace  from  perihepatitis  over  a  cancerous  nodule. 

Metallic  Tixklixg.  The  impression  imparted  to  the  listener  is 
that  of  the  falling  of  some  material  into  fluid  in  a  hollow  space.  The 
physical  condition  is  that  of  a  cavity  partly  filled  with  fluid,  partly 
filled  with  air,  into  which  there  is  dropping  from  an  opening  above. 
It  is  seen  in  hydropneumothorax  or  pyopneumothorax  and  in  a  few 
cases  of  large  cavities.  The  air-chamber  acts  as  a  consonance-box  and 
resonator,  and  gives  a  metallic  quality  to  the  sound.  Other  physical 
signs  of  cavity  and  fluid  are  associated.  It  may  be  heard  when  the 
patient  is  breathing  quietly,  or  only  after  coughing.  Sometimes  only 
tinkling  is  heard,  or  the  sound  of  a  number  of  drops  is  transmitted. 
The  latter  occurs  after  coughing. 

Bell-tympaxy.  The  bell-sound  is  heard  when  air  is  confined  in 
the  pleura.  If  the  stethoscope  is  placed  over  the  pleural  cavity,  and 
two  coins  are  used  as  plessor  and  pleximeter,  a  distinct  metallic  or 
anvil-sound  is  transmitted  to  the  ear.  The  cavity  containing  air  can 
be  clearly  outlined  if  the  metal  pleximeter  is  moved  about.  As  soon 
as  it  passes  over  a  part  of  the  chest  under  which  no  air  is  confined  the 
sound  is  not  heard.  Although  heard  in  nearly  all  cases  of  pneumo- 
thorax, there  are  some  cases  in  which  it  cannot  be  elicited,  probably 
because  of  the  small  size  of  the  aperture  in  the  pleura. 

Succussion.  The  ear  is  placed  to  the  side  of  the  chest,  and  the 
patient's  body  moved  suddenly  by  himself  or  by  the  observer.  A 
splashing  sound  is  heard.  It  can  only  be  produced  when  there  is  air 
as  well  as  fluid  present  in  a  cavity.  It  was  first  described  by  Hippo- 
crates, and  the  term  "  Hippocratic  succussion  "  has  been  given  to  it. 
It  is  characteristic  of  hydropneumothorax,  although  not  present  in  all 
cases  of  this  disease.  The  sound  may  be  audible  at  a  distance.  Metal- 
lic tinkling  can  usually  be  heard  at  the  same  time. 

Auscultation  of  the  Voice.  When  the  ear  or  stethoscope  is  applied 
to  the  surface  of  the  chest  and  the  patient  is  asked  to  speak,  the  vibra- 
tions of  the  air  in  the  trachea  and  bronchial  tubes  are  transmitted  to 
the  chest-wall  and  become  audible.  The  sound  is  known  as  the  vocal 
resonance.  It  is  a  sign  which  goes  hand-in-hand  with  vocal  or  tactile 
fremitus,  and  is  modified  by  the  same  conditions  which  modify  the 
latter.  While,  in  general,  conditions  which  increase  the  fremitus 
increase   the  vocal    resonance  also,   this  is    not   invariably  the  case. 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  513 

Sometimes  one  is  increased  and  not  the  other,  without  there  being  any 
evident  reason  for  it. 

Vocal  Resonance  in  Health.  It  varies  in  health  conjointly  with 
the  fremitus.  The  sound  is  purring  or  buzzing.  It  is  heard  more 
pronouncedly  at  the  right  apex  than  at  the  left ;  in  persons  with  thin 
chest-walls  ;  in  individuals  in  whom  the  voice  is  low  in  pitch  and 
strong.  It  is  lessened,  therefore,  in  females  and  children.  It  dimin- 
ishes the  further  away  the  ear  gets  from  the  larynx,  and  hence  is 
feebler  at  the  bases.  It  is  immaterial  what  words  are  selected  by  the 
patient  to  create  the  resonance.  It  is  important  for  the  student,  how- 
ever, to  become  familiar  with  the  resonance  of  a  definite  series  of  words 
which  when  pronounced  do  not  need  any  marked  change  in  inflection 
of  the  voice.  The  words  "  one,"  "  two,"  "  three,"  or  "  ninety-nine," 
spoken  repeatedly,  are  selected.  The  patient  should  not  raise  or  lower 
his  voice  during  the  act  of  speaking.  Symmetrical  portions  of  the  two 
sides  of  the  chest  must  be  examined  successively. 

Vocal  Resonance  Increased.  Increased  vocal  resonance  de- 
pends upon  the  intensity  or  extent  of  the  cause.  When  slightly  above 
normal  it  is  referred  to  as  slight  increase,  or  when  the  voice  is  trans- 
mitted comparatively  distinctly  to  the  ear  it  is  known  as  bronchophony. 
This  may  be  heard  in  health  over  the  trachea,  or  over  the  bronchi  be- 
hind. When  heard  over  the  vesicular  structures  of  the  lung,  it  indi- 
cates that  the  vibrations  are  transmitted  to  the  ear  by  some  better 
conducting  material.  This  is  usually  a  consolidated  lung,  and  hence  : 
1.  In  all  cases  of  consolidation  the  resonance  is  increased,  that  is,  bron- 
chophony is  created  ;  but  in  pneumonia,  if  the  bronchus  is  occluded  by 
exudate,  it  is  absent.  2.  If  the  lung  is  collapsed  but  the  bronchi  open, 
the  resonance  is  increased.  3.  It  is  also  increased  in  cavities.  Some- 
times the  resonance  is  intensified  and  the  sound  is  even  more  pro- 
nounced than  when  heard  over  the  trachea. 

Pectoriloquy.  The  voice  may  be  so  distinctly  transmitted  that 
we  have  the  impression  that  the  patient  is  speaking  into  the  mouth  of 
the  stethoscope.  If  the  patient  speaks  slowly  the  words  may  be  dis- 
tinctly heard.  It  is  more  striking  when  the  patient  whispers.  The 
term  "  whispering  pectoriloquy  "  is  then  applied  to  it.  It  is  detected 
over  a  cavity  if  it  communicates  with  a  large  bronchus,  and  sometimes 
in  consolidation  of  the  lung. 

Vocal  Resonance  Diminished.  Vocal  resonance  is  diminished 
or  absent  when  anything  cuts  off  the  supply  of  air,  and  intercepts  the 
vibrations  from  the  part  over  which  the  observer  is  auscultating.  Frem- 
itus and  resonance  are  absent  over  the  area  supplied  by  a  bronchus 
which  is  occluded  by  external  pressure,  as  an  aneurism.  Diminution 
or  absence  of  vocal  resonance  is  more  marked  in  cases  of  pleural  effu- 
sion (serum,  blood,  pus,  or  air)  or  thickened  pleura.  The  vibrations 
are  impeded  because  of  the  difference  of  conducting  material.  The 
degree  of  diminution  depends  upon  the  amount  of  effusion. 

Modifications  of  Vocal  Resonance.  1.  At  the  uppermost 
limit  of  the  pleural  effusions,  at  which  point  the  layer  of  fluid  is  thin, 
the  resonance  is  transmitted  in  a  modified  form.  It  is  tremulous  and 
bleating  in  character,  and  is  known  as  wgophony  because  it  resembles 

33 


514  SPECIAL  DIAGNOSIS. 

the  bleat  of  a  goat.  It  is  especially  heard  at  the  angle  of  the  scapula, 
or  below  it  in  cases  of  moderate  effusion.  It  is  due  to  the  fact  that 
the  fundamental  tones  are  intercepted  by  the  fluid,  while  the  other 
tones  are  allowed  to  pass  through  and  give  the  peculiar  bleating  sound 
(Gee).  2.  The  vocal  resonance  may  have  a  metallic  character  in  pneu- 
mothorax when  there  is  free  communication  with  the  bronchus. 

Cavities.  Pulmonary  cavities  are  due  to  destruction  of  lung  by 
abscess,  gangrene,  or  tuberculosis,  or  to  dilatation  of  the  bronchi. 

As  there  is  usually  a  local  increase  in  the  amount  of  air  in  cavities, 
there  is  in  consequence  a  local  area  of  exaggerated  resonance,  or  tym- 
pany, and  with  it  the  occurrence  of  cavernous  breathing,  or  breathing 
of  an  amphoric  type.  The  presence  of  a  cavity,  however,  is  often  diffi- 
cult to  recognize,  because  of  the  relation  to  the  surrounding  structure 
or  because  of  fluid  contents.  If  the  lung  about  it  is  the  seat  of  con- 
solidation, the  physical  signs  of  this  consolidation  may  over-ride  the 
signs  of  a  cavity.  If  compensatory  emphysema  surrounds  the  cavity, 
it  may  be  almost  impossible  to  recognize  it.  Moreover,  the  contents 
of  the  cavity  render  the  recognition  of  its  presence  difficult.  If  it  con- 
tains a  large  amount  of  fluid,  the  signs  of  consolidation  alone  may  be 
present.  Much  attention  has  been  paid  to  the  recognition  of  cavities, 
and  some  methods  have  been  proposed  by  which  it  is  thought  they  can 
be  distinguished.  While  it  is  a  satisfaction  to  determine  exactly  the 
presence  and  location  of  a  cavity,  it  is  not  an  essential  to  diagnosis. 
To  confirm  the  presence  of  an  excavation,  even  if  the  physical  signs 
point  to  its  occurrence,  the  diagnosis  should  be  controlled  by  exami- 
nation of  the  sputum.  If,  on  such  examination,  yellow  elastic  tissue 
is  found,  the  presence  of  a  cavity  is  more  probable.  The  methods 
employed  to  determine  their  presence  absolutely  have  been  named  after 
the  observers  who  devised  them. 

First,  Wintrich's  change  of  sound.  If  the  cavity  communicates  with 
a  large  column  of  air  in  the  bronchus,  and  percussion  is  employed  with 
a  moderate  degree  of  force,  the  note  will  change  as  the  patient  alter- 
nately opens  and  closes  the  mouth.  If  the  mouth  is  open  wide,  the 
sound  is  louder  and  more  distinctly  tympanitic  and  higher  in  pitch. 
If  the  mouth  is  closed,  the  sound  is  correspondingly  lessened  and  not 
so  tympanitic.  Indeed,  sometimes  a  sound  is  obtained  Avith  scarcely 
a  trace  of  tympany.  This  change  of  sound  is  in  all  probability  due  to 
change  in  the  resonant  cavities  in  the  upper  respiratory  tract.  It  must 
not  be  confounded  with  "  Williams'  tracheal  tone,"  which  can  be 
elicited  near  the  junction  of  the  clavicle  and  sternum  on  the  left  side, 
in  cases  of  consolidation  of  the  underlying  portion  of  the  lung,  partic- 
ularly if  the  force  of  the  blow  is  directed  toward  the  trachea.  Strong 
percussion  is  necessary  to  bring  out  Williams'  tone.  ■* 

Second,  interrupted  change  of  sound,  also  described  by  Wintrich,  is 
distinguished  from  the  simple  change,  in  that  it  occurs  in  different 
positions  of  the  body.  It  may  be  heard  when  the  patient  is  in  an 
upright  position,  and  disappear  when  he  assumes  the  recumbent  posture  ; 
or  the  converse  may  be  true.  The  change  in  position  changes  the 
relation  of  the  bronchus  to  the  cavity,  on  account  of  which  the  varying 
tympanitic  sound  is  produced. 


DISEASES  OF  THE  LUNGS  AND  PLEURJE.  51 5 

Third,  Gerhardt's  change  of  sound.  This  change  depends  upon  the 
alteration  of  the  level  of  the  fluid  when  the  patient  assumes  the  up- 
right, or  the  dorsal  position.  It  is  not  necessary  that  the  cavity  com- 
municate with  the  large  bronchus.  It  is  a  positive  symptom  of  a  cavity, 
but  rarely  present.  The  sound  changes  in  pitch  and  in  the  degree  of 
tympany.  It  may  be  absolutely  dull  over  the  lower  part  of  the  cavity 
when  the  upright  position  is  assumed,  because  the  fluid  gravitates  to 
this  portion  and  comes  in  contact  with  the  chest- wall. 

Fourth,  Friedreich's  respiratory  change  of  sound.  Respiratory  per- 
cussion. (Da  Costa.)  The  pitch  of  the  sound  becomes  higher  at  the 
end  of  a  deep  inspiration.  It  depends  upon  increased  tension  of  the 
chest-wall  and  lung-tissue,  and  the  wall  of  the  cavity,  during  the  act 
of  inspiration.  It  may  be  a  source  of  confusion,  which  is  obviated  by 
percussing  at  the  same  stage  of  the  breathing  each  time,  or  percussing 
only  on -superficial  breathing. 

Fifth,  Seitz  has  called  attention  to  a  form  of  breathing  named  meta- 
morphosing. Inspiration  begins  harshly  bronchial,  then  becomes  faintly 
bronchial,  the  latter  sound  being  heard  also  in  expiration.  It  is  said 
to  be  a  sure  sign  of  cavity. 

Resume.  The  student  must  bear  in  mind  in  auscultation  to  note  : 
(1)  If  the  sounds  are  increased  or  diminished  in  intensity ;  (2)  the 
rhythm  of  the  inspiratory  and  expiratory  sounds  ;  (3)  if  the  respiratory 
murmur  is  replaced  by  bronchial  breathing  or  its  modification  ;  (4)  the 
presence  of  new  sounds  (rales  and  friction) ;  (5)  the  voice-sounds. 

Mensuration.  By  mensuration  or  thoracometry,  the  results  secured 
by  palpation  are  confirmed  more  accurately.  The  size  and  the  degree 
of  expansion  of  the  chest  are  ascertained.  Hence  the  circumference 
and  diameter  of  the  chest  are  determined  and  the  differences  in  the 
shape  and  movement  of  two  sides  made  manifest.  If  the  measure- 
ment is  taken  from  day  to  day,  it  can  be  graphically  recorded  by 
tracing  sections  on  paper,  and  delicate  changes  can  thus  be  definitely 
ascertained.  The  circumference  of  the  chest  is  measured  by  means  of 
the  ordinary  tape-measure  or  by  metal  tapes  joined  together  by  a 
hinge.  The  latter  can  be  made  to  fit  the  circumference  of  the  chest 
accurately,  and  are  essential  in  order  to  transfer  the  section  to  paper. 
The  middle  of  the  hinge  is  held  firmly  over  the  spinous  process  of  the 
vertebra,  while  the  two  limbs  are  carried  around  the  chest,  moulded 
to  all  inequalities,  and  crossed  in  front,  one  above  the  other  ;  a  mark 
is  made  on  each  where  it  crosses  the  middle  line.  Measurements 
should  be  taken  at  about  the  level  of  the  nipples,  and  two  inches  below 
them,  and  care  should  be  taken  to  have  the  level  the  same  in  front  and 
behind.  They  sin  mid  be  taken  in  full  inspiration  and  expiration,  and 
in  repose.  The  outline  secured  by  this  method  need  not  be  disturbed, 
as  by  flexion  on  the  hinges  we  are  enabled  to  remove  it  intact.  The 
tapes  arc  carefully  transferred  to  a  sheet  of  paper,  on  which  imaginary 
diameters  have  been  marked.  After  fixing  the  corresponding  points  of 
the  tapes  on  the  lines  of  the  respective  diameters,  the  outline  can  then 
be  traced. 

Woillez's  cyrtometer  is  a  chain  with  links  which  is  used  to  ascertain 
the  exact  circumference.     The  diameter  of  the  thorax   is  secured  by 


516  SPECIAL  DIAGNOSIS. 

means  of  caliper  compasses.  The  antero-posterior  diameter  should  be 
taken  on  a  level  with  the  nipple  and  the  insertion  of  the  second  rib 
behind  ;  the  transverse  diameter  at  the  highest  points  of  the  axilla?. 
The  length  of  the  chest  may  be  ascertained  by  measuring  in  the  mid- 
clavicular line  from  the  clavicle  to  the  border  of  the  ribs.  It  is  im- 
portant to  remember  that  the  right  side  of  the  chest  measures  a  little 
more  than  the  left  in  people  who  are  right-handed. 

The  respiratory  capacity  is  estimated  by  measurement  of  the  circum- 
ference of  the  chest.  This  is  secured  by  taking  the  measurement  at 
the  end  of  complete  expiration  and  then  at  the  end  of  complete  inspi- 
ration. In  health  the  difference  between  the  two  should  be  from  five 
to  ten  centimetres  (two  to  four  inches).  If  the  expansion  is  less  than 
two  inches,  it  is  considered  deficient  by  insurance  companies,  and  the 
risk  is  not  regarded  as  first-class.  The  expansion  is  less  in  women. 
In  taking  the  measurement  the  observer  must  be  particular  to  keep  the 
terminal  portion  of  a  tape-measure  fixed  in  the  median  line  of  the 
structure.  The  other  portion  is  to  be  held  in  the  hand,  so  as  to  move 
with  inspiration  and  expiration.  Always  mark  in  advance  the  ante- 
rior mesial  line  and  note  the  exact  level  at  which  measurements  are 
made  when  they  are  taken  daily.  Deficiency  of  chest-expansion  not 
only  indicates  the  presence  of  a  local  morbid  process — notably  incipi- 
ent tuberculosis,  but  it  also  indicates  lack  of  strength  and  of  muscular 
development,  of  physiological  deficiencies,  rather  than  physical,  and  is 
an  unerring  guide  to  the  need  of  respiratory  gymnastics. 

Spirometry.  By  means  of  the  spirometer  Dr.  John  Hutchinson 
has  been  able  to  estimate  the  quantity  of  air  taken  in  with  each  inspi- 
ration and  discharged  with  expiration.  By  it  the  respiratory  or  vital 
capacitv  is  estimated.  The  data  ascertained  are  not  of  much  diagnostic 
significance,  although  if  measurements  are  made  from  day  to  day  we 
may  be  able  to  estimate  the  extent  of  recovery  from  disease  of  the  lung 
which  was  incapacitated.  When,  however,  there  is  an  important 
diminution  of  lung-capacity,  tuberculosis  may  be  suspected,  before 
subjective  and  objective  signs  warrant  a  diagnosis.  We  can  also  esti- 
mate the  degree  of  interference  with  breathing  by  disease  below  the 
diaphragm.  Spirometry  is  of  particular  value  because  it  shows  in  a 
graphic  manner  the  need  for  respiratory  gymnastics.  By  means  of 
Waldenburg's  pneumotometer  the  respiratory  pressure  of  air  on  inspi- 
ration and  expiration  is  determined.  Expiratory  pressure  is  dimin- 
ished in  emphysema,  and  the  degree  of  diminution  may  furnish  a  clue 
to  the  severity  of  the  disease  or  the  degree  of  improvement.  It  is 
to  be  remembered  that  the  expiratory  pressure  always  exceeds  the  in- 
spiratory pressure  in  health  by  as  much  as  20  to  30  millimetres,  accord- 
ing to  Waldenburg.  It  is  natural  to  find  that  inspiratory  pressure  is 
lessened  in  stenosis  of  the  air-passages,  in  phthisis  and  in  pleural  effu- 
sions, although  it  is  not  of  diagnostic  significance. 

The  following  measurements,  secured  by  laborious  investigation,  are 
excellent  criteria  from  which  pathological  inductions  can  be  made. 


DISEASES  OF  THE  LUNGS  AND  PLEURjE. 


517 


Measurements  of  the  Chest  and  Lung  Capacity. 

(Otis,  Boston  Medical  and  Surgical  Journal,  1895.) 
Table  I.— Chest  Measurements. 


Girth,  muscular. — Men: 

Average  of  Dr.   E    0.  Otis,   1000  measurements, 

between  sixteen  and  forty  years  of  age 
Average  of  Dr.  Hitchcock,  of  Amherst  College, 

8000  measurements    ...... 

Average  of  E.  Hitchcock,  J.,  of  Cornell  College, 

15,000  measurements  ..... 

Girth,  muscular. — Women: 

Mt.  Holyoke  and   Wellesley  students.     Measure- 
ments of  Miss  Wood  and  Dr.  Mary  Colton 
Chest,  respiratory. — Men: 

Average  of  Dr.  E.  O.  Otis,  1000  measurements    . 
Chest,  respiratory. — Women  : 

50  per  ct.  of  1500  of  Wellesley  students,  Miss  Wood 
Depth  of  chest. — Men  : 

Average  of  Dr.  E.  O.  Otis,  1 250  measurements  in 
repose  and  362  inflated      ..... 
Depth  of  chest. — Women  : 

50  per  ct.  of  1500  students  at  Wellesley,  Miss  Wood 
Breadth  of  chest. — Men 

Average  of  Dr  E.  O.  Otis,  400  measurements 


Repose, 
inches. 

Inflated, 
inches. 

Difference, 
inches. 

34.0 

36.1 

2.1 

3^.6 

36.5 

1.9 

34.5 

36.3 

1.8 

29.5 

31.5 

3.0 

31.1 

33.1 

2.0 

24.6 

27.2 

2.6 

7.5 
6.9 
9.9 


8.3 


10.8 


0.8 


0.9 


Men : 


Table  II.—  Capacity  of  Lungs. 


Average  of  Dr.  E.  O.  Otis,  1000  measurements  . 

Hitchcock,  8000  measurements  ........ 

Hitchcock,  Jr.,  15,000  measurements  ...... 

Women : 

Mt.   Holyoke  and  Wellesley  students,  measurements  of  Miss  Wood 
and  Dr.  Mary  Colton      ......... 

50  per  cent,  of  1500  Wellesley  students,  Miss  Wood  .... 


Cubic  inches. 

240.6 

230.0 
,     236.6 


145.8 
150.3 


Table  III. — Comparison  of  the  "vital"  or  lung  capacity  and  the  amount  of 

air  expelled  after  an  ordinary  quiet  respiration. 

Average  of  Dr.  E.  O.  Otis,  150  measurements. 

Cubic  inches. 

Vital  capacity,  or  the  amount  of  air  exhaled  after  a  full  inspiration  .     230.5 
Amount  of  air  exhaled  after  an  ordinary  quiet  respiration  .         .     129.3 

Difference,  or  "  complemental  "  or  "  reserve  "  air        ....     101.2 
Difference  as  given  by  Hermann  .         .         .         .         .         .         .97.6 


66  to  67 

167.7  to 

67  to  68 

170.3  to 

68  to  69 

172.8  to 

69  to  70 

175.4  to 

70  to  71 

177.9  to 

71  to  72 

180.5  to 


Average 

Height. 

inches  inclusive. 

170.3  centimetres, 
inches  inclusive. 
172.  S  centimetres, 
inches  inclusive. 

175.4  centimetres, 
inches  inclusive. 
177.9  centimetres, 
inches  inclusive. 

180.5  centimetres, 
inches  inclusive. 
183.0  centimetres. 


Lung  Capacity  for  Height  (Otis 

Lung  capacity. 

231.62  cubic  inches. 
3797  cubic  centimetres. 
237.10  cubic  inches. 
3903  cubic  centimetres. 
244.44  cubic  inches. 
4007  cubic  centimetres. 
259. 34  cubic  inches. 
4250  cubic  centimetres. 
261.38  cubic  inches. 
4284  cubic  centimetres. 
201.34  cubic  inches. 
4284  cubic  centimetres. 


Average  for  each  inch  or 
centimetre  in  height. 

3.4  -f-  cubic  inches. 
22.4    cubic  centimetres. 

3.46  cubic  inches. 
22.7    cubic  centimetres. 

3.5  cubic  inches. 
23.06  cubic  centimetres. 

3.66  cubic  inches. 
24.06  cubic  centimetres. 

3.64  cubic  inches. 
23.9    cubic  centimetres. 

3.5  cubic  inches. 
23.03  cubic  centimetres. 


General  average 


3.52  cubic  inches,  for  each  inch  of  height. 
23.19  cubic  centimetres,  for  each  centimetre  of  height. 


518  SPECIAL  DIAGNOSIS. 

Powel  lays  great  stress  upon  the  fact  that  in  phthisis  the  inspiratory 
capacity  is  diminished,  but  the  expiratory  power  remains  normal. 

Combination  of  Physical  Signs.  In  order  to  determine  the  physi- 
cal condition  of  the  lung,  it  is  necessary  to  draw  conclusions  from  the 
results  obtained  by  all  the  methods  of  physical  examination.  It  is  the 
exception  that  any  one  sign  is  pathognomonic  of  a  physical  condition. 
If  the  student  will  glance  over  the  abnormal  physical  conditions  which 
may  take  place  in  the  lung,  he  will  find  that'  they  may  be  divided, 
first,  into  physical  changes  in  the  lung  proper,  and,  second,  into  physi- 
cal changes  in  the  pleura.  With  regard  to  the  lung,  it  will  be  further 
noted  that  the  changes  are  due  to  an  increased  amount  of  air  or  to  a 
diminution  in  the  amount  of  air. 

Increase  in  the  amount  of  air  may  be  general,  unilateral,  or  local, 
and  is  indicated  by  a  combination  of  physical  signs  which  are  usually 
unerring.  On  inspection  (a)  enlargement,  general,  unilateral,  or  local ; 
(b)  increased  action  in  general  emphysema,  although  with  diminished 
respiratory  excursion  ;  when  unilateral  or  local,  increased  action  and 
increased  expansion  (compensatory  emphysema).  On  palpation,  in- 
spection confirmed,  and  vocal  fremitus  diminished  when  the  increased 
amount  of  air  is  general,  slightly  increased  when  it  is  unilateral  or 
local.  On  percussion  in  each  instance  exaggerated  resonance  or  tym- 
pany. On  auscultation,  when  general  (emphysema),  feeble  respiratory 
murmur,  with  prolonged  expiration  ;  when  unilateral  or  local,  exagger- 
ated respiratory  murmur.  The  difference  in  the  physical  signs  of 
increased  amount  of  air  is  not  due  to  the  difference  in  quantity,  but 
to  the  associate  physical  condition  and  the  force  of  the  movement  of 
the  air.  The  diminished  expansion  and  feeble  respiratory  murmur  in 
emphysema  are  due  to  inability  to  exhale  the  air  because  of  the  dimin- 
ished elasticity  of  the  lung,  while  the  bronchioles  occluded  from  bron- 
chitis lessen  the  fremitus.  In  cavities — local  increase  of  air — the 
physical  condition  of  the  tissue  which  surrounds  them  modifies  the 
physical  signs. 

Decrease  in  the  Amount  oj  Air.  The  diminution  in  the  amount  of 
air  from  change  in  the  physical  condition  of  the  lung  is  due  to  consoli- 
dation or  to  collapse.  The  latter  occurs  when  the  bronchus  is  obstructed, 
the  former  in  congestion,  pneumonia,  gangrene,  abscess,  forms  of  tuber- 
culosis, and  hemorrhagic  infarct.  The  physical  signs  are  the  same 
under  all  circumstances,  except  in  collapse  :  expansion  lessened,  fremi- 
tus increased,  dulness,  bronchial  breathing.  The  signs  vary  with  the 
degree  of  consolidation  as  follows  :  Slight  increase  to  greatly  increased 
fremitus,  unpaired  resonance  to  complete  dulness,  broncho-vesicular  to 
bronchial  breathing.  In  tuberculosis  there  may  be  flattening  of  the 
chest-wall,  but  otherwise  the  signs  are  the  same.  The  presence  of 
new  sounds  depends  upon  the  amount  of  secretion  or  fluid,  as  is  the 
case  when  there  is  increase  of  air  in  the  part, 

Broadly  speaking,  therefore,  in  affections  of  the  lung  proper,  the  two 
conditions  just  mentioned  must  be  differentiated — air  increased,  air 
diminished.  We  do  not  refer  to  bronchitis,  because  no  physical  change 
takes  place  in  the  lung,  and  the  signs  depend  upon  the  amount  of 
fluid  in  the  tubes. 


DISEASES  OF  THE  LUNGS  AND  PLEURJS.  519 

The  Pleura.  If  satisfied  that  the  physical  condition  is  not  due  to 
change  in  the  king  structure,  the  state  of  the  pleura  must  be  investi- 
gated. Here,  too,  the  physical  condition  may  be  due  to  an  excessive 
accumulation  of  air  or  to  an  accumulation  of  fluid  or  solid  material. 
In  effusion  there  is  enlargement  of  the  affected  side,  diminished  move- 
ment, diminution  of  fremitus  and  of  vocal  resonance.  When  air  is 
present,  however,  there  is  tympany  ;  when  fluid,  there  is  dulness  on 
percussion. 

The  problem  may,  however,  be  looked  at  from  another  side.  1.  The 
percussion-note  is  tympanitic  and  indicates  that  there  is  an  increased 
amount  of  air.  Is  this  in  the  pleura  or  in  the  lung  ?  If  in  the  pleura,  it 
can  only  be  unilateral,  and  is  recognized  by  diminution  of  the  move- 
ment and  of  fremitus,  as  against  increased  movement  and  fremitus 
when  due  to  unilateral  increase  of  air  in  the  lung  proper  (compensatory 
emphysema).  2.  The  percussion-note  is  dull  and  indicates  the  absence 
of  air.  Is  this  in  the  pleura  or  in  the  lung  ?  A  distinction  between 
consolidation  and  pleural  effusion  must  be  made.  In  consolidation 
there  are  increased  fremitus,  increased  vocal  resonance,  bronchial  breath- 
ing, and  dulness  on  percussion.  There  mayor  may  not  be  contrac- 
tion. In  pleurisy  with  effusion,  diminished  or  absent  movement,  absent 
fremitus  and  resonance,  dulness  on  percussion,  feeble,  distant,  or  absent 
breath-sounds.  The  distinction  of  the  two  physical  conditions  seems 
easy,  and  yet  the  physical  signs  may  not  be  sufficiently  definite  to 
warrant  a  positive  conclusion.  There  are  cases  in  practice  in  which  it 
is  almost  impossible  to  determine  which  is  present.  It  has  been  stated 
previously  that  bronchial  breathing  may  be  present  in  pleural  effu- 
sions. To  add  to  the  difficulty  in  certain  cases  of  consolidation  it  may, 
however,  be  absent,  and  so  may  the  vocal  fremitus  and  resonance. 
Apart  from  the  associate  general  and  local  symptoms,  we  must  look 
to  two  methods  of  corroborative  proof  of  the  presence  of  fluid.  First, 
exploratory  puncture;  and,  second,  displacement  of  organs.  The  former 
has  been  spoken  of.  The  latter  includes  displacement  of  the  heart  to 
the  right  or  to  the  left,  depending  upon  the  seat  of  the  effusion  ;  dis- 
location of  the  liver  ;  and,  in  cases  of  left  pleural  effusion,  obliteration 
of  the  half-moon  space  (Traube's  line). 

Sputum. 

This  term  is  applied  to  all  the  products  of  secretion  of  the  mucous 
membrane  of  the  respiratory  tract,  and  other  substances  that  may  be 
brought  up  through  the  respiratory  tract.  The  characters  of  sputa  in 
disease  vary  with  the  part  affected,  as  well  as  with  the  pathological 
nature  of  the  disease.  It  is  always  well  to  examine  each  specimen 
both  macroscopicaMy  and  microscopically. 

Method  of  Collection.  Sputum  that  is  to  be  examined  should 
be  collected  in  perfectly  clean  vessels,  containing  no  fluid,  preferably 
in  glass  or  white  earthenware  spittoons,  and  care  should  be  exercised 
against  the  entrance  of  any  extraneous  substances,  as  tobacco  or  parti- 
cles of  food  from  the  mouth,  or  from  outside  sources,  or  from  the 
stomach  through  vomiting.     Tobacco,  prunes,  and  bread  crusts  arc  at 


520  SPECIAL  DIAGNOSIS. 

times  mistaken  for  blood.  It  is  also  necessary  to  see  that  the  matter 
sent  for  examination  is  derived  from  the  lungs,  and  is  not  simply  the 
oral  and  faucial  accumulation.  If  practicable,  the  mouth  and  pharynx 
should  be  first  rinsed  with  a  warm  alkaline  solution.  The  true  sputum 
is  coughed  up. 

We  usually  require  in  the  examination  one  or  two  glass  dishes  or 
plates,  a  large  and  a  small  piece  of  window-glass,  mounted  needles,  and 
forceps  ;  for  microscopic  work,  in  addition  to  these,  a  good  microscope 
and  accessories,  and  certain  staining  fluids.  Sputa  which  upon  exam- 
ination has  been  found  to  contain  tubercle  bacilli  should  not  be  allowed 
to  dry  in  the  air,  but  should  be  thoroughly  mixed  with  a  1  :  20  car- 
bolic acid  solution,  or  a  6  per  cent,  formalin  solution  should  be  added 
to  the  sputa  after  the  examination  is  completed. 

In  describing  sputum  we  note  the  quantity  in  twenty-four  hours  ; 
its  color,  odor,  specific  gravity,  its  composition  and  consistency,  whether 
mucous,  purulent,  mucopurulent,  frothy,  watery,  bloody,  tenacious  or 
viscid,  and  whether  it  is  made  up  of  separate  layers  or  is  homogeneous. 

The  quantity  in  twenty-four  hours  varies  from  a  few  c.c.  to  even 
1000  c.c,  as  in  a  discharging  empyema. 

The  color  changes  with  the  composition  and  the  nature  of  the  disease. 
Thus,  in  acute  bronchitis  and  (edema  of  the  lung  it  is  white  ;  in  puru- 
lent sputa,  no  matter  what  the  cause,  it  is  yellow  or  greenish-yellow  ; 
in  pneumonia,  "  rusty  ;"  in  abscess  of  the  liver  with  amoeba?  character- 
istics, brownish-red  or  like  "  anchovy  sauce." 

The  odor  is  characteristic  in  a  few  cases  only.  That  of  bronchiec- 
tasis, gangrene,  and  putrid  bronchitis  is  particularly  heavy  and  fetid — 
a  characteristic  which  renders  its  origin  almost  unmistakable. 

The  reaction  is  always  alkaline. 

The  specific  gravity  may  vary  from  1.0043  (mucus  sputum)  to 
1.0375  (serous).     (Von  Jaksch). 

Varieties  of  Sputum.  Mucus  sputum,  on  account  of  the  mucin, 
is  usually  glairy,  clear,  and  tough.  It  is  seen  in  acute  bronchitis  in 
the  early  stage,  and  in  oedema  of  the  lung.  In  health  a  small  amount 
of  mucus  is  expectorated,  which  in  cities  and  smoky  towns  is  apt  to 
contain  black  pigment-particles,  due  to  inhaled  soot. 

Purulent  sputum  is  composed  almost  entirely  of  pus.  Typical 
purulent  sputum  is  that  from  an  empyema  discharging  through  a  bron 
chus.  It  may  also  occur  in  bronchiectasis,  chronic  bronchitis,  abscess 
of  the  lung,  of  the  liver,  or  more  rarely  of  the  mediastinum,  discharging 
through  a  bronchus  ;  or  it  may  be  the  discharge  of  a  tubercular 
vomica.  The  special  condition  can  usually  be  determined  by  micro- 
scopical examination  and  the  accompanying  symptoms  and  signs. 

Mucopurulent  Sputum.  It  is  most  common  to  have  mucus  and 
pus  mixed  together  in  varying  proportions,  and  then  it  is  termed 
mucopurulent,  Such  sputa  may  be  found  in  the  same  conditions  as 
purulent  sputa.  When  flat,  coin-shaped  masses  are  formed,  sinking 
to  the  bottom  if  the  vessel  contains  water,  as  in  phthisis  and  chronic 
bronchitis,  it  is  known  as  "  nummular  "  sputum  ;  or  it  may  be  more 
spherical,  and  is  then  called  "  globular."  At  times  the  sputa  may  be 
seen  to  separate  into  three  distinct  layers,  the  upper  frothy,  mueopuru- 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  521 

lent,  greenish-yellow,  or  dirty-green,  sometimes  lumpy,  sometimes 
composed  of  shreds  ;  the  middle  thin  and  watery,  with  shreds  from 
the  upper  layer  ;  and  the  bottom  layer,  apparently  made  up  of  pus 
and  debris,  opaque,  and  without  air-bubbles.  It  points  to  gangrene 
of  the  lung  in  most  instances,  but  may  also  occur  in  bronchiectasis. 

Watery  or  serous  sputum  is  the  result  of  oedema  of  the  lung. 
Such  sputum,  also  called  albuminous  expectoration,  is  discharged  after 
paracentesis  of  the  chest.  Beginning  during  or  as  late  as  two  hours 
after  the  operation,  from  one  to  three  pints  may  be  discharged  in  a  few 
hours. 

Bloody  Sputum — Haemoptysis.  As  blood  in  sputum  is  always 
of  importance,  the  entrance  of  substances  as  mentioned  above,  which 
simulate  it  in  appearance,  should  be  guarded  against.  It  may  be  seen 
in  greatly  varying  quantities  and  have  many  different  sources,  aud  it 
may  be  of  slight  or  grave  significance.  It  may  come  from  the  gums, 
nose,  pharynx,  or  larynx,  and  in  all  cases  such  sources  should  be  exam- 
ined. Again,  there  may  be  cases  in  which  bleeding  from  the  stomach 
(hfematemesis)  or  oesophagus  simulates  hemorrhage  from  the  lungs, 
but  still  more  often  people  speak  of  vomiting  blood  that  really  has 
come  from  the  lungs.  Usually  that  from  the  lungs  is  much  more 
frothy  and  bright-red,  while  that  from  the  stomach  is  darker  and 
acid,  and  may  contain  particles  of  food.  Diagnosis  is  more  difficult 
when  some  blood  from  the  lungs  is  first  swallowed  and  then  vomited. 

Usually  there  is  a  distinct  history  of  preceding  cough,  and  for  some 
time  afterward  small  amounts  of  blood  continue  to  be  expectorated. 
(See  Lungs  ;  Hemorrhage.) 

Small  amounts  of  blood  streaking  the  mucus  sputum  or  appearing 
in  small  clots  often  come  from  the  throat  or  nose  or  upper  air-pas- 
sages, but  may  come  from  the  lungs.  Mucopurulent  sputum  streaked 
with  blood  is  frequently  indicative  of  phthisis.  In  pneumonia  the 
rusty  sputa  are  the  result  of  an  admixture  of  mucus  and  blood,  and 
usually  contain  small  air-bubbles.  When  the  blood-coloring  matter 
is  changed  there  may  be  a  yellowish  or  greenish  tinge.  In  certain 
cases  of  chronic  pneumonia,  in  which  the  blood  remains  longer  in  the 
lung-tissue,  the  expectoration  has  a  darker  color.  The  same  color  may 
be  observed  when  there  is  a  slight  leakage  from  an  aneurism.  Pneu- 
monia accompanied  by  expectoration  of  large  amounts  of  blood  is  often 
of  tuberculous  origin.  Blood  may  be  mixed  with  the  greenish  expec- 
toration of  gangrene.  According  to  Finlayson,  this  is  especially  true 
in  children.  In  chronic  valvular  disease  of  the  heart,  and  in  oozing 
from  aneurism,  frothy  mucus  containing  more  or  less  blood  is  com- 
monly seen.  "  Currant-jelly  "  sputa  are  more  or  less  characteristic  of 
malignant  growths  of  the  lungs,  while  the  expectoration  from  a  liver 
abscess  with  amoebae  is  reddish-brown  in  color,  from  the  mixture  of 
blood,  pus,  and  bile-elements,  and  is  not  unlike  "  anchovy  sauce." 
We  may  have  hemorrhage  from  the  lungs  as  part  of  a  general  hemor- 
rhagic tendency,  as  in  purpura  and  hemorrhagic  smallpox  ;  in  so-called 
"  vicarious  menstruation  "  there  may  be  haemoptysis.  But  a  patient 
presenting  such  symptoms  should  be  examined  with  the  greatest  care, 
to  exclude  actual  pulmonary  complication.      When  great  quantities  of 


522 


SPECIAL  DIAGNOSIS. 


blood  are  expectorated  we  suspect  tuberculosis  of  the  lung,  aneurism,  or 
cardiac  valvular  disease. 

The  unaided  eye  may  distinguish  other  foreign  substances,  such  as 
fibrinous  and  spiral  casts  of  the  bronchi  or  trachea  ;  but  full  considera- 
tion of  them  will  be  given  further  on. 

Microscopical  Examination  of  the  Sputum.  (See  Fig.  143.) 
TThite  blood-corpuscles,  usually  of  the  polymorphonuclear  variety, 
are  present  in  all  sputa,  but  in  varying  numbers  and  size.  They  are 
most  abundant  in  purulent  sputa.  Often  they  contain  fat-drops  and 
pigment-particles.  In  stained  preparations  of  sputa  in  cases  of  acute 
croupous  pneumonia,  influenza,  pneumonia,  or  phthisis,  frequently 
many  of  the  leucocytes  contain  large  numbers  of  organisms — i.  e.,  pneu- 
mococci,  influenza  bacilli,  or  tubercle  bacilli. 

Red  blood-corpuscles  are  to  be  found  in  most  sputa.  They 
may  be  so  few  as  not  to  give  a  red  color.  The  source  is  often  high  up 
in  the  respiratory  tract.  When  they  are  present  in  large  numbers  the 
sputum  is  more  or  less  tinged,  and  in  heemoptysis  it  is  almost  wholly 
made  up  of  red  cells.  Usually  each  cell  is  well  preserved,  but  they  may 
appear  as  pale  bodies  or  as  rings,  the  pigment  remaining  in  the  sputum 
as  pigment-particles  or  as  crystals  of  heematoidin,  as  in  pneumonia. 

Eosixophile  cells  are  frequently  found  in  large  numbers  in  the 
sputum  in  cases  of  asthma.  They  are  also  present  in  the  sputum  in 
acute  and  chronic  bronchitis  and  in  phthisis.  Their  presence  in  the 
sputum  in  cases  of  phthisis  is  considered  by  Teichmuller  to  be  of 
favorable  import. 

Fig.  143. 


'V- 
~n    7"       "      // 


-    ■ 


fe 


6  -,'••' 


Various  objects  from  sputum.  1,  squamous  epithelium  ;  2,  red  blood-corpuscles  ;  3,  polynuclear 
leucocytes  ,  4,  alveolar  cells :  5,  ravelin-cells  ;  6,  pigment-cells  ;  7,  elastic-tissue  fibres ;  8.  squamous 
cells  ;  9,  hsematoidin-crystals ;  10,  phosphate  crystals  :  11,  fungi ;  12,  fat-globules  ;  13,  free  pigment. 
(Original  observation.) 

Epithelium.  Two  general  varieties  are  found  in  the  sputum — squa- 
mous and  cylindrical.  The  former  comes  from  the  mucous  membrane 
of  the  mouth,  the  tongue,  tonsils,  true  vocal  cords,  and  perhaps  from 
the  salivary  and  small  bronchial  glands.  It  has  no  clinical  impor- 
tance.    (See  Fig.  143.) 


DISEASES  OF  THE  LUNGS  AND  PLEURAE. 


523 


Cylindrical  cells  in  sputum  are  rarely  perfect.  It  is  uncommon  to 
find  the  cilia  intact,  and  still  more  so  in  motion,  while  the  body  of  the 
cells  is  likely  to  be  changed.  They  are  found  in  inflammations  of 
the  trachea  and  bronchi,  or  the  posterior  nasal  fossa — a  locality  where, 
it  must  be  remembered,  ciliated  epithelium  exists. 

"  Alveolae  "  epithelium,  so  called,  when  found  in  the  sputum, 
is  more  important  than  the  above,  as  different  observers  consider  its 
presence  to  have  more  or  less  clinical  significance.  The  cells  are  ellip- 
tical or  round,  somewhat  larger  than  white  corpuscles,  with  a  single 
nucleus,  which  is  indistinct  without  the  addition  of  acetic  acid.  The 
protoplasm  is  granular  and  contains  particles  of  iron-dust,  carbon,  or 
blood-coloring  matter,  and  often  fat-drops.  The  cells  may  also  have 
undergone  complete  fatty  degeneration,  and  they  have  been  considered 
the  source  of  rny elm-drops  in  the  sputum. 

Bizzozero  has  shown  that  alveolar  epithelium  not  only  occurs  in 
almost  all  pulmonary  affections,  but  also  at  times  in  normal  sputum. 

Detection.  A  small  bit  of  sputum  is  placed  on  a  microscope-slide 
and  a  cover-slip  applied.  Examine  with  varying  powers,  and  again, 
after  acetic  acid  is  added,  stain  the  cells  with  an  aqueous  solution  of 
methylene-blue. 

Frequently  in  cases  of  heart  disease  with  failing  compensation,  espe- 
cially where  the  mitral  valve  is  affected,  the  alveolar  cells  may  contain 
large  amounts  of  blood  pigment. 

Gtaxt  cells  have  been  found  in  the  sputum  of  phthisis  cases. 

Elastic  Fibres.  As  the  presence  of  elastic  fibres  in  sputa  is  of 
much  import,  denoting  destruction  of  the  lung-tissue,  bronchi,  or  the 
larynx  or  bloodvessels,  their  presence  from  food  remaining  in  the 
mouth  must  be  especially  guarded  against.     They  may  be  mistaken 


Fig.  144. 


Elastic  fibres  of  lung-tissue  obtained  from  sputa  after  digestion  in  caustic  soda. 
(Drawn  by  Dr.  John  Wilson.) 


for  fat-crystals.  Tiny  arc  found  as  single  threads  in  bundles,  or  show- 
ing an  alveolar  arrangement.  They  are  to  be  recognized  by  the  double 
contour  and  curling  ends,  and  at  times  by  their  alveolar  arrangement. 
They  may  be  due  to  tuberculosis,  abscess  of  the  lung,  bronchiectasis, 
gangrene  of  the  lung,  pneumonia  (von  Jaksch),  and  rarely  to  destruc- 
tive diseases  of  the  larynx.     In  a  very  great  majority  of  cases  they  are 


524  SPECIAL  DIAGNOSIS. 

due  to  tuberculosis.  It  is  uncommon  to  find  them  in  gangrene,  proba- 
bly because,  as  Traube  first  suggested,  thev  are  destroyed  by  a  ferment. 
(See  Fig.  143.) 

Elastic  tissue  from  the  alveoli  often  shows  the  diagnostic  alveolar 
arrangement ;  the  fibres  that  form  a  bronchus  are  branched  ;  those 
from  eroded  artery  appear  in  the  form  of  a  network,  or  the  fibres  are 
bound  together.     (See  Fig.  144.) 

Detection.  The  method  employed  by  Osier,  modified  from  Sir  Andrew 
Clark's,  is  the  best.  A  small  amount  of  the  thick,  purulent  portions 
of  sputum  is  pressed  out  in  a  thin  layer  between  two  pieces  of  plain 
window-glass,  15  x  15  cm.  and  10  x  10  cm.  The  particles  of  elastic 
tissue  appear  on  a  black  background  as  grayish-yellow  spots,  and  can 
be  examined  in  situ  under  a  low  power.  Or  the  upper  piece  of  glass  is 
slid  off  till  the  piece  of  tissue  is  uncovered,  when  it  is  picked  out  and 
examined  on  a  microscopic  slide,  first  with  a  low  power,  as  the  one  or 
one-half  inch  objective,  and  then  with  a  higher  power.  At  first  there 
will  be  some  difficulty  in  distinguishing  with  the  naked  eye  between 
elastic  fibres  and  particles  of  bread  or  milk  globules,  or  collections  of 
epithelium  and  debris,  but  with  practice  such  mistakes  can  be  avoided, 
and  the  microscope  always  reveals  the  difference.  This  method  is 
much  easier  of  accomplishment  and  quite  as  satisfactory  in  results  as 
the  one  generally  employed— boiling  an  equal  quantity  of  sputum  and 
solution  of  caustic  potash  (8  to  10  per  cent.)  for  a  short  time,  and  then 
allowing  it  to  stand  for  twenty-four  hours  in  a  conical  glass.  The 
elastic  tissue  remains  intact  and  is  found  in  the  sediment. 

Connective  tissue  and  caetilage,  in  fragmentary  bits,  are  rare 
constituents  of  sputum.  The  former  may  occur  with  abscess  or  gan- 
grene of  the  lung,  and  the  latter  when  there  is  ulceration  of  the 
larynx. 

Fibrinous  Coagula.  These  striking,  tree-like  bodies  are  found 
in  the  sputa  of  plastic  bronchitis,  and  at  times  in  that  of  pneumonia, 
phthisis,  and  in  diphtheria  and  croup  when  there  has  been  an  exten- 
sion into  the  bronchi.  They  are  usually  mixed  with  mucus,  and  are 
rolled  up  into  a  mass.  Their  peculiar  form  is  best  seen  when  they 
are  washed  and  unravelled  in  water.  They  are  then  seen  to  be  a  com- 
plete mould  of  a  small  bronchus  with  its  ramifications.  The  size  varies 
greatly.  They  may  be  many  centimetres  long.  In  fibrinous  bron- 
chitis the  size  and  shape  of  the  moulds  in  different  ■  attacks  may  be 
exactly  similar,  as  if  they  came  from  the  same  bronchus.  They  are 
grayish-white  in  color,  hollow,  and  on  transverse  section  are  seen  to 
be  made  up  of  cast  upon  cast.  Leucocytes,  blood-cells,  and  alveolar 
epithelium  are  found  in  the  meshes  by  the  microscope,  and  at  times 
Charcot-Leyden  crystals  and  Cursclnnann's  spirals  also.  They  are 
almost  pathognomonic  of  fibrinous  bronchitis.  AVhen  they  occur  in 
any  number  in  pneumonia  they  make  the  prognosis  unfavorable. 
Blood-casts  of  the  smaller  bronchi  have  been  found  in  cases  of  haemop- 
tysis. They  are  rare,  and  have  no  apparent  connection  with  the  fibrous 
coagula. 

Spirals.  Under  this  name  are  included  spiral  bodies  that  are 
found  in  the  sputa  of  bronchial  asthma,  and  occasionally  in  that  of 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  525 

pneumonia  and  capillary  bronchitis  (von  Jaksch),  and  chronic  pulmo- 
nary tuberculosis  (Vierordt).  At  the  beginning  of  an  asthmatic  attack 
tough  rounded  balls  are  expectorated — "  perles  "  of  Lamnec--  which,  if 
freed  from  the  mucus  surrounding  them  and  spread  out  on  a  glass  with 
a  dark  background,  may  be  seen  by  the  naked  eye  to  have  a  twisted 
spiral  form.  With  the  aid  of  the  microscope  they  are  found  to  be 
made  up  of  spirally  arranged  mucin  in  a  more  or  less  tight  twist,  with 
many  cells  from  the  alveoli  and  bronchi.  In  some  of  these  spirals  a 
shining  central  thread  runs  through  the  entire  length  like  a  core,  re- 
markable for  its  clearness  and  its  high  refractive  index.  The  fine 
fibres  composing  the  spiral  may  be  closely  arranged  or  not.  Epithe- 
lium and  Charcot-Leyden  crystals  may  be  found  lying  among  the  coils. 
The  main  constituent  of  the  spirals  is  mucin,  and  Osier  has  suggested 
that  the  central  thread  is  made  up  of  transformed  mucin.  On  the 
other  hand,  von  Jaksch  believes  it  to  be  chemically  distinct  from  the 
mucin  spiral  and  to  approach  rather  to  the  character  of  fibrin.  Vier- 
ordt considers  it  either  made  of  tightly  twisted  central  fibres  or  to  be 
an  optical  image  of  a  core-cavity.  They  are  probably  the  result  of  an 
acute  bronchiolitis.  Why  they  should  assume  this  remarkable  form 
is  still  an  open  question.  It  has  been  suggested  (Osier)  that  the 
ciliated  epithelium  of  the  bronchi  may  have  a  rotary  action,  and  their 
action,  combined  with  the  spasm  of  the  bronchioles,  causes  the  spiral 
formation. 

Sections  for  Microscopical  Examination.  Schmidt  (Zeitschrift 
f.  Mm.  3Ied.,  1892,  p.  476)  fixes  sputum  in  J  per  cent,  salt  solution 
saturated  with  mercuric  chloride,  hardens  in  alcohol,  and  sections  in 
the  usual  manner.  For  hardening  sputum  Zenker's  fluid  has  been 
found  most  satisfactory.  After  hardening  the  sputum  is  embedded  in 
paraffin  and  cut.  In  many  cases  it  is  advisable  to  roll  up  the  sputum 
in  a  little  ball  before  fixation.  For  the  study  of  spirals  thick  pieces 
should  be  embedded  in  celloidin  ;  for  the  study  of  the  cellular  elements, 
thin  sections  are  embedded  in  paraffin. 

Sections  of  sputum  with  mucin  swell  when  treated  with  watery 
solutions  of  the  dyes  ;  hence  the  celloidin  should  be  first  removed  to 
prevent  folding  of  the  sections.  All  specimens  of  sputum,  except  the 
very  thin  ones,  can  be  prepared  in  the  manner  described. 

The  spirals  are  best  stained  with  Weigert's  fibrin-method  ;  they 
stain  blue.  Yet  they — i.  e.,  the  central  threads — are  not  fibrin  :  (1) 
Because  they  are  perfectly  homogeneous;  (2)  they  assume  a  violet 
color  after  prolonged  staining — fibrin  is  always  blue  ;  (3)  unformed 
blue  masses  are  found  which  could  only  be  compact  mucin  masses  ; 
(4)  their  specific  mucin  reaction  with  thionin  ;  (5)  the  greenish  color 
assumed  when  Ehrlich's  triacid  stain,  as  modified  bv  Babes,  is  used. 
(See  Fig.  145.) 

That  there  is  a  connection  between  the  spirals  and  Charcot-Leyden 
crystals  seems  very  probable,  as  the  latter  are  absent  from  the  sputum 
at  the  beginning  of  an  attack  of  bronchial  asthma  ;  but  if  a  portion  of 
such  sputum  is  allowed  to  stand  for  twenty-four  to  forty-eight  hours, 
taking  care  that  evaporation  does  not  take  place,  crystals  will  be  found. 
As  has  been  said,  the  crystals  are  often  found  among  the  spirals,  and 


526 


SPECIAL  DIAGNOSIS. 


this  when  they  are  seen  nowhere  else.  Later  on  the  spirals  disappear, 
but  crystals  derived  from  them  (?)  continue  to  be  expectorated.  (See 
Fig.  145.) 

The  method  of  examining  for  spirals  is  as  given  above. 


Fig.  145. 


Spirals  from  bronchial  tubes.    X  80.    (Alter  Ley  den.) 

Crystals.  Charcot-Leyden,  eholesterin,  hsematoidin,  fatty,  tyrosin, 
oxalate  of  lime,  and  triple  phosphate  crystals  are  to  be  found  in  sputa 
under  various  conditions. 

Charcot-Leyden  crystals  are  octahedral,  sharply  pointed,  color- 
less or  slightly  bluish,  soluble  in  warm  water,  alkalies,  and  acetic  and 
mineral  acids.  The  practised,  unaided  eye  may  recognize  these  as 
small  yellowish  bodies,  not  unlike  grains  of  sand  ;  under  the  micro- 


DISEASES  OF  THE  LUNGS  AND  PLEUBJE. 


527 


scope  they  are  unmistakable.  Their  size  varies  greatly.  They  occur 
most  abundantly  during  (invariably)  and  after  an  attack  of  bronchial 
asthma  ;  they  have  also  been  seen  in  sputa  of  acute  and  chronic  bron- 
chitis and  tuberculosis.  They  are  identical  with  crystals  found  in 
semen,  feces,  and  leukemic  blood  and  bone-marrow.  Their  connec- 
tion with  spirals  has  been  mentioned  above.  Schreiner  considers  them 
to  be  the  phosphate  of  an  unknown  base,  which  Ladenburg  and  Abel 
think  may  be  identical  with  sethyleninim  or  di-sethyleninim.  This 
identity,  however,  is  disputed  by  Th.  Kohn. 

Detection.  Examine  the  sputum  of  an  asthmatic  patient  a  day  or 
two  after  the  beginning  of  an  attack  for  round,  hard,  yellowish  bodies, 
and  place  these  under  the  microscope  with  different  powers.  They 
are  readily  recognized.     (See  Fig.  146.) 


Charcot  crystals.    (Scheube.) 


Cholesterix  Crystals. 
cholesterin  found   elsewhere 


irregular  corners  and  high  refractive  index 


These  crystals  are  similar  to  those  of 
being  thin  rhombic  plates,  often  with 
They  are  soluble  in  ether  ; 
and,  when  treated  with  dilute  sulphuric  acid  and  tincture  of  iodine, 
become  violet,  blue,  or  green,  and  then  red.  They  may  be  present  in 
the  sputum  of  tuberculosis,  abscess,  and  hydatid  abscess  of  the  lung, 
and  in  pus  from  an  abscess  of  another  organ,  as  the  liver.  They  have 
but  little  clinical  significance. 

H.ematoidin  Crystals.  Hamiatoidin  crystals  are  at  times  recog- 
nizable by  the  naked  eye  as  distinct  spots  of  yellowish  or  brownish- 
red  color.  Under  the  microscope  they  have  a  broAvnish-yellow  or 
ruby-red  color,  and  are  either  in  the  form  of  small  rhomboid  prisms  or 
of  fine  needles,  single  or  arranged  in  bunches  of  various  shapes,  or  as 
free  pigment-particles  without  crystalline  form  ;  smaller  particles  may 
be  contained  within  a  leucocyte.  Their  presence  indicates  that  blood 
has  remained  in  the  respiratory  tract  for  some  time  before  being  expec- 
torated, or  that  an  abscess  has  discharged  into  a  bronchus.  They  occur 
in  phthisis,  following  hemorrhage  ;  in  thoracic  aneurism  when'  blood 
is  oozing  into  the  lung  ;  in  gangrene  ;  in  abscesses  discharging  through 
a  bronchus.  Von  Jaksch  states  that  when  the  crystals  are  contained 
in  cells  there  has  been  a  preceding  hemorrhage,  but  that  when  there 
is  considerable  free  hsematoidin  one  infers  that  an  abscess  of  a  neigh- 
boring organ  has  discharged  into  the  lung. 


528  SPECIAL  DIAGNOSIS. 

Fatty  Crystals.  Crystals  of  margaric  acid  occur  as  long,  thin 
needles,  greatly  curved  or  bent  at  one  end  like  a  fish-hook,  and  either 
singly  or  in  bundles.  They  are  found  in  unhealthy  pus — as  in  gan- 
grene, putrid  bronchitis,  bronchiectasis,  and  tuberculosis  ;  in  the  plugs 
formed  in  inflamed  tonsils  ;  and  in  purulent  sputum  in  general  which 
is  allowed  to  stand  in  a  warm  place.  They  dissolve  in  ether  and  boil- 
ing alcohol ;  this  characteristic,  together  with  the  regularity  of  their 
curve,  should  distinguish  them  from  elastic  fibres,  with  which  they 
are  sometimes  confused  by  beginners. 

Tyrosix  crystals  have  been  found  in  the  sputum  of  putrid  bron- 
chitis and  empyema  discharging  into  the  lung,  and  usually  in  conjunc- 
tion with  leucin.  They  are  most  abundant  in  sputum  that  has  been 
allowed  to  stand  for  some  time.  Under  the  microscope  they  appear 
as  fine  needles,  and  can  be  mistaken  for  fatty  crystals.  They  are  with- 
out diagnostic  importance. 

Oxalate  of  lime  and  triple  phosphates  have  been  noted 
occasionally  in  sputa  ;  the  former  in  a  case  of  diabetes,  and  also  in  an 
asthmatic  ;  the  latter  occur  only  in  alkaline  sputa,  as  they  are  soluble 
in  acids. 

Uric  acid  crystals  have  been  observed  by  Moore  in  the  sputum 
of  a  gouty  patient. 

Concretions  are  rarely  present  in  the  sputum.  They  arise  usually 
from  the  bronchial  glands  or  lungs,  from  foci  of  tuberculosis  which 
have  become  healed  with  the  deposition  of  lime-salts.  They  may  be 
single  or  multiple.  Hievoiles  reports  finding  tubercle  bacilli  in  the 
centre  of  one  of  these  concretions. 

Corpora  Amylacea.  Starch-like  bodies  have  been  found  in  the 
sputum  after  pulmonary  hemorrhage  and  in  that  of  pulmonary  gan- 
grene. They  have  the  shape  of  starch-corpuscles,  and  sometimes  give 
the  amyloid  reaction  with  iodine  or  iodide  of  potassium.  They  are 
at  present  without  clinical  significance. 

Parasites. 

A.  Animal  Parasites.  Echinococcus  cysts  are  to  be  found  in  spu- 
tum, generally  broken  into  fragments,  and  only  very  rarely  hi  a  per- 
fect whole,  when  there  is  rupture  of  a  cyst  of  the  liver  or  lung  into  a 
bronchus.  Scolices  and  free  hooklets  from  the  same  may  be  recog- 
nized, and  pieces  of  the  cyst-wall  will  be  known  by  their  remarkable 
formation.     Their  presence  is  of  great  clinical  value. 

Infusoria  have  been  found  in  the  expectoration  from  gangrene  of 
the  lungs.     They  belong  to  the  monad  and  cercomonad  varieties. 

Distoma  ha?matobium  eggs  may  occur  in  sputa  when  the  lung-tissue 
is  broken  down  by  its  presence,  the  eggs  being  thrown  off  in  the  sputum. 

The  distoma  Westermanii  or  pulmonale  is  found  in  the  sputuni  in 
Japan  in  certain  cases  resembling  phthisis.  Both  the  worm  and  the 
ova  may  be  present  in  the  sputum. 

Amceba  Dysexteeije  (Amoeba  Coli).  Of  far  more  interest  and  im- 
portance is  the  presence  of  this  parasite  in  the  expectoration.  A  full 
description  of  the  amceba  will  be  given  in  the  article  on  Dysentery. 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  529 

They  are  the  same  in  every  respect  when  found  in  the  sputum,  except 
that  they  are  often  slightly  larger.  The  sputum  containing  the  amoeba 
is  partly  diffluent,  tenacious,  frothy,  bright  red  hi  color  at  first,  due  to 
the  presence  of  blood,  and  later  brick  or  brownish-red,  sometimes  bile- 
stained.  Small  yellowish-white  cheese-like  particles  are  seen.  Upon 
exposure  to  the  air  the  sputum  becomes  thin,  syrupy,  and  oily,  and  it 
then  looks  much  like  anchovy  sauce.  The  sputa  are  alkaline  and  of 
a  faintly  sweetish  odor,  never  putrid.  Later  on  they  become  more 
purulent,  somewhat  nummular,  reddish-yellow,  and  contain  less  blood. 
If  there  is  a  favorable  termination,  they  become  more  fluid  and  frothy, 
with  less  blood  and  pus,  and,  on  standing,  show  the  three  layers. 
The  quantity  varies  from  25  c.c.  to  500  c.c.  in  twenty-four  hours. 
Under  the  microscope  will  be  found,  beside  the  amoeba,  red  blood- 
corpuscles,  leucocytes,  alveolar  and  oval  epithelium,  and  bodies  look- 
ing like  degenerated  liver-cells  without  a  nucleus  ;  occasionally  elastic 
fibres,  hseniatoidin,  leucin,  tyrosin,  and  Charcot-Leyden  crystals  and 
bacteria  are  seen.  The  cheesy  particles  are  made  up  of  amorphous 
granular  matter  and  oil-globules.  Amcebse  are  constantly  present  in 
varying  numbers,  usually  not  so  many  as  in  the  stool,  but  somewhat 
larger.  The  number  varies  from  day  to  day,  and  diminishes  with  the 
disappearance  of  the  cough  and  expectoration.  The  sputa  should  be 
examined  as  soon  after  their  discharge  as  possible,  and  in  the  interim 
should  be  kept  at  a  temperature  of  30°  to  35°  C.  If  examined  on  a 
warm  stage,  active  movements  of  the  amoebae  will  be  kept  up  much  longer. 

They  should  be  examined  under  various  powers  :  J,  -I-  or  ],  and  y1^ 
inch  objectives.  Of  these  the  1-  or  \  inch  will  be  found  most  suitable 
for  following  the  movements.  They  measure  from  10//  to  20/7..  They 
will  be  readily  recognized  by  their  size,  formation,  and  movements. 
That  they  have  important  clinical  value  is  true,  as  cases  have  been 
reported  in  which  the  observer  diagnosticated  hepatic  or  hepato-pul- 
monary  abscess  secondary  to  amoebic  dysentery,  by  the  peculiar  anchovy- 
sauce  expectoration  and  subsequent  detection  of  the  amoebae. 

B.  Vegetable  Parasites.  Fungi — Non-pathogenic  :  Moulds. 
O'idium  albicans  may  be  a  constituent  of  the  sputum  when  the  bronchi 
are  invaded  by  it,  but  usually  it  is  from  the  saliva.  Certain  other 
moulds  have  lately  been  considered  to  cause  disease  of  the  lungs  by 
multiplication,  but  nothing  very  definite  has  resulted  from  the  experi- 
ments thus  far  made. 

Yeast-fungi.  Von  Jaksch  reports  having  seen  scattered  yeast- 
cells  in  the  pus  from  a  phthisical  cavity.  Otherwise  we  have  no 
knowledge  of  yeast  being  found  in  sputa. 

Fission-fungi.  Leptotheix.  Lcptothrix  occurs  alone,  in  the 
sputum  or  in  the  bronchial  plugs,  in  putrid  bronchitis,  along  with  the 
fatty  acid  and  hsematoidin  crystals.  It  is  probably  derived  from  the 
mouth,  having  thence  entered  the  air-passages,  or  it  is  taken  up  from 
the  mouth  by  the  expectoration.  It  is  recognized  by  its  staining  blue 
with  iodine  and  potassium  iodide. 

Sarctn.e  Pulmonalis.  Sarcinoe  may  be  seen  in  sputa.  Thev  are 
larger  than  sarcinse  ventriculi,  with  which  they  have  no  connection, 
nor  have  they  pathological  significance  when  present  in  sputa. 

34 


530  SPECIAL  DIAGNOSIS. 

Non-pathogenic  bacilli  and  cocci  may  occur  in  all  sputa,  but  are 
without  significance.  They  are  more  numerous  in  fetid  sputa.  They 
stain  with  methylene-blue  and  other  simple  dyes. 

Pathogenic  Fungi.  Tubercle  Bacillus.  The  organism  which 
is  the  cause  of  tuberculosis  is  a  rod,  straight  or  slightly  curved,  without 
motion,  varying  in  length  from  '2/j.  to  o/j.  (about  J  to  §•  the  diameter  of 
a  red  corpuscle).  It  usually  has  a  beaded  appearance  when  stained, 
due  to  the  spores,  which  do  not  take  up  the  stain  that  affects  the  rod 
as  a  whole,  and  which  often  bulge  slightly  beyond  the  edge.  It  is 
probable  that  this  beaded  appearance  is  caused  by  the  contraction  and 
breaking  up  of  the  stainable  portion,  permitting  us  to  see  the  empty 
spaces  between  the  fragments  and  the  other  membrane.  Bacilli  pre- 
senting this  appearance  are  supposed  to  be  undergoing  degeneration. 
Attention  has  recently  been  called  to  the  presence  in  the  sputum  of 
branching  forms  of  the  tubercle  bacillus.  The  bacillus  of  tuberculosis 
cannot  be  recognized  in  the  sputum  unless  stained,  and  in  the  staining 
it  shows  a  peculiarity  which  belongs  to  but  few  organisms — the  smegma 
bacillus,  the  bacillus  of  leprosy,  and  the  bacillus  of  syphilis.  As  under 
ordinary  conditions  these  bacilli  are  not  met  with,  this  peculiarity  in 
staining  in  a  vast  majority  of  cases  is  diagnostic  of  tubercle  bacilli. 

Recently,  Pappenheim  found  in  the  sputum  from  a  case  of  gangrene 
of  the  lung  stained  by  Gabbet's  method  numerous  bacilli  which  were 
considered  to  be  tubercle  bacilli.  At  the  autopsy  no  evidence  of  tuber- 
culosis could  be  found.  Further  examination  led  Pappenheim  to 
believe  that  these  bacilli  were  smegma  bacilli.  A  similar  case  has 
been  recently  seen  where  large  numbers  of  bacilli  were  present  in  the 
sputum  hi  a  case  of  gangrene  of  the  lung  secondary  to  a  sub-dia- 
phragmatic abscess,  which,  stained  by  Gabbet's  method,  were  consid- 
ered to  be  tubercle  bacilli.  The  autopsy  showed  no  evidence  of  tuber- 
culosis, macroscopically  or  microscopically.  Inoculation  from  the 
lung  into  a  guinea-pig  was  also  negative.  Fraenkel  has  observed 
similar  bacilli  in  the  sputum  when  stained  by  Gabbet's  method  from 
patients  with  bronchiectasis. 

Preparation  of  Sputum  axd  Method  of  Staining  Tubercle 
Bacilli.  A  small  amount  of  the  purulent  portion  of  the  sputum  is 
spread  in  a  thin  and  uniform  layer  on  a  perfectly  clear  cover-glass  by 
means  of  forceps,  needles,  or  the  "oese,"  which  must  previously  be 
held  a  moment  in  the  flame  of  a  Bunsen  burner  or  spirit  lamp  ;  or 
by  pressing  a  small  amount  of  sputum  between  two  cover-glasses, 
then  sliding  them  apart.  It  is  then  dried  in  the  air,  or  more  quickly 
by  holding  the  cover-glass  with  forceps  some  distance  above  the  flame 
of  a  burner  or  lamp.  Finally,  it  is  to  be  passed  three  or  four  times 
through  the  flame  and  so  "  fixed."  The  edge  of  the  cover-glass,  with 
sputum  side  up,  is  then  grasped  with  forceps  and  covered  with  the 
staining  solution,  care  being  taken  to  prevent  the  fluid  from  extending 
to  the  under  surface,  and  held  in  or  just  above  the  flame,  until  the 
solution  boils  for  a  second  or  two  or  a  bubble  rises.  AVhen  the  excess 
of  the  solution  is  washed  off  in  water,  the  slip  is  treated  with  the 
decolorizing  agent  until  the  color  is  almost  or  wholly  removed.  It  is 
again  washed  in  water  to  remove  the  excess  of  the  decolorizer,  and 


PLATE    XV. 


•••    ™E>-  a 


Pneumocoeei  from  a  Case  of  Empyema. 

(Oc.  4,  ob.  yj  immersion.)     Drawn  by  J.  D.  Z.  Chase. 


A 


9 


\ 


K 


I?     ^<s  \ 


/    —  -_ 


Tubercle-bacilli  (red).     Streptococci  (blue  chains). 

(Oc.  4.  T'5  oil  immersion.)     Drawn  by   J.  D.  Z.  Chase. 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  531 

mounted  for  examination,  or  given  a  contrast-stain  ;  the  latter  is  pref- 
erable. 

A  second  rapid  method  is  as  follows  :  Select  with  the  sterilized 
oese  a  suspicious  yellowish  particle  from  the  sputum  ;  smear  it  thinly 
over  one  end  of  a  slide  which  has  previously  been  passed  several  times 
through  the  flame  of  an  alcohol  lamp  or  Bunsen  burner.  Dry  by 
holding  over  flame  ;  fix  by  passing  several  times  through  the  flame. 
Cover  the  dried  sputum  with  the  desired  stain,  and  steam  gently  for 
two  minutes  over  the  alcohol  or  low  Bunsen  flame  ;  the  slide  can  be. 
held  in  the  fingers,  or,  after  heating,  can  be  laid  aside  for  a  moment ; 
wash  off  the  excess  of  stain  with  water,  then  cover  the  stained  sputum 
with  decolorizing  agent  and  counter-stain,  which  should  not  remain 
more  than  thirty  seconds.  Wash  away  excess  with  water,  dry  the 
slide  by  blowing  upon  it  through  a  pipette,  and  cover  with  a  clear  cover- 
glass,  using  distilled  water  as  a  mount.  This  method  is  extremely 
satisfactory  for  ordinary  clinical  work,  especially  with  Ziehl's  and 
Gabbet's  solution. 

If  fuehsin  has  been  used  to  stain  the  tubercle  bacilli,  methylene- 
blue  is  a  good  contrast-stain  ;  while  if  gentian-violet  was  selected 
Bismarck-brown  is  better  in  contrast.  These  contrast-stains  are  made 
as  needed  by  dissolving  enough  of  the  dye  in  a  few  c.c.  of  water  to 
make  the  solution  as  seen  through  a  test-tube  of  14  mm.  diameter  only 
transparent,  and  then  filtering ;  or,  a  concentrated  watery  solution 
may  be  made  for  stock  just  as  the  concentrated  alcoholic  solutions  of 
fuehsin  and  gentian-violet  were  made,  diluting  a  small  quantity  of 
this  when  needed  with  enough  distilled  water  to  make  it  just  trans- 
parent in  a  similar  test-tube.  To  apply  the  contrast-stain,  place  a  few 
drops  on  the  cover-glass  that  has  been  prepared  as  above — stained, 
decolorized,  and  washed — allow  it  to  remain  thirty  or  forty  seconds, 
wash  off  in  water,  and  mount  for  examination  on  a  glass  slip,  in  water, 
oil  of  cloves,  or  Canada  balsam.  A  drop  of  water  will  serve  perfectly 
well  for  examining  when  the  preparation  is  not  to  be  preserved.  In 
the  microscopical  examinations  a  -^  inch  oil-immersion  lens  and  Abbe 
condenser,  or,  at  the  least,  a  -^  or  J  inch  objective  is  used.  If  gentian- 
violet  has  been  used,  the  tubercle  bacilli  appear  as  dark-blue  rods,  with 
all  other  bodies  brown,  if  Bismarck-brown  is  used  for  contrast-stain 
while  with  fuehsin  staining  for  tubercle  bacilli,  and  ruethylene-blue  as 
a  contrast,  the  former  will  be  found  as  red  rods  in  a  blue  field  (back- 
ground).    (See  Plate  XV.,  Fig.  2.) 

The  above  rapid  method  of  staining  takes  much  less  time  than  the 
method  usually  described,  and  gives  most  satisfactory  results.  The 
steps  in  the  old  method  are  the  same  as  given  above,  except  that 
instead  of  placing  the  staining  solution  on  the  smeared  and  dried  cover- 
glass,  and  holding  it  in  or  above  the  flame  until  the  solution  boils,  the 
cover-glass  is  floated  in  a  cold  solution,  in  a  watch-glass,  sputum  side 
down,  for  twenty-four  hours,  or  in  a  hot  solution  for  six  to  eight  min- 
utes, or  until  moisture  appears  on  the  upper  surface  of  the  cover-glass. 
The  remaining  steps  are  similar. 

Tubercle  bacilli  do  not  stain  with  the  simpler  dyes,  but  when  stained 
by  solutions  of  dyes  made  more  penetrating  by  the  addition  of  aniline 


532  SPECIAL  DIAGNOSIS. 

oil,  carbolic  acid,  or  like  substances,  they  retain  the  color  when  subjected 
to  decolorizing  agents.  In  this  thev  differ  from  all  other  organisms, 
except,  as  stated,  the  smegma  bacillus,  the  bacillus  of  leprosy,  and  the 
bacillus  of  syphilis. 

The  Smegma  Bacilli.  Pappenheim  distinguishes  them  from  tubercle 
bacilli  by  staining  with  a  solution  of  corallin  in  absolute  alcohol  satu- 
rated with  methyle'ne-blue,  when  decolorization  takes  place  without  acid. 
If  fat  acids  and  myaline  are  present  in  the  sputa,  the  bacilli  are,  in  all 
probability,  not  tuberculous.  They  are  not  found  in  mucopurulent, 
but  in  putrid,  sputum. 

Housell's  method  of  staining  them  is  the  best.  After  the  preparations 
are  stained  in  carbol-fuchsin  they  are  placed  in  a  mixture  of  3  per  cent. 
HC1  in  absolute  alcohol  for  ten  minutes.  They  stain  best  with  an 
alcohol  solution  of  methylal-blue,  which  decolorizes  the  micro-organism. 

A  number  of  methods  have  been  devised  for  the  detection  of  the 
tubercle  bacillus  by  means  of  its  peculiar  action  toward  stains.  The 
most  satisfactory  are  those  known  as  the  Koch-Ehrlich,  Ziehl-Xeelson, 
Gabbet,  and  Gibbes.  These  methods  differ  chiefly  in  the  solutions  used. 
Slightly  modified  from  the  original  in  execution,  they  are  as  follows  : 

A.  Koch-Ehrlich  method  : 

Solutions  Used. 

I.   Concentrated  alcoholic  solution  of  fuchsin  or  gentian-violet. 
II.  Saturated  solution  of  aniline  oil  in  water. 
III.  Thirty  per  cent,  solution  of  nitric  acid  in  water  (decolorizing  solution). 

I.  Place  in  a  clear  bottle  fuchsin  or  gentian-violet  in  substance  to 
one-fourth  its  capacity,  and  fill  with  alcohol  (95  per  cent.)  ;  shake  well 
and  cork  and  allow  it  to  stand  for  twenty-four  hours.  If  all  the  dye  has 
been  dissolved,  add  more  and  shake,  and  let  stand  for  another  twenty- 
four  hours,  and  so  on  until  some  of  the  dye  remains  permanently 
undissolved  at  the  bottom  of  the  bottle.  This  solution  remains  good 
until  used. 

II.  To  about  100  c.c.  of  distilled  water,  in  a  flask  or  other  suitable 
vessel,  add  aniline  oil,  drop  by  drop,  shaking  the  flask  continuously, 
until  the  solution  is  opacme,  or  drops  of  the  oil  float  on  the  surface, 
then  filter  through  moist  filter-paper  until  the  filtrate  is  perfectly 
clear.     This  solution  must  be  made  fresh  as  needed. 

III.  Mix  a  few  c.c.  of  nitric  acid  and  water  in  about  the  above  pro- 
portion, never  stronger,  each  time  bacilli  are  to  be  stained. 

The  Koch-Ehrlich  solution  is  made  by  adding  11  c.c.  of  the  fuchsin 
or  gentian  solution  (Xo.  I.),  and  10  c.c.  of  absolute  alcohol  to  100  c.c. 
of  the  clear  aniline  filtrate  (Xo.  II.).  It  should  not  be  used  after  it  is 
a  week  old. 

B.  Ziehl-Xeelson  method  : 

Solutions  Used. 

I.   Carbolic-fuchsin  solution : 

Distilled  water     .         .         .         .         .         .  100  c.c 

Carbolic  acid  (crystalline)    ....  5  grammes. 

Alcohol        .         .         .         .         .         .         .  10  c.c. 

Fuchsin  in  substance    .....  1  gramme. 


DISEASES  OF  THE  LUNGS  AND  PLEUBJE.  533 

This  solution  can  also  be  prepared  by  adding  saturated  alcoholic 
solution  of  fuchsin  (see  above)  to  a  5  per  cent,  watery  solution  of  car- 
bolic acid,  until  a  metallic  lustre  is  seen  on  the  surface  of  the  fluid. 
This  solution  does  not  decompose  so  easilv  as  those  made  with  aniline 
oil. 

II.   Decolorizing  solution  of  nitric  acid,  and 
III.  Contrast  stain  of  methylene-blue,  as  above. 

The  preparation  and  staining  are  exactly  the  same  as  in  method  A. 
The  tubercle  bacilli  are  stained  red,  the  other  bodies  blue. 

C.  Gabbet's  method  : 

Solutions  Used. 

I.   Carbolic-fuchsin  solution  I  as  in  B). 
II.    Methylene-blue  solution : 

Methylene  blue1 2  grammes. 

Sulphuric  acid       .         .         .         .         .         .25         " 

])istilled  water       .         .         .         .         .         .     75  c.c. 

This  solution  is  apt  to  decompose  if  old. 

Pkeparation  of  Slips  axd  Staining.  The  cover-glass  is  pre- 
pared and  stained  with  the  carbolic-fuchsin  solution  and  washed  in 
water  as  in  A.  Then  (instead  of  decolorizing  with  nitric  acid  or  add- 
ing in  contrast-stain)  the  slip  is  washed  for  twenty  to  thirty  seconds  in 
the  methylene-blue  solution,  until  a  faint  blue  replaces  the  red  tinge 
in  the  (slip)  sputum  ;  the  excess  of  the  solution  is  washed  off  in  water, 
and  the  slip  is  mounted  and  examined  as  above.  The  tubercle  bacilli 
are  stained  red  and  the  other  bodies  blue.  In  sputum  from  gangrene 
of  the  lung  and  bronchiectasis,  decolorization  with  alcohol,  in  addition, 
must  be  employed  to  eliminate  the  presence  of  the  smegma  bacillus. 

The  writer  lias  found  that  this  method  can  be  rapidly  applied,  and 
that  it  gives  good  results  ;  he  recommends  it  highly. 

D.  Gibbes'  method  : 


Solutions  Used. 

Methylene-blue       ..... 

Mix  thoroughly  in  a  mortar. 
h.   Aniline  oil      .....         . 

Alcohol  ....... 

.       1         " 

5  c.c. 
.     20  c.c. 

Dissolve  ami  add  b  to  a  -lowly,  stirring  vigorously  until  a  is  evi- 
dently dissolved,  then  add  20  c.c.  of  distilled  water,  and  keep  in  a 
stoppered  bottle,  ready  fur  use. 

Prepare  -lip  and  stain  with  this  solution,  as  with  the  others,  up  to 
the  point  of  decolorizing.  Then  wash  with  alcohol  until  the  dye  ceases 
to  come  away.  .Mount  and  examine  as  above.  Tubercle  bacilli  will 
l>i'  stained  dark  red,  the  other  objects  dark  blue. 

When  the  bacilli  are  few  in  number,  Biedert  proposes  that  the  fol- 
lowing preliminary  steps  be  taken  :  About  4  c.c.  of  sputum  are  mixed 
with  8  c.c.  of  water  and  1  c.c.  of  solution  of  caustic  soda,  and  boiled  a 

1  An  alcoholic  solution  of  methyl-blue  should  first  be  made,  and  then  added,  drop 
by  drop,  with  constant  stirring,  to  the  sulphuric  acid  and  water. 


534  SPECIAL  DIAGNOSIS. 

few  minutes,  when  about  15  c.c.  of  water  are  added  and  the  whole 
again  boiled  until  a  homogeneous  fluid  is  formed.  This  is  allowed  to 
stand  in  a  conical  glass  for  twenty-four  to  forty-eight  hours,  when  the 
sediment  is  stained  by  the  Ziehl-Neelson  or  Gabbet  method.  Or,  the 
homogeneous  fluid  can  be  put  at  once  in  a  centrifugal  machine,  and  the 
resulting  sediment  stained. 

Sputa  hardened  in  Zenker's  fluid,  embedded  in  paraffin  and  cut,  has 
proven  most  satisfactory  in  the  study  of  the  branching  forms  of  the 
tubercle  bacillus,  the  study  of  giant-cells  in  the  sputum  in  phthisis, 
and  in  the  study  of  bacteria  in  the  sputum  in  cases  of  pneumonia. 

It  is  well  to  remember  that,  in  the  absence  of  a  proper  decolorizing 
agent,  hot  water  applied  for  some  minutes  has  been  shown  to  decolor- 
ize very  satisfactorily. 

Importance.  The  greatest  importance  attaches  to  the  presence  or 
continuance  of  tubercle  bacilli  in  sputa.  It  indicates  tuberculosis  of 
the  lung  or  larynx  ;  in  the  vast  majority  of  cases  of  the  former. 

They  are  often  to  be  found  in  the  sputum  when  physical  signs  are 
not  yet  present  or  are  indefinite.  The  number  varies  so  greatly  in 
different  cases,  and  in  the  same  case  at  different  times,  that  a  in  recent 
attack  it  is  impossible  to  judge  of  the  extent  of  the  disease  by  the 
number  present  in  a  given  preparation.' 

The  absence  of  bacilli  from  sputa  has  no  true  value  unless  negative 
results  are  obtained  after  many  trials  and  careful  examination  by  an 
experienced  observer,  using  good  stains.  Hence,  too  great  care  cannot 
be  taken  in  each  and  every  step. 

Biological  Properties.  The  tubercle  bacillus  is  difficult  to  cul- 
tivate, as  it  grows  readily  only  in  conditions  found  within  the  body. 
The  best  medium  is  blood-serum.  The  cheesy  mass  from  the  sputum 
or  the  tubercular  nodule  from  a  tissue  is  placed  on  the  surface  of  the 
serum  and  rubbed  carefully  over  it.  It  is  best  to  make  twenty  or 
thirty  such  inoculations.  The  tubes  must  then  be  sealed  to  prevent 
evaporation  and  drying,  and  exposed  for  twelve  days  to  a  temperature 
of  37.5°  C.  When  a  pure  culture  is  obtained  further  cultivations  may 
be  made  on  agar-agar,  to  which  6  per  cent,  of  glycerin  has  been  added. 

The  pure  cultures  appear  as  dry  masses  on  the  surface  of  the  medium, 
either  as  flat  scales  or  clumps  of  mealy-looking  granules.  They  are 
of  a  dirty  drab  or  brownish-gray  color.  (See  Plate  VII.,  Fig.  6.)  The 
bacillus  is  parasitic,  aerobic,  non-motile  (facultative  anaerobic). 

Pneumococcus.  Diplococcus  Pneumoniae.  Micrococcus  Lan- 
ceolatus.  The  causative  factor  in  most  cases  of  acute  croupous  pneu- 
monia in  its  typical  form  is  a  paired  lancet-shaped  coccus,  often  irreg- 
ular in  size,  with  a  tendency  to  chain  formation.  Frequently  oval  or 
conical  forms  are  present,  and  there  is  apt  to  be  variation  in  the  size 
of  the  two  cocci  forming  the  pair.  The  organism  has  a  distinct  cap- 
sule. In  the  sputum  of  croupous  pneumonia  these  pneumococci  are 
usually  present  in  large  numbers.     Their  presence  within  leucocytes 

1  "  A  Method  for  the  Examination  of  the  Actual  Number  of  Tubercle  Bacilli  in 
Tuberculous  Sputum."  By  George  H.  F.  Nuttall,  M.D.,  Ph.D.,  Johns  Hopkins 
Hospital  Bulletin,  May,  1891.  The  method  is  of  pathological  but  not  of  diagnostic 
interest. 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  535 

and  their  tendency  to  chain  formation  has  been  especially  noted  in 
such  cases. 

Pneumococci  are  stained  in  cover-glass  preparations  with  the  ordi- 
nary aniline  dyes,  as  given  above.  The  capsule  may  be  stained  and 
differentiated  in  the  same  way,  but  it  more  often  requires  a  special 
method.  Welch  recommends  the  following  :  Spread  and  dried  cover- 
glass  preparations  are  treated  first  with  glacial  acetic  acid,  which  is 
allowed  to  drain  off,  and  is  replaced  (without  washing  in  water)  with 
aniline  oil-gentian-violet  solution.  (See  under  Tubercle  Bacilli.)  The 
staining  solution  is  repeatedly  added  to  the  surface  of  the  cover-glass 
until  all  of  the  acid  is  displaced.  The  specimen  is  now  washed  in  a 
weak  salt  solution  (about  2  per  cent.),  and  examined  in  the  same,  not 
in  balsam.  The  capsule  and  coccus  can  then  be  differentiated.  Spu- 
tum stained  by  Gram's  method,  thoroughly  decolorized  by  alcohol, 
counter-stained  with  a  watery  solution  of  eosine,  or  a  1  per  cent,  aque- 
ous solution  of  aurantia,  has  been  found  satisfactory  for  microphoto- 
graphic  work.  Degenerative  and  involution  forms  are  constantly  met 
with.  There  will  be  variations  in  size  and  shape,  and  the  capsule  may 
contain  only  remains  of  a  coccus,  or  be  entirely  empty.  (See  Plate 
XV.) 

Biological  Properties.  The  pnenmococcus  is  not  motile.  It 
stains  by  Gram.  It  grows  well  on  blood-serum.  The  growth  is 
minute,  transparent,  colorless  colonies,  resembling  drops  of  dew.  A 
favorable  growth  of  very  minute  colonies  appears  in  glycerin  agar- 
agar.  Bouillon  is  faintly  clouded.  Litmus  milk  will  sometimes 
turn  pink  and  coagulate.  Growth  on  other  culture  media  is  usually 
feeble.  The  tendency  to  form  chains  is  especially  observed  in  the 
water  of  condensation  on  blood-serum  tubes.  The  lancet  shape  of 
the  cocci  enables  them  to  be  differentiated  from  the  streptococcus. 
The  capsules  are  not  usually  observed  in  the  cultures  with  ordinary 
methods  of  staining. 

By  inoculation  into  susceptible  animals  a  typical  fibrinous  pneumo- 
nia is  developed.  The  pathogenic  power  attenuates  rapidly  in  cul- 
tures, but  recovers  its  virulence  by  passing  through  susceptible  animals. 

This  micro-organism  is  found  in  nearly  all  cases  of  acute  croupous 
pneumonia,  and  in  many  cases  of  bronchopneumonia.  Its  presence 
has  also  been  observed  in  health  in  the  saliva.  It  is  found  also  in 
acute  pleuritis,  endocarditis,  pericarditis,  peritonitis,  acute  purulent 
meningitis,  and  otitis  media.  Its  presence  in  empyema  is  considered 
of  favorable  import.  It  has  also  been  found  in  cases  of  synovitis, 
osteomyelitis,  and  abscess  formation  in  various  situations.  It  may 
cause  a  general  septicaemia — /.  e.,  pneumococcus  septicaemia. 

Bacillus  Mucous  Capsulatus.  This  organism  is  found  in  the 
sputum  in  health  in  a  certain  number  of  cases.  In  association  with 
the  pneumococcus  it  can  cause  pneumonia.  It  can  also  produce  pneu- 
monia by  itself  in  rare  instances. 

In  three  fatal  cases  of  pneumonia  due  to  the  capsule  bacillus  alone, 
there  have  been  found  in  the  sputa  large  numbers  of  capsule  bacilli. 
These  were  frequently  inside  of  leucocytes,  and  many  alveolar  cells 
were  filled  with  these  bacilli. 


536  SPECIAL  DIAGNOSIS. 

Bacillus  of  Influenza.  This  organism  is  found  in  the  sputum 
in  cases  of  influenza  or  influenza  pneumonia.  It  was  first  isolated 
from  the  sputum  by  Pfeiffer.  The  organism  appears  as  a  small 
bacillus  with  rounded  ends.  Its  length  varies  somewhat,  and  thread- 
like, involution  forms  may  appear.  It  stains  more  deeply  at  the  ends 
than  at  the  middle,  and  the  long  forms  may  show  irregularity  of  stain- 
ing. It  does  not  grow  on  the  ordinary  media.  It  is  best  cultivated 
upon  agar-agar  slants,  upon  the  surface  of  which  has  been  smeared  a 
few  drops  of  blood.  The  colonies  appear  after  twenty-four  to  thirty- 
six  hours  as  minute,  colorless,  watery,  clear,  dew-like  colonies,  best 
seen  with  a  hand  lens.  In  the  sputum  these  bacilli  are  frequently 
present  in  large  numbers  in  cases  of  influenza,  and  their  presence  fill- 
ing up  the  protoplasm  of  the  leucocytes  and  the  purulent  sputum  of 
pneumonia  is  not  uncommon.  Thin  smears  of  the  sputum,  stained 
with  aniline  oil-gentian-violet,  somewhat  decolorized  with  alcohol,  and 
counter-stained  with  a  1  per  cent,  aqueous  solution  of  aurantia,  have 
shown  these  bacilli  much  better  than  the  ordinary  methods  of  staining 
with  Ldffler's  methylene-blue  or  dilute  carbol-fuchsin. 

Whooping-cough.  Minute  bacilli  have  been  discovered  in  the 
sputum  in  cases  of  whooping-cough  by  Czplewski,  Koplik,  Zusch,  and 
others.  At  present  the  results  are  not  sufficiently  uniform  to  prove 
these  bacilli  of  etiological  value  in  the  disease. 

Actinomyces.  When  the  lungs  or  pleura  are  infected  by  this 
fungus  actinomyces  may  be  found  in  the  sputum.  The  disease  in 
these  organs  is  rare.  Macroscopically  they  appear  as  small  kernels, 
yello  wish- white  or  greenish-yellow,  and  having  the  shape  of  a  millet- 
seed.  Under  the  microscope  they  are  recognized  by  the  rounded, 
club-like  bodies  projecting  from  all  sides  of  an  unformed  central  mass. 
They  are  seen  better  when  not  stained.     (See  page  352.) 

Chemistry  of  Sputum.  As  the  chemical  examination  of  the 
sputum  does  not  aid  us  in  diagnosis,  it  has  but  little  or  no  value. 
Mucin,  nuclein,  and  serum  albumin  are  constituents  of  sputa  in  health. 
Peptone  is  present  whenever  there  is  pus,  and  is  especially  marked  in 
pneumonia.  Volatile  fatty  acids,  such  as  butyric  and  acetic,  occur  at 
times,  markedly  so  in  pulmonary  gangrene.  Glycogen  has  been 
obtained  by  Solomon,  and  a  ferment  resembling  one  of  the  pancreatic 
ferments  has  been  detected,  especially  in  pulmonary  gangrene  and 
putrid  bronchitis.  Of  inorganic  substances,  chlorides  of  soda  and 
magnesia  ;  phosphates  of  soda,  lime,  and  magnesia  ;  sulphates  of  soda 
and  lime  ;  carbonate  of  soda,  lime,  and  magnesia  ;  and  in  a  few  cases 
phosphate  of  iron  and  silicates  have  been  obtained  (Von  Jaksch). 

SPECIAL  DIAGNOSIS. 

Pictoric  Records  of  Physical  Signs. 

In  order  to  draw  accurate  conclusions  from  the  various  data  obtained  during 
the  physical  examination  of  a  patient,  the  physician  must  carry  iu  his  mind  the 
results  of  the  inspection,  the  palpation  and  percussion,  and  the  auscultation  of 
each  individual  part  of  the  thorax  and  abdomen.     For  the  beginner  the  grouping 


PLATE  XVI. 


FIG.    1. — Anterior  Aspect. 


;iv    '?   / 


-x 


Physical  Signs  in  Health. 

Normal  percussion  outlines  of  the  viscera.     Normal   heart  and   breath  sounds. 
Vertical  lines  for  localization. 


DISEASES  OF  THE  LUNGS  AND  PLEUBJE.  537 

together  of  these  phenomena  according  to  regions  of  the  body,  instead  of  by 
methods  of  examination,  is  extremely  difficult.  He  is  taught  to  examine  the 
thorax,  first,  by  inspection,  then  by  palpation  and  percussion,  and,  finally,  by 
auscultation ;  and  in  following  this  routine  the  results  of  the  examination 
naturally  divide  themselves  into  the  signs  obtained  by  this  method  or  that.  In 
making  the  diagnosis,  however,  the  grouping  must  be  rearranged,  for  in  order  to 
determine  the  condition  of  a  certain  organ  or  part  of  an  organ,  all  the  local 
phenomena,  by  whatever  method  recognized,  must  be  considered  in  their  rela- 
tion to  one  another  and  not  merely  as  isolated  facts.  By  weighing  all  the 
evidence  obtained  by  the  various  methods  of  examination,  and  by  balancing  the 
relative  importance  of  this  sign  or  that,  a  verdict  is  finally  reached  in  regard  to 
the  condition  of  the  part  in  question.  Only  after  the  status  of  each  organ  has 
been  thus  separately  determined  can  a  complete  diagnosis  of  the  case  be  made 
with  certainty. 

In  describing  in  the  text  the  physical  signs  of  the  various  diseases  of  the 
internal  organs,  it  is  necessary,  in  order  to  avoid  endless  confusion,  to  consider 
data  in  the  order  in  which  they  are  elicited — i.  e.,  grouped  according  to  the 
method  of  their  recognition.  To  redescribe  them  grouped  according  to  regions 
would  involve  constant  repetition,  and  would  still  fail  to  give  a  clear  picture  of 
the  sign-complex  of  the  part.  And  yet  it  is  essential  that  this  picture  should  be 
so  clear  and  well  defined  that  the  physician,  in  summing  up  the  examination, 
has  but  to  glance  at  the  part  in  order  to  call  up  to  his  mind  all  the  various  data 
obtained  by  its  examination.  Experience  adds  daily  to  the  facility  with  which 
this  piece  of  mental  gymnastics  is  performed,  and  it  finally  becomes  half-auto- 
matic, but  for  the  beginner  it  is  most  discouragingly  difficult.  He  may,  how- 
ever, obtain  great  assistance  in  acquiring  the  right  habit  of  thought  by  system- 
atically writing  down  each  sign  as  it  is  perceived,  and  by  grouping  with  it  the 
other  signs  belonging  to  the  same  region.  This  he  may  do  by  means  of  short 
descriptions,  or,  better  still,  he  may  employ  symbols  to  represent  the  various 
sounds,  etc.,  and  may  mark  them  directly  on  the  patient's  body,  or  may  fill  them 
in  on  blank  diagrams  of  the  thorax  and  abdomen,  and  thus  obtain  a  complete 
and  vivid  picture  of  the  results  of  the  examination  of  each  separate  region 
The  practical  value  of  this  method,  both  as  an  aid  to  the  beginner  and  as  an 
easy  and  accurate  means  for  preserving  records,  has  been  widely  recognized, 
and  numerous  symbols  have  been  devised,  to  represent  graphically  the  various 
physical  signs.  Those  suggested  by  Wyllie,  of  Edinburgh,  and  by  Sahli,  of 
Bern,  are  among  the  best.  Many  of  the  symbols  used  in  the  following  plates 
will  be  recognized  as  borrowed  from  the  above  authors. 

Explanation  of  the  Symbols  Used  in  the  Plates  Illustrating  Special 

Diseases. 

Percussion  Sounds.  Superficial  dulness  (also  called  absolute  dulness)  is 
alone  indicated  in  the  following  plates.  As  has  already  been  stated,  the  per- 
sonal equation  enters  so  largely  into  the  determination  of  the  extent  of  deep 
(relative)  dulness  that  it  is  scarcely  possible  to  make  any  positive  statements  in 
regard  to  the  areas  over  which  it  is  obtained  in  health  and  in  disease.  Absolute 
dulness  is,  on  the  other  hand,  easily  recognized,  and  it  is,  therefore,  far  better 
that  the  student  first  become  thoroughly  familiar  with  this,  about  which  there 
can  be  little  or  no  question,  before  being  taught  what,  in  the  case  of  relative 
dulness,  is  after  all  merely  the  expression  of  the  individual  skill  and  acuteness 


538  SPECIAL  DIAGNOSIS. 

of  ear  of  the  instructor.  With  a  clear  picture  of  the  areas  of  superficial  dulness 
once  firmly  fixed  in  the  mind,  the  student  should  for  himself  determine  just  how 
far  he  individually  is  able  to  rely  upon  his  perception  of  deep  dulness.  As  his 
skill  in  percussion  increases,  and  as  his  ear  becomes  better  trained,  he  will  find 
himself  progressively  better  able  to  make  use  of  deep  dulness  as  an  aid  in  diag- 
nosis. He  should,  however,  remember  that  many  skilled  diagnosticians  are 
content  to  rely  almost  exclusively  upon  superficial  dulness. 

Blue  shading  =  Areas  of  superficial  dulness  ;  the  intensity  of  the  color  ex- 
presses the  intensity  of  the  dulness. 

HR  =  Hyper-resonance. 

T  =  Tympany  ;  the  pitch  is  indicated  by  a  dot  above  or  below 

the  letter. 

Breath-sounds.  An  ascending  line  indicates  inspiration ;  a  descending  line 
expiration.  The  length  of  the  line  shows  the  length  of  the  sound,  the  thickness, 
its  intensity.  A  dot  above  or  below  the  line  indicates  high  or  low  pitch.  Two 
cross  lines  are  used  to  designate  bronchial  breathing ;  a  single  cross  line  indi- 
cates bronchovesicular  breathing.  An  interrupted  line  stands  for  cog-wheel  or 
interrupted  breath-sounds. 

/\  =  Normal  vesicular  breath-sounds. 


=  Weak  vesicular  breath-sounds. 

=  Harsh  vesicular  breath-sounds  (puerile  breathing). 

=  Harsh  vesicular  inspiration,  prolonged  vesicular  expiration. 


/\ 

J\  =  Sharp  vesicular  inspiration,  slightly  prolonged  vesicular  expi- 

ration. 

/\  =  Interrupted  (cog-wheel)  breath-sounds. 

=  Bronchial  breath-sounds  (bronchial  breathing),  inspiratory 
and  expiratory. 

=  Bronchovesicular  inspiration,  low-pitched  bronchial  expira- 
tion. 

Rales.  Dry  rales  are  represented  by  undulating  lines,  the  length  corresponding 
to  the  duration,  while  a  dot  above  or  below  the  line  indicates  the  pitch. 

^v^v^A  =  Sonorous  rales. 

^^  =  Sibilant  rales. 

Moist  rales  are  represented  by  circles  the  diameter  of  which  indicates  the  size 
of  the  rales.  An  ascending  line  drawn  through  the  circle  shows  that  the  rale  is 
heard  during  inspiration,  a  descending  line  that  it  is  heard  during  expiration. 
The  clear,  sharp,  moist  rales  heard  over  consolidated  areas,  rales  with  over-tones, 
are  indicated  by  large  or  small  dots,  according  to  their  size. 

o°0  =  Small,  moist  (subcrepitant)  rales. 

°0°  —  Medium-sized  moist  rales. 

jtf  fo  =  Large  moist  rales  heard  during  both  inspiration  and  expira- 

tion. 
000  o  =  Large  and  small  moist  rales. 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  539 

•;•  =  Small  moist  rales  heard  over  consolidated  areas. 

%•  =  Medium-sized  moist  rales  heard  over  consolidated  areas. 

•  •  =  Large  moist  rales  heard  over  consolidated  areas. 

0J0  =  Large  and  small  moist  rales  heard  over  consolidated  areas. 

••• 

Crepitation. 

rP^  =  Crepitant  rales,  to  be  heard  only  during  inspiration. 

Friction  Rub. 

AVVAm  =  Friction  rub,  as  heard  over  any  serous  surface. 

Heart-sounds.  The  symbols  used  to  indicate  the  feet  in  Latin  poetry  are 
made  to  represent  the  heart-sounds.  The  straight  line  indicates  the  longer,  the 
curved  line  the  shorter  sound.  The  thickness  of  the  lines  shows  the  relative  as 
well  as  the  absolute  loudness. 

—  v  =  Normal  heart-sounds  as  heard  over  the  mitral  and  tricuspid 

regions. 
w   —  =  Normal  heart-sounds  as  heard  over  the  aortic  and  pulmonic 

regions, 
u    —  =  Normal  first  sound,  accentuated  second. 

~  uu  =  Loud  first  sound,  reduplicated  second. 

—  "~  =  Loud  first  and  second  sounds  of  equal  intensity. 
Murmurs.     Murmurs  are  represented  by  short  parallel  lines  either  increasing 

or  diminishing  in  length,  according  as  the  murmur  increases  or  diminishes  in 
intensity.  The  thickness  of  the  lines  shows  the  loudness  of  the  murmur,  the 
number  of  lines  shows  its  duration. 

Illllin.  =  A  soft  murmur,  commencing  distinctly  and  gradually  fading 


'lllllllllll.. 


[Illlin.  =  A  loud  murmur  of  the  same  character. 

i|||  =  A  short  loud  murmur,  increasing  in  intensity  (type  of  pre- 

systolic murmur). 
=  Loud  first  sound,  slightly  accentuated  second  sound;    short 
loud  presystolic  murmur,  increasing  in  intensity  to  end  with 
the  first  sound ;  long,  soft,  systolic  murmur. 

Fremitus. 

F  +  =  Increased  fremitus. 

F  —  =  Diminished  fremitus. 

NoF  =  Absent  fremitus. 

Other  Symbols. 

X  =.  Impulse. 

M  =  Margin  (of  an  organ). 

R  =  Retraction. 

B  =  Bulging. 

v  =  Visible. 

p  =  Palpable. 

Xvp  =  Visible  and  palpable  impulse. 

Mvp  =  Visible  and  palpable  margin, 


540  SPECIAL  DIAGNOSIS. 

The  Neuroses. 

The  neuroses  are  affections  of  the  lungs  unattended  by  structural 
change.  To  this  class  belong  the  varieties  of  rapid  breathing,  of  slow 
breathing,  of  cough  and  of  dyspnoea  which  appear  to  arise  without 
structural  change,  and  which  are  discussed  exhaustively  in  the  section 
devoted  to  the  subjective  symptoms.  Among  other  neuroses,  asthma 
is  fully  treated  of,  and  other  forms  of  dyspncea  and  cough  are 
considered.  Reference  need  not  be  made  further  to  the  respiratory 
neuroses  other  than  to  bear  in  mind  that  their  presence  may  or  may 
not  be  unattended  bv  organic  change  in  the  lungs.  On  the  other 
hand,  we  are  likely  to  find  the  general  phenomena  or  stigmata  which 
are  associated  with  neuroses  of  other  organs,  as  well  as  the  lungs. 
Hence,  the  condition  of  neurasthenia  is  likely  to  be  present  on  the  one 
hand,  or  the  numerous  stigmata  of  hysteria  may  be  found  on  the  other. 

The  Congestions. 

Congestion  of  the  Lungs.  Active  Congestion.  In  active  con- 
gestion there  is  an  increased  amount  of  blood,  which  diminishes  the 
air-space  by  encroachment  and  causes  more  or  less  consolidation.  The 
signs  of  that  physical  condition  are  present — increased  fremitus,  im- 
paired resonance  or  dulness,  and  bronchial  breathing.  They  are 
observed  on  both  sides,  usually  at  the  bases.  Dyspnoea,  cough,  and 
frothy,  bloody  expectoration  attend  the  fluxion.  Xo  cases  have  vet 
been  reported  in  which  bacteriological  examination  of  the  sputum  was 
made.     Of  course,  the  micrococcus  lanceolatus  is  not  found. 

If  the  above  signs  and  symptoms  develop  suddenly — within  twenty- 
four  hours — a  fluxion  to  the  lung  has  in  all  probability  taken  place. 
If  the  patient  is  subject  to  heart  disease,  or  if  he  has  been  exposed  to 
and  has  inhaled  hot  vapors  or  irritants,  the  probability  of  fluxion  is 
increased.  The  occurrence  of  fever  would  point  to  pneumonia  as  the 
cause  of  the  objective  and  subjective  symptoms. 

Passive  Congestion.  The  physical  condition  that  results  is  con- 
solidation, manifesting  itself  by  slight  dulness  and  feeble  or  bronchial 
breathing ;  the  bronchial  mucous  membrane  is  also  congested,  giving 
rise  to  abundant  large  rales.  The  affection  is  bilateral  and  usually 
confined  to  the  posterior  portions  of  the  bases.  It  is  also  secondary. 
a.  Mechanical  congestion  occurs  when  the  flow  of  blood  to  the  heart  is 
obstructed,  as  in  organic  valvular  disease  or  insufficiency.  Rarely  the 
pressure  of  tumors  on  the  pulmonary  veins  acts  in  a  similar  manner. 
6.  Hypostatic  congestion  occurs  in  fevers,  as  protracted  typhoid,  and 
in  prolonged  general  exhaustion  or  adynamia.  Ascites  or  other  affec- 
tions below  the  diaphragm,  which  lessen  the  respiratory  excursion, 
cause  this  form.  Dyspnoea,  cough,  and  expectoration  of  blood-stained 
sputum  are  common.  The  sputum  contains  alveolar  cells,  often  pig- 
mented, but  no  micro-organisms. 

CEdema.  The  air-cells  and  alveolar  walls  are  filled  with  serous 
exudation,  as  in  oedema  of  the  skin.  It  is  frequently  due  to  the  weak- 
ness of  the  heart,  which  occurs  at  the  end  of  long-continued  diseases 


DISEASES  OF  THE  LUNGS  AND  PLEUBJE.  541 

of  an  exhaustive  nature,  particulaly  if  the  heart  is  overtaxed.  It 
occurs,  therefore,  in  the  terminal  stages  of  chronic  Bright' s  disease,  of 
organic  heart  disease,  of  the  anaemias  and  cachexias.  Both  congestion 
and  oedema  occur  in  cerebral  affections. 

Symptoms.  They  are  those  of  congestion  in  a  more  aggravated 
form.  Dyspnoea,  cough,  and  the  expectoration  of  large  quantities  of 
a  seromucoid  fluid  are  seen.  The  diagnosis  is  based  upon  the  result 
of  physical  examination  and  the  history  of  the  above  causal  factors. 
In  cases  of  myocarditis  or  acute  dilatation  of  the  heart,  in  valvulitis 
with  failing  compensation,  oedema  of  the  lungs  often  takes  place  sud- 
denly. It  may  follow  some  unusual  exertion.  Its  onset  is  attended 
with  more  or  less  collapse,  increased  pulse-rate,  hurried,  oppressed, 
noisy  breathing,  cyanosis,  and  an  anxious  expression.  The  physical  signs 
are  an  unusual  number  of  small  rales  throughout  the  chest,  apparently 
created  in  the  air  sacs,  and  imperfect  resonance,  showing  that  some 
lobules  are  collapsed. 

Pulmonary  Embolism  and  Thrombosis.  Pulmonary  embolism 
consists  in  plugging  of  the  pulmonary  artery  or  its  branches  by  coagula 
formed  in  the  right  heart  or  in  the  veins.  The  symptoms  depend  upon 
the  size  of  the  occluded  vessel  and  upon  the  nature  of  the  embolus — i.  e., 
whether  septic  or  not.  If  the  artery  itself  is  plugged,  death  takes  place 
suddenly  or  after  a  short  interval,  with  symptoms  of  syncope  or  asphyxia. 

Symptoms.  If  a  large  branch  is  plugged,  the  first  symptom  is  gen- 
erally intense  dyspnoea,  which  may  amount  to  an  agonizing  craving 
for  air.  Pain  in  the  chest,  which  may  or  may  not  be  acute,  is  com- 
plained of,  and  may  be  referred  to  the  seat  of  the  embolus.  Cough  is 
not  a  common  symptom,  and  may  be  altogether  absent.  The  breath 
ing  is  considerably  altered  ;  it  is  usually  increased  in  frequency,  and 
may  be  much  hurried  ;  it  may  or  may  not  be  shallow,  and  while  the 
patient  can  take  a  deep  inspiration,  it  does  not  give  relief  to  his  dysp- 
noea.    At  times  it  is  irregular  and  gasping. 

The  face  is  pale  or  may  be  cyanosed,  and  is  apt  to  be  bathed  in  per- 
spiration. The  veins  are  swollen  and  prominent.  The  heart's  action 
is  irregular  and  may  be  tumultuous.  Exophthalmos  has  been  ob- 
served. The  temperature  falls  below  normal,  but  a  febrile  rise  may 
occur  later.     The  intellect  is  unclouded. 

The  physical  signs  are  indefinite.  The  respiratory  murmur  is  rough- 
ened and  exaggerated  in  most,  but  not  in  all  cases.  Fox  states  that 
rales  are  very  rarely  heard.  Collapse,  oedema,  and  bronchitis  are  possi- 
ble results.  A  systolic  blowing  murmur  may  be  heard  over  the  heart 
and  pulmonary  artery,  and  in  protracted  cases  albuminuria  and  oedema 
may  be  met  with. 

When  the  embolus  is  septic,  a  septic  pneumonia  or  metastatic  abscesses 
are  probable  results  in  cases  not  immediately  fatal. 

When  the  emboli  produce  hemorrhagic  infarcts  the  symptoms  are 
milder,  and  consist  principally  in  dyspnoea,  pulmonary  hemorrhage, 
and  palpitation.  The  onset  is  sudden  and  accompanied  by  a  fall  in 
temperature.  The  physical  signs  indicate  consolidation,  if  the  pneu- 
monia or  infarcted  area  is  of  moderate  size.  It  may  be  discovered  at 
the  root  of  the  lungs  in  the  interscapular  region. 


542  SPECIAL  DIAGNOSIS. 

Haemoptysis  is  a  common  symptom  when  the  embolus  has  arisen  in 
the  heart.  The  amount  of  blood  varies  from  a  copious  expectoration 
to  the  rusty  sputum  seen  in  pneumonia  ;  it  may  persist  for  weeks. 
Pleurisy  and.  pleural  effusion  are  frequent  complications  ;  chills  occur 
sometimes,  and  pneumonia,  with  corresponding  rise  of  temperature, 
may  develop. 

The  most  important  points  in  diagnosis  are  the  sudden  onset  of  the 
dyspnoea  and  other  pulmonary  symptoms,  and  the  detection  of  a  con- 
dition which  would  give  rise  to  emboli,  such  as  puerperal  fever  or 
heart  disease. 

The  Inflammations. 

The  Bronchi.  Inflammations  of  the  bronchi  are  distinguished  from 
other  diseases  of  the  lungs  chiefly  by  the  difference  in  the  physical 
signs.  Except  in  capillary  bronchitis,  the  general  and  subjective 
symptoms  are  not  so  severe  as  in  other  affections. 

Signs  Peculiar  to  Inflammations  of  Bronchi.  AVe  are  aided 
in  the  recognition  of  bronchial  affections,  first,  by  the  fact  that  they 
are  bilateral ;  second,  that  the  bases  are  usually  affected  ;  third,  that 
there  is  diminution  of  fremitus  determined  by  palpation  ;  fourth,  that 
there  is  absence  of  dulness  on  percussion  ;  fifth,  that  rales  are  more 
pronounced  in  proportion  to  other  physical  signs,  and  more  general 
than  in  other  lung  affections. 

Bronchitis.  Bronchitis  is  an  mflammation  of  the  mucous  mem- 
brane of  the  bronchial  tubes.  It  may  be  acute  or  chronic,  may  in- 
volve any  part  of  the  bronchial  tree,  the  large,  the  middle-sized,  or 
the  most  minute  branches,  and  may  be  primary,  or  occur  secondarily 
to  some  general  disease,  or  to  disease  of  the  heart  or  kidneys. 

Acute  bronchitis  occurs  most  frequently  by  extension  of  the 
catarrhal  inflammation  from  the  nose  and  throat ;  but  in  some  persons 
it  develops  so  suddenly  that  it  appears  to  be  primary  in  the  tubes. 

When  the  larger  or  middle-sized  tube*  are  involved,  the  patient  com- 
plaius  of  soreness  or  rawness  underneath  the  sternum,  especially  at  its 
upper  part.  There  are  frequently  a  feeling  of  tickling  in  the  throat, 
and  a  sense  of  weight  or  oppression  on  the  chest.  Chest  pain  is  due 
to  myalgia  or  the  strain  upon  the  muscles  from  coughing.  The  cough 
is  at  first  hard  and  dry,  and  often  produces  pain  of  a  tearing  character 
in  the  muscles  of  the  chest  and  abdomen.  The  cough  is  apt  to  be 
worse  when  the  patient  first  lies  down,  and  again  on  rising,  especially 
after  a  night's  rest.  Fever  is  usually  slight  and  of  short  duration. 
The  respirations  are  accelerated,  but  not  markedly,  and  there  is  no 
dyspnoea.  The  expectoration  is  at  first  a  white,  frothy,  viscid  mucus, 
subsequently  becoming  more  abundant  and  mucopurulent. 

Physical  Signs.  In  uncomplicated  case.-  there  arc  no  changes  in  the 
physical  structure  of  the  lungs.  On  examination  of  the  chest  the  per- 
cussion-note is  found  to  be  clear  ;  the  respiratory  murmur  more  rough- 
ened and  harsher  than  normal,  but  not  broncho  vesicular  or  bronchial; 
accompanying  breathing  there  are  heard  sibilant  and  sonorous  rales. 
and,  in  the  later  stages,  some  large  and  medium-sized  mucous  rales. 
The  rales  vary  in  position  from  time  to  time,   and  especially  after 


DISEASES  OF  THE  LUNGS  AND  PLEUBJE.  543 

coughing.     Vocal  resonance  and  fremitus  are  unaltered.     A  fremitus 
may  be  produced  by  sonorous  rales. 

The  cough  and  expectoration  usually  last  for  some  time  after  fever 
has  subsided.  The  duration  of  the  disease  is  from  a  few  days  to  sev- 
eral weeks.  It  is  never  fatal  except  in  the  very  old  and  very  young, 
or  in  those  who  are  much  debilitated. 

The  diagnosis  of  acute  bronchitis  is  easily  made  by  noting  the  fact 
that  the  disease  runs  an  acute  course,  marked  by  fever,  cough,  and  ex- 
pectoration ;  and  that  the  physical  signs  are  negative,  except  as  to 
roughening  of  the  respiratory  murmur  and  the  existence  of  bronchial 
rales,  heard  on  both  sides  of  the  chest. 

From  croupous  pneumonia  and  local  tuberculosis  of  the  lungs  it  is 
distinguished  by  the  absence  of  dulness  on  percussion,  bronchial 
breathing,  and  increase  of  vocal  resonance  and  fremitus ;  by  the 
absence,  in  other  words,  of  the  ordinary  sigus  of  consolidation.  From 
pneumonia  it  is  further  distinguished  by  the  milder  character  of  the 
subjective  symptoms,  and  by  the  fact  that  in  bronchitis  the  physical 
signs  are  almost  always  bilateral,  in  pneumonia  generally  unilateral. 
It  is  further  distinguished  from  tuberculosis  by  the  slow  progress  of 
the  latter,  which  involves  the  apices  preferably,  whereas  bronchitis  is 
more  marked  at  the  bases  ;  and  by  the  occurrence,  sooner  or  later,  of 
hectic  fever  and  emaciation,  which  are  absent  in  bronchitis.  Doubt 
will  exist  only  at  first ;  the  progress  of  the  case  will  in  time  make 
everything  clear.  Systematic  examination  of  the  sputum  is  an  impor- 
tant diagnostic  aid,  and  will  lead  to  the  differentiation  of  many  cases 
of  bronchitis  from  tuberculosis  and  from  pneumonia.  In  infants  and 
children  especially,  bronchitis  is  at  times  so  rebellious  to  treatment 
that  tuberculosis  is  suspected. 

In  bronchopneumonia  (catarrhal  pneumonia)  there  is  a  diffuse  bron- 
chitis associated  with  small  areas  of  pneumonic  consolidation.  It  is 
distinguished  by  having  graver  general  symptoms  and  by  the  presence 
of  small  areas  over  which  there  are  dulness  on  percussion  and  bronchial 
breathing,  associated  with  physical  signs  of  bronchitis  already  de- 
scribed. 

Acute  miliary  tuberculosis  of  the  lungs  is  very  easily  mistaken  for 
bronchitis,  because  dulness,  if  present,  amounts  to  nothing  more  than 
tympanitic  dulness,  because  the  signs  are  diffused  through  both  lungs, 
and  because  the  respiratory  murmur  is  fainter  than  normal,  but  only 
slightly  roughened.  Close  inspection  of  the  patient  will,  however, 
make  it  evident  that  his  condition  is  worse  than  could  be  accounted 
for  by  bronchitis  alone.  The  fever  is  higher,  the  respirations  more 
frequent,  pallor,  with  a  dusky  or  faintly  cyanotic  hue  intermingled,  is 
common,  perspiration  is  more  pronounced.  A  primary  focus  or  a 
source  of  infection  may  be  discovered. 

Acute  bronchitis  may  be  mistaken  for  spasmodic  laryngitis  (Croup). 
It  is  distinguished  by  the  fact  that  the  spasms  are  less  pronounced  in 
bronchitis,  and  there  is  fever  in  addition  to  the  physical  signs.  In 
bronchitis  the  breathing  is  rarely  so  stridulous  as  in  laryngeal  spasm. 

Whooping-cough  cannot  be  distinguished  positively  from  bronchitis 
before  the  characteristic  whoop  appears  ;  but  it  may  be  suspected  when 


544  SPECIAL  DIAGNOSIS. 

the  child  has  been  exposed  to  contagion,  and  when  the  coryza  and 
redness  of  the  fauces  persist  in  spite  of  treatment. 

In  the  diagnosis  of  bronchitis  it  is  more  often  difficult  to  determine 
the  primary  cause  than  it  is  to  distinguish  it  from  other  pulmonary 
affections.  Yet  the  former  is  more  important ;  it  must  be  borne  in 
mind  that  bronchitis  is  a  frequent  accompaniment  of  many  febrile  dis- 
eases, such  as  typhoid  fever,  measles,  and  whooping-cough  ;  of  diseases 
of  the  heart  and  kidneys,  and  of  septic  diseases  and  blood  disorders. 
The  primary  will  not  be  likely  to  be  mistaken  for  the  seconday  dis- 
order if  one  is  upon  his  guard  and  insists  upon  finding  a  cause  for  each 
case  that  presents  itself. 

Measles  can  usually  be  diagnosticated  from  the  first  by  the  coryza, 
but  especially  by  the  red  spots  upon  the  anterior  half-arches  of  the 
soft  palate,  which  appear  usually  several  days  before  the  eruption  upon 
the  body. 

Bronchitis  is  a  common  and  important  early  symptom  of  typhoid 
fever.  The  latter  disease  may  be  suspected  when  the  fever,  prostra- 
tion, and  headache  are  greater,  and,  especially  if  these  symptoms  coex- 
ist with  a  loose  condition  of  the  bowels,  chilliness,  and  occasional  nose- 
bleed. 

Chronic  bronchitis  occurs  most  frequently  in  middle  or  later 
life.  Its  special  feature  is  long  duration,  without  fever,  and  with 
comparatively  little  impairment  of  the  general  health.  Cough  is  not 
constant ;  there  are  periods  when  it  is  entirely  absent ;  the  disease 
then  returns,  perhaps  with  increased  severity,  and  lingers  indefinitely. 

Chronic  bronchitis  in  its  milder  form  consists  in  what  is  often 
called  "  winter  cough."  It  attacks  especially  persons  past  middle  life 
who  have  emphysema.  It  appears  with  the  cold  weather,  and  lasts 
until  the  following  summer.  The  cough  is  not  severe,  though  some- 
times paroxysmal,  and  expectoration  is  scanty,  non-purulent,  and  may 
be  confined  to  the  morning.  Dyspnoea  is  not  marked  unless  there  is 
considerable  emphysema.  Acute  exacerbations  occur  from  time  to 
time,  and  the  tendency  of  the  disease  is  to  become  worse  from  year 
to  year,  and  to  be  more  continuous,  even  persisting  all  summer. 

In  the  dry  catarrh,  or  catarrhe  sec  of  Lsennec,  paroxysms  of.  cough 
occur  on  the  slightest  provocation,  with  the  expectoration  of  small, 
hard  pellets,  or  without  any  expectoration.  The  patients  are  emphy- 
sematous. 

The  diagnosis  is  made  by  noting  the  long  duration  of  the  disease 
without  impairment  of  the  general  health,  its  relation  to  season,  and 
the  absence  of  physical  signs  of  involvement  of  lung  tissue. 

The  physical  signs  of  chronic  bronchitis  are  those  of  bronchitis  of 
the  larger  and  middle-sized  tubes.  Large  moist  rales  are  more  or  less 
abundant,  depending  upon  the  degree  of  swelling  of  the  mucous  mem- 
brane, and  the  quantity  and  fluidity  of  the  secretions.  The  respiratory 
murmur  is  roughened  and  less  intense  than  normal. 

"W.  Fox  says  that  in  chronic  bronchitis  there  is  commonly  hyper- 
resonance  from  coexisting  emphysema,  but  under  acute  exacerbations 
the  bases  may  be  dull  from  congestion  or  oedema.  Respiration  is 
harsh,  and  in  some  cases  of  senile  bronchitis  expiration  may  be  both 


DISEASES  OF  THE  LUNOS  AND  PLEURJE.  545 

prolonged  and  high  pitched,  when  other  signs  of  dilatation  of  bronchial 
tubes  are  absent.     The  percussion-note  is  clear. 

The  sputa  of  the  severe  forms  of  chronic  bronchitis  are  usually 
copious  and  mucopurulent,  the  latter  predominating.  They  vary  in 
color  from  yellowish-white  to  ashy,  greenish,  or  black  when  the  lungs 
are  anthracotic  or  collapsed. 

The  subjective  symptoms  of  the  patient  consist,  in  ordinary  cases,  of 
a  moderate  amount  of  dyspnoea,  and  tightness  across  the  chest.  At 
the  onset  of  a  fresh  attack  the  symptoms  may  be  those  of  acute  bron- 
chitis. The  cough  is  paroxysmal,  somewhat  resembling  that  of  whoop- 
ing-cough, but  without  the  characteristic  whoop.  It  is  usually  severest 
on  lying  down  and  when  rising  in  the  morning. 

The  quantity  and  character  of  the  sputa  vary  more  than  in  acute 
bronchitis.  Sometimes  they  are  very  copious,  consisting  of  serum 
mixed  with  mucus,  constituting  bronehorrhoea.  More  commonly  they 
are  scanty,  glairy,  and  tenacious. 

Chronic  bronchitis  may  be  the  result  of  repeated  acute  attacks,  or, 
rarely,  of  only  one.  It  is  frequently  found  in  association  with  gout, 
chronic  heart  disease,  chronic  endarteritis,  B  right's  disease,  emphy- 
sema, asthma,  and  chronic  alcoholism.  It  may  alternate  with  other 
gouty  affections,  as  articular  inflammation  or  eczema,  being  relieved 
when  the  other  manifestations  are  more  marked.  It  also  accompanies 
tuberculosis  of  the  lungs.  Climate  and  season  have  a  marked  influ- 
ence ;  the  disease  is  worse  in  damp,  cold  climates,  and  in  the  winter 
months. 

Chronic  bronchitis  can  be  diagnosticated  from  the  cough  of  aneurism 
by  the  absence  of  the  stridulous  breathing,  due  to  paralysis  of  one-half 
of  the  vocal  cords,  and  by  the  local  signs  of  a  tumor  of  the  vessel. 
Other  tumors  may  cause  cough  by  pressure,  and  the  possibility  of  their 
existence  should,  therefore,  be  borne  in  mind. 

Capillary  Bronchitis,  or  Suffocative  Catarrh,  is  bron- 
chitis of  the  smaller  tubes.  It  occurs  most  frequently  as  an  extension 
of  the  catarrhal  process  from  the  larger  tubes,  but  sometimes  seems  to 
attack  the  smaller  tubes  from  the  beginning,  or  coincidently  with  the 
larger  tubes.  Infants,  young  children,  and  the  aged  are  most  liable  to 
it.  It  begins  with  a  succession  of  chills  or  chilliness,  followed  by  high 
fever.  The  temperature  may  rise  to  104°.  The  skin  is  hot,  the  face 
flushed.  The  head  and  neck  and  the  upper  portion  of  the  trunk  may 
be  covered  with  perspiration.    The  pulse  rapidly  increases  in  frequency. 

The  aspect  of  the  patient  from  the  first  shows  that  the  illness  is 
graver  than  ordinary  bronchitis.  The  face  expresses  anxiety,  and  in 
children  the  alse  nasi  dilate  in  respiration,  which  is  both  accelerated 
and  difficult  (dyspnoea).  The  respirations  may  be  as  many  as  60  or 
80  to  the  minute,  the  pulse  not  being  correspondingly  rapid.  Dysp- 
noea is  more  or  less  constant,  but  becomes  urgent  in  paroxysms,  and 
the  patient  may  have  to  be  propped  up  in  bed  to  enable  him  to  breathe 
(orthopncea).  It  is  expiratory :  inspiration  may  be  free  and  easy,  or 
difficult  ;  but  expiration  is  always  difficult  and  prolonged.  In  children 
the  pause  in  the  act  of  breathing  takes  place  at  the  end  of  inspiration, 
instead  of  expiration. 


546  SPECIAL  DIAGNOSIS. 

Cough  is  more  frequent  and  violent  than  in  ordinary  bronchitis,  and 
the  expectoration  is  viscid  and  difficult  to  raise.  As  the  disease  pro- 
gresses, dyspnoea  becomes  more  intense,  and  signs  of  insufficient  aera- 
tion of  the  blood  make  their  appearance  (cyanosis).  The  lips  and 
finger-nails  become  bluish,  and  the  extremities  cool  and  clammy.  If 
the  patient  is  unable  to  expel  the  tenacious  secretions  from  his  bron- 
chial tubes,  the  further  progress  of  the  case  is  that  of  rapidly  develop- 
ing cyanosis  ;  the  breathing  continues  frequent,  but  is  shallow  and 
more  labored.  Children  often  have  convulsions,  followed  by  coma  and 
death,  while  old  persons  sink  into  coma  without  preceding  convulsions. 

The  physical  signs  (Plate  XVII.)  are  those  of  bronchitis  of  the  larger 
and  smaller  tubes  ;  sibilant  and  sonorous  rales,  if  present  at  first,  give 
way  to  fine  subcrepitant  and  crepitant  rales,  which  speedily  become 
moist  and  very  abundant.  As  an  ordinary  bronchitis,  the  bases  of 
the  lungs  posteriorly  are  the  parts  most  involved.  The  percussion-note 
of  both  lungs  remains  clear,  but  there  is  apt  to  be  increased  resistance. 
The  fremitus  may  be  lessened  in  some  areas,  increased  in  others.  If 
an  area  of  dulness  appears,  it  may  be  due  to  pneumonia  or  to  collapse 
of  the  lung  ;  if  the  former,  there  is  usually  an  access  of  fever. 

The  sputum  contains  mucus,  pus,  occasionally  blood-cells,  granular 
matter,  and  sometimes  fibrinous  casts  of  the  tubes.  The  micro-organ- 
isms found  are  the  micrococcus  lanceolatus,  streptococcus  pyogenes,  and 
staphylococcus  aureus  et  albus.      Mixed  infections  are  usually  present. 

Plastic  bronchitis  is  a  form  of  bronchitis,  usually  chronic,  the 
characteristic  feature  of  which  is  the  expectoration  of  fibrinous  casts, 
which,  when  unravelled  under  water,  are  found  to  be  solid  casts  of 
the  smaller  bronchial  tubes.  The  casts  are  often  tree-like  in  shape, 
showing  that  a  bronchial  tube  and  its  smaller  subdivisions  have  been 
occluded  by  the  casts. 

Persons  of  all  ages  are  liable  to  it,  but  it  affects  males  about  twice  as 
often  as  females. 

The  subjective  symptoms  are  cough  and  dyspnoea ;  haemoptysis 
occurs  in  about  one-third  of  the  cases  (Biermer).1  The  cough  occurs 
in  paroxysms,  which  are  frequent  and  severe  ;  relief  follows  expecto- 
ration of  the  casts. 

Hemorrhage  may  appear  only  as  streaks  of  blood  upon  the  casts,  or 
may  be  considerable,  and  follow  their  dislodgement.  The  casts  them- 
selves when  ejected  are  usually  coated  with  mucus,  so  that  they  appear 
as  solid  masses  of  sputum  ;  their  arrangement  into  cylinders  may  not 
be  suspected  until  they  are  agitated  in  water.  The  size  of  the  cylin- 
der varies  from  that  of  the  little  finger  to  that  of  a  bodkin,  but  they 
do  not  often  exceed  the  size  of  a  goose-quill.  The  larger  casts  may 
be  hollow,  but  the  smaller  ones  are  solid,  and  are  arranged  in  layers. 
They  are  whitish  or  gray  in  color,  and  firm  in  consistence,  but  become 
softer  as  the  disease  improves.  Microscopically,  the  casts  are  nearly 
structureless,  consisting  of  a  fibrillated  base,  with  pus  and  mucous  cor- 
puscles, a  few  gland-cells,  and,  occasionally,  blood-cells  in  the  outer 
layers.     Charcot-Leyden  crystals  and  Curschmann's  spirals  are  found. 

1  Virchow:  Handbuch  der  spec.  Path.  u.  Ther.,  Bd.  v.,  Abth.  1. 


PLATE    XVII. 


FIG.    1. — Anterior  Aspect. 


FIG.   2.— Posterior  Aspect. 

-etc 


/ 

Capillary  Bronchitis  (early  stage). 

Rough  or  sharp  breath  sounds-expiration   in   places  prolonged.    Sonorous, 
sibilant  and  small   nioist  rales.     Local    increase  of  fremitus. 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  547 

The  acute  form  is  rare,  and  out  of  ten  cases  accepted  by  Biermer  six 
proved  fatal.  The  disease  begins  with  fever,  dyspnoea  appears  early, 
severe  paroxysms  of  cough  occur,  sometimes  hemorrhage.  Death 
results  from  asphyxia.  Grave  symptoms  are  excessive  dyspnoea, 
scanty  expectoration,  and  drowsiness.  Copious  expectoration  is  a 
favorable  sign. 

The  Physical  Signs.  The  casts  obstruct  the  bronchial  tubes.  There 
is  less  air  entering  the  part,  hence  there  are  diminished  fremitus  and 
respiratory  murmur  over  the  portions  of  lung  supplied  by  the  obstructed 
tubes.  If  collapse  ensues,  there  is  dulness  on  percussion  ;  if  the  casts 
are  dislodged,  the  murmur  becomes  normal,  or  but  slightly  roughened. 
In  unaffected  portions  of  the  lung  resonance  is  clear  or  exaggerated, 
and  the  respiratory  murmur  remains  unaltered. 

Fuller  says  (quoted  by  Peacock  in  Diseases  of  Chest)  that  the  upper 
portions  of  the  lungs  are  oftener  affected  than  the  lower  portions. 

Fetid  or  Putrid  Bronchitis  is  the  name  applied  to  the  condi- 
tion in  which  the  sputa  have  a  highly  offensive  odor  and  are  copious 
and  semi-putrid.  The  odor  is  said  by  some  to  be  due  to  microscopic 
sloughs,  and  by  others  to  a  special  bacillus. 

Putrid  bronchitis  may  accompany  (1)  dilatation  of  the  bronchial 
tubes  ;  (2)  chronic  pneumonia  ;  (3)  phthisis  or  (4)  empyema  with  a 
fistulous  communication  with  a  bronchus  ;  or  (5)  it  may  occur  indepen- 
dently. The  subjective  symptoms  are  cough,  irregular  fever,  and 
occasional  chills.  The  physical  signs  are  those  of  chronic  bronchitis, 
or  of  bronchitis  and  the  conditions  with  which  it  may  be  associated 
(q.  v.).  It  is  diagnosticated  from  gangrene  by  the  absence  of  physical 
signs  of  disintegration  of  lung-tissue  and  by  the  absence  from  the 
sputum  of  fragments  of  lung-tissue  and  elastic  fibres.  Nevertheless, 
gangrene  of  the  lung  may  be  the  final  result  of  putrid  bronchitis. 

The  sputa  of  fetid  bronchitis  have  an  odor  of  gangrene  or  fasces. 
On  standing  they  separate  into  three  layers.  The  upper  one  consists 
of  a  greenish,  fluid,  or  frothy  layer  ;  the  second  is  sero-albuminous  ; 
and  the  third  a  thick  granular  deposit  in  which  are  small  masses,  the 
size  of  peas  (Dittrich's  plugs),  and  flake  sconsisting  of  granular  detritus, 
and  containing  fat-crystals  and  bacteria,  the  oklium  albicans,  and  crys- 
tals of  leucin  and  ty rosin.     (See  Sputum.) 

Infectious  Bronchitis.  In  addition  to  the  bronchitis  that  attends 
the  infectious  disorders  mentioned  above,  three  forms  are  seen  of  an 
infectious  nature  which  are  properly  classified  among  the  infectious 
diseases.  It  is  proper  to  refer  to  them  now,  as  bronchitis  is  usually 
the  most  pronounced  local  manifestation.  They  are  influenza,  whoop- 
ing-cough, and  hay-fever.     The  last  only  will  be  spoken  of  at  present. 

Hay- fever.  Hay-fever  is  a  specific  catarrh  of  the  respiratory  pas- 
sages, caused  by  the  pollen  of  certain  plants,  principally  the  grasses. 
The  attack  begins  with  itching,  burning,  and  lacrvmation  of  the  eyes, 
and  pain  in  the  brow  or  eyeballs.  Subsequently  there  is  itching  or 
pricking  of  the  nasal  mucous  membrane,  frequent  sneezing,  and  an 
irritating  watery  discharge.  The  mucous  membrane  of  the  nose  is 
red  and  swollen.  A  similar  condition  obtains  in  the  throat  when  that 
is  affected.     If  the  disease  attacks  the  bronchial  mucous  membrane  a 


548  SPECIAL  DIAGNOSIS. 

bronchitis  is  set  up,  which,  if  it  differs  at  all  from  ordinary  bronchitis, 
is  more  persistent  and  attended  by  greater  dyspnoea,  with  asthmatic 
attacks. 

Collapse  of  the  Lung.  Collapse  of  the  lung  is  a  condition  pro- 
duced by  exhaustion  of  air  from  the  air-vesicles.  It  may  affect  alveoli 
here  and  there,  or  a  large  section  of  the  lung.  Formerly  such  collapse 
was  invariably  looked  upon  as  pneumonia,  until  Legendre  and  Bailly 
proved  by  forcible  inflation  that  the  air-vesicles  had  simply  collapsed 
from  absence  of  air.  Collapse  occurs  most  frequently  in  the  course  of 
bronchitis  and  in  cases  with  feeble  respiratory  power.  The  bronchial 
twigs  supplying  certain  air-vesicles,  or  tubes  supplying  sections  of  lung, 
become  occluded  to  such  a  degree  that  no  air  can  enter.  The  air 
already  contained  in  the  vesicles  then  becomes  exhausted  gradually 
until  the  vesicles  are  completely  airless.  The  vesicles  or  sections  of 
lung  involved  then  return  to  the  foetal  condil  ion.  When  the  collapse 
is  congenital  the  term  atelectasis  is  preferable.  Anything  which  in- 
duces great  muscular  weakness  predisposes  to  collapse  of  the  lung ; 
hence,  in  the  aged  and  feeble,  in  wasting  diseases,  and  in  low  febrile 
diseases  of  long  standing,  collapse  is  very  apt  to  occur.  But  bronchitis 
is  the  most  frequent  and  direct  cause.  The  secretions  which  are 
poured  out,  and  the  swelling  of  the  mucous  membrane,  occlude  the 
tubes,  and  if  the  patient  have  not  strength  enough  to  expel  the  secre- 
tions, and  by  forced  inspiration  expand  the  collapsing  vesicles,  collapse 
ensues. 

Diagnosis.  The  diagnosis  of  the  condition  in  life  is  difficult.  The 
site  of  collapse,  being  airless,  is,  of  course,  dull  on  percussion.  The 
respiratory  murmur  is  more  likely  to  be  faint  or  absent  than  to  be 
increased  in  intensity  or  approach  the  bronchial.  ^Nevertheless,  there 
is  sometimes  heard  a  faint  bronchovesicular  expiration. 

"SVhen  oedema  is  superadded  to  collapse,  moist  crepitant  rales  are 
heard,  difficult  if  not  impossible  to  distinguish  from  those  of  pneumo- 
nia. Respiration  is  embarrassed,  and  is  accompanied  by  sucking-in  of 
the  lower  part  of  the  chest  in  inspiration.  Sometimes  the  plug  of 
mucus  which  occludes  the  tubes  becomes  dislodged  while  the  physician 
is  auscultating,  and  then  the  respiratory  murmur  will  be  heard,  accom- 
panied by  a  succession  of  crepitant  rales,  which  disappear  after  a  few 
inspirations.  The  dull  areas,  as  a  rule,  are  less  persistent  than  those 
of  pneumonia  ;  thus  it  may  be  foimd  at  successive  examinations  that 
one  area  has  cleared  up  and  another  has  become  dull.  Stress  is  laid 
by  some  writers  upon  the  signs  of  emphysema  surrounding  collapsed 
areas.  But  this  does  not  give  assistance  in  the  cases  in  which  most 
help  is  required — cases  in  which  there  is  diffuse  bronchitis  with  more 
or  less  oedema. 

Subjective  symptoms  are  those  of  dyspnoea  and  insufficient  oxygena- 
tion of  the  blood.  If  these  are  developed  suddenly,  and  are  accom- 
panied by  the  appearance  of  dull  areas  in  the  lung  without  bronchial 
breathing,  the  diagnosis  is  tolerably  certain  ;  but  when  scattered  lob- 
ules only  are  involved,  the  physical  signs  of  collapse  are  absent,  and 
its  existence  must  be  a  matter  of  inference. 

From  lobar  pneumonia  the  diagnosis  is  easily  made  by  the  difference 


PLATE    XVIII. 


FIG.  2. 


Broncho- pneumonia. 

Consolidation  in  the  right  upper  and  the  left  lower  lobes.     Physical  signs 
of  bronchitis  over  both  lungs. 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  549 

in  the  physical  signs,  and  by  the  absence  in  pulmonary  collapse  of 
inflammatory  symptoms,  by  the  lower  temperature,  and  the  difference 
in  onset. 

The  diagnosis  from  bronchopneumonia,  or  catarrhal  pneumonia,  is 
beset  with"  greater  difficulties.  But  here  also  the  low  temperature, 
and  the  fact  that  the  physical  signs  and  the  location  of  the  dull  areas 
are  subject  to  rapid  changes,  are  of  aid  in  diagnosis. 

The  Bronchi,  the  Alveoli,  and  Connective  Tissue. 

Bronchopneumonia,  or  Catarrhal  Pneumonia,  is  a  pneumonia 
occurring  secondarily  to  bronchitis,  and  is  characterized  by  the  devel- 
opment of  areas  of  consolidation  in  both  lungs  and  the  persistence  of 
a  bronchitis  of  the  middle-sized  or  smaller  tubes.  In  proportion  as 
the  areas  of  consolidation  are  large,  the  symptoms  and  physical  signs 
approach  those  of  lobar  pneumonia.  It  is  more  common  in  children 
and  in  debilitated  persons.  It  is  the  chief  form  in  infants.  1.  It  is 
frequently  secondary  to  measles,  diphtheria,  scarlet  fever,  and  per- 
tussis. 2.  As  aspiration  pneumonia,  it  occurs  when  food,  septic  parti- 
cles, blood,  or  tissue  enter  the  lungs  during  the  loss  of  sensibility  of 
the  larynx  in  apoplectic,  ursemic,  or  other  forms  of  coma,  and  in  opera- 
tions about  the  upper  air-passages  and  mouth.  It  is  a  fatal  complica- 
tion of  tracheotomy.     3.  It  is  frequently  of  tuberculous  origin. 

Catarrhal  pneumonia,  except  the  aspiration-form,  develops  gradu- 
ally, and  it  may  not  always  be  easy  to  mark  the  point  at  which  the 
bronchitis  which  precedes  merges  into  pneumonia  ;  but  as  a  rule  there 
are  more  or  less  chilliness  (rarely  a  decided  chill)  and  an  access  of 
fever.  There  is  usually  greater  prostration  than  in  the  lobar  form,  in 
proportion  to  the  amount  of  pneumonia  present.  The  pulse  is  more 
frequent  and  more  likely  to  be  feeble.  Cough  and  expectoration  are 
marked  symptoms.  The  sputum  is  tenacious  and  glairy,  not  rusty. 
It  contains  streptococci  and  staphylococci  in  much  greater  numbers 
than  are  found  in  ordinary  bronchitis  ;  fatty  epithelial  cells,  epithe- 
lium, fat-globules,  and  diplococci. 

Dyspnoea  is  more  extreme  than  in  lobar  pneumonia.  The  respira- 
tions are  excessively  rapid — 60  to  80  per  minute  ;  cyanosis  rapidly 
ensues.  The  finger-tips  become  blue,  the  face  dusky.  The  fever 
does  not  rise  as  high  as  in  the  lobar  form.  At  first  the  skin  is  hot 
and  dry ;  later  it  becomes  cold  and  clammy,  and  in  the  tuberculous 
form  sweats  are  common.  The  duration  of  the  disease  is  usually  much 
longer  than  in  lobar  pneumonia. 

The  physical  signs  (Plate  XVIII.)  are  those  of  bronchitis,  with  here 
and  there  larger  or  -mailer  areas  of  consolidation,  over  which  the  rales 
are  liner  and  closer  set  ;  the  percussion-note  is  dull,  and  the  respiratory 
murmur  bronchial  or  bronchovesicular.  An  entire  Lobe  may  be  consoli- 
dated. Areas  of  collapse  and  portions  more  or  less  oedematous  combine 
to  make  the  more  complex  physical  signs.  While  both  lungs  a  re  affected, 
they  are  not  usually  so  to  the  same  extent.  It  is  said  that  the  apices 
are  more  prone  to  involvement  in  this  than  in  the  lobar  form  ;  and  some 
writers  (Osier)  look  upon  it  almost,  if  not  always,  of  tubercular  origin. 


550  SPECIAL  DIAGNOSIS. 

In  the  common  form  seen  in  infants  the  symptoms  of  asphyxia  set 
in  at  variable  periods  in  the  course  of  the  disease.  General  cyanosis 
supervenes.  Stupor  sets  in,  the  hurried  respirations  grow  shorter  and 
more  gasping,  the  pulse  becomes  excessively  rapid  and  feeble,  the  ex- 
tremities cool  and  clammy  ;  with  the  stupor  the  cough  abates  and  the 
breathing  becomes  more  shallow.  The  lungs  fill  up  with  fluid  mucus, 
and  the  child  drowns  in  its  own  secretions,  or  cardiac  paralysis  sets  in 
after  dilatation  of  the  right  heart. 

Diagnosis.  The  affection  is  distinguished  (1)  by  its  pathological 
antecedents  and  causal  relations  ;  (2)  its  gradual  onset ;  (3)  its  distri- 
bution in  both  lungs  ;  (4)  the  preponderance  of  physical  signs  of  bron- 
chitis over  those  of  consolidation  ;  (5)  the  extreme  dyspnoea  and  cyan- 
osis with  a  lower  temperature  than  in  lobar  pneumonia  ;  (6)  the  onset 
of  carbondioxide-poisoning  ;  (7)  the  long  duration  and  gradual  decline. 
The  tuberculous  form  is  distinguished  by  (1)  the  history  of  exposure  to 
infection  or  of  a  focus  of  infection  in  the  body,  glands,  or  joints  ;  (2) 
the  longer  course  ;  (3)  delayed  asphyxia  ;  (4)  rapid  emaciation  ;  (5) 
diffused  sweats  ;  (6)  physical  signs  of  consolidation  and  subsequently 
of  cavity  at  the  apex  ;  and  (7)  absolutely  by  tubercle  bacilli  in  the 
expectoration  coughed  up  or  vomited.  I  have  seen  a  child  aged  fifteen 
months,  of  a  tuberculous  mother,  completely  recover.  The  tuberculous 
form  is  common  in  colored  infants. 

Bacteriological  Diagnosis.  Examination  of  the  sputum  shows  an 
abundance  of  the  streptococci  and  staphylococci  and  the  special  micro- 
organism which  belongs  to  the  primary  infection,  as  that  of  influenza, 
diphtheria,  and  tuberculosis. 

Lobar  Pneumonia,  or  Croupous  Pneumonia.  (Plate  XIX.)  This 
inflammatory  affection  of  the  lung  may  be  due  to  one  of  many  micro- 
organisms (single  infection),  or  it  may  be  a  mixed  infection.  For  its 
consideration,  the  reader  is  referred  to  the  Infectious  Diseases,  Chapter 
XX.,  Part  I. 

Chronic  Interstitial  Pneumonia.  Cirrhosis,  fibroid  phthisis,  and 
chronic  interstitial  pneumonia  are  names  given  to  a  condition  of 
chronic  induration  of  the  lung,  caused  by  interstitial  overgrowth  of 
fibrous  tissue.  Obliteration  of  the  air-vesicles  and  contraction  of  the 
lung  result  from  the  overgrowth.  The  bronchi  are  frequently  dilated, 
and  cavities  and  gangrene  may  occur.  The  disease  is  rare  except  as 
the  result  of  tuberculosis,  but  it  may  follow  pneumonia  and  pleurisy,  and 
it  is  said  to  be  caused  by  inhalation  of  fine  particles  of  steel  or  cotton. 
Pneumonokoniosis  is  the  term,  first  employed  by  Zenker,  for  the 
chronic  interstitial  pneumonia  from  the  inhalation  of  dust. 

Physical  Signs.  (See  Plates,  Bronchiectasis.)  Inspection.  The  dis- 
ease is  unilateral.  The  chest-wall  is  retracted.  The  ribs  are  drawn 
together,  so  that  the  interspaces  are  obliterated.  The  shoulder  is  drawn 
over  the  sunken  thorax.  The  spinal  column  is  curved.  The  heart  is  dis- 
placed. It  is  drawn  toward  the  affected  side.  If  the  right  lung  is  the  seat 
of  disease,  an  impulse  is  seen  to  the  right  of  the  sternum  ;  if  the  left,  the 
precordial  area  of  impulse  is  increased  and  extends  upward.  There  is 
no  expansion  whatever  (immobility)  of  the  affected  apex  or  base.  The 
healthy  lung  is  the  seat  of  compensatory  emphysema.     (See  Fig.  147.) 


PLATE    XIX. 

FIG.  1. 


FIG.  2. 


Lobar    Pneumonia. 

Consolidation  of  the  right  lower  lobe.      Transmitted   bronchial   breathing  and 
signs  of  bronchitis  over  the  left  lung  posteriorly. 


DISEASES  OF  THE  LUNGS  AND  PLEURA. 

Fig.  147. 


551 


Fibroid  (tuberculous)  phthisis ;  right  apex.    Heart  displaced  as  indicated  by  oval. 

Palpation.  Inspection  is  confirmed.  Fremitus  is  increased,  espe- 
cially at  the  apex.  At  the  base,  pleural  thickening  lessens  the  frem- 
itus. 

Percussion.  The  physical  signs  show  increased  density  of  lung 
tissue,  with  dulness  on  percussion,  or,  over  a  dilated  bronchus,  a  tym- 
panitic or  amphoric  note. 

Auscultation.  The  respiratory  murmur  is  bronchial,  or,  over  a 
dilated  bronchus,  has  a  hollow  sound.  At  the  base  breath-sounds  are 
feeble,  distant,  or  absent.     Rales  are  also  heard. 

The  disease  runs  a  very  chronic  course,  attended  by  cough,  and 
mucopurulent  and  sometimes  bloody  expectoration,  even  hemorrhage  ; 
but  there  is  no  fever  and  not  much  loss  of  flesh.  Dyspnoea  occurs  on 
ascending  heights  only.  Dilatation  of  the  right  heart  is  likely  to 
ensue,  with  cardiac  murmurs  and  increased  lateral  dulness  and  increase 
of  dyspnoea.  Death  is  hastened  by  the  disease,  and  is  often  brought 
on  by  acute  pneumonia. 

In  pneumonokoniosis  (also  known  as  anthracosis,  coal-miner's  dis- 
ease ;  siderosis,  from  metallic  dust ;  chalicosis,  from  mineral  dust,  as 
in  stone-cutter's  phthisis)  there  is  a  history  of  exposure  to  the  irri- 
tating particles  for  a  considerable  period,  during  which  time  cough 


552  SPECIAL  DIAGNOSIS. 

develops,  gradually  increases,  and  the  general  health  fails.  Emphy- 
sema simultaneously  arises,  causing  dyspnoea.  The  patients  wheeze, 
cough  in  paroxysms,  and  expectorate  sputum  which  contains  the  dust- 
particles.  In  anthracosis  it  is  black.  On  microscopical  examination 
the  special  dust-particles  are  often  found.  The  symptoms  of  emphy- 
sema and  chronic  bronchitis  predominate.  Tubercular  infection  may 
take  place  late  in  the  disease. 

Pulmonary  Tuberculosis.  For  convenience  of  diagnosis  the  specific 
inflammation  of  the  lungs  caused  by  the  bacillus  tuberculosis  will  be 
considered  in  this  section.  If  a  strict  etiological  classification  were 
followed,  it  would  be  considered  among  the  infectious  diseases. 

Clinically,  we  see  tuberculosis  in  the  lungs  manifesting  itself  in  one 
of  the  forms  of  acute  pneumonic  phthisis,  acute  miliary  tuberculosis, 
and  chronic  ulcerative  phthisis.     (See  Chapter  XX.,  Part  I.) 

Definition.  Tuberculosis  of  the  lungs,  pulmonary  phthisis,  and 
consumption  are  names  applied  to  an  infectious  and  mildly  contagious 
disease  of  the  lungs,  caused  by  the  tubercle  bacillus,  appearing  in  an 
acute  and  chronic  form,  and  characterized  by  cough,  fever,  sweats, 
more  or  less  rapid  emaciation,  purulent  expectoration  containing  elastic 
fibres,  and  tubercle  bacilli,  and  by  peculiar  physical  signs. 

Acute  Pulmonary  Tuberculosis,  Acute  Phthisis,  Acute 
Pneumonic  Phthisis,  Galloping  Consumption,  may  be  primary,  or 
be  secondary  to  a  localized  area  in  the  lung,  causing  rapid  infection,  or 
to  tubercular  pleurisy,  tubercular  peritonitis,  or  to  tuberculosis  of  some 
other  organ.  Its  onset  is  usually  marked  by  cough,  fever  with  or 
without  chills,  dyspnoea,  and  sometimes  haemoptysis.  The  fever  rises 
to  103°  or  104°,  and  is  of  a  continued  type  (lobar-pneumonic  form), 
or  rapidly  assumes  a  hectic  type,  accompanied  by  restlessness  and  ex- 
hausting night-sweats,  anorexia,  and  rapid  emaciation.  Prostration  is 
extreme,  but  the  mind  is  at  first  clear  and  the  spirits  cheerful.  Cough 
increases,  the  expectoration,  at  first  mucoid  and  scanty,  but  often  tinged 
with  .blood,  becomes  more  copious  and  mucopurulent.  The  bowels 
may  be  loosened  or  constipated.  The  urine  may  show  the  diazo- 
reaction. 

When  death  takes  place  without  more  decided  pulmonary  symptoms 
the  tuberculosis  has  been  secondary  to  tuberculosis  elsewhere,  or  death 
is  the  result  of  a  general  miliary  tuberculosis. 

When  the  acute  pulmonary  tuberculosis  is  primary,  the  character  of 
the  disease  is  soon  made  clear  by  the  early  development  of  consolida- 
tion of  the  lungs,  usually  of  an  apex  first,  rapidly  followed  by  soften- 
ing and  the  formation  of  cavities.  The  sputum  becomes  mucopuru- 
lent, is  frequently  streaked  with  blood,  and  pure  blood  is  often  coughed 
up.  The  sputum  contains  yellow  elastic  tissue  and  abundant  tubercle 
bacilli.  The  patient  often  presents  a  cachectic  appearance  ;  emaciation 
has  been  very  rapid,  and  has  reached  an  extreme  degree  ;  there  is  fre- 
quently a  red  flush  about  the  cheek-bones,  which,  with  the  bright  eyes, 
contrasts  strongly  with  the  hollow  cheeks  and  temples,  and  the  white 
wasted  hands  and  clubbed  fingers  with  bluish  nails. 

The  patient's  mental  attitude  is  often  peculiarly  and  characteristi- 
cally hopeful.     He  expresses  himself  as  better  each  day,  though  he  is 


PLATE  XX. 

FIG-    1-— Anterior  Aspect. 


FIG.    2.— Posterior  Ast 


'C.    \t£*£, 


Acute  Pulmonary  Tuberculosis. 


Consolidation    of  the   enti 


re    right    upper    lobe    and    of   the    left 


apex. 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  553 

occasionally  subject  to  despondency,  and  is  sure  that  if  he  could  only 
gain  a  little  strength  he  would  soon  be  well. 

Sometimes,  especially  in  children,  the  disease  is  latent.  The  patient 
suffers  from  weariness,  the  cheeks  flush  easily,  the  pulse  is  readily  dis- 
turbed, there  are  nocturnal  fever  and  occasional  sweats.  Emaciation 
proceeds  very  gradually,  and  a  long  time  may  elapse  before  any  dis- 
ease is  demonstrable. 

In  a  few  cases  the  cerebral  symptoms  are  so  pronounced  as  to  mask 
the  pulmonary,  and  in  other  cases  there  is  actual  coincident  involve- 
ment of  the  cerebral  meninges. 

The  physical  signs  (Plate  XX.)  are  those  of  consolidation,  often  with- 
out conjoint  pleurisy.  The  apex  is  usually  first  invaded.  There  are 
diminished  movement,  increased  fremitus,  and  dulness  on  percussion. 
At  first  the  breathing  is  bronchovesicular.  It  rapidly  becomes  bronchial. 
At  first  small  moist  rales  are  detected.  Later  they  become  large  and 
gurgling.  A  pleural  friction  may  be  heard.  It  may  be  first  heard  above 
the  spine  of  the  scapula  behind,  above  the  clavicle  in  front,  or  high  up 
in  the  axilla.  The  upper  lobe  of  the  right  lung  may  be  affected  first, 
or  the  anterior  portion  of  the  middle  lobe.  The  physical  signs  may 
be  observed  first  in  the  axillary  region  of  either  side.  The  consoli- 
dation extends  to  the  remainder  of  the  lung,  being  preceded  by  phys- 
ical signs  indicating  gradual  encroachment  upon  the  air-containing 
structure.  The  respiratory  murmur  is  harsh,  but  soon  becomes 
bronchovesicular  and  then  bronchial.  {Lobar -pneumonic  form.)  As 
consolidation  progresses  in  the  middle  and  lower  portions  of  the  affected 
lung,  signs  of  cavity  or  multiple  cavities  appear  in  the  upper.  (The 
whole  of  a  lobe  may  be  the  seat  of  small  cavities  filled  with  muco- 
purulent or  purulent  fluid.)  Cavernous  breathing  and  pectoriloquy,  or 
the  bronchial  sniff  of  consolidation,  become  more  pronounced.  The 
dull  note  of  consolidation  is  relieved  by  a  dull  tympanitic  or  full  tym- 
panitic note.  Xow  moist  rales  of  all  degrees  are  heard.  {Broncho- 
pneumonic  form.)  Above  they  are  gurgling ;  below,  small  and  large 
moist  rales.  If  the  progress  is  not  too  rapid  throughout  the  lung  first 
affected,  signs  of  invasion  are  found  in  the  remaining  lung,  usually  at 
a  point  corresponding  to  the  primary  focus  in  the  original  lung.  The 
apex,  therefore,  is  first  invaded  in  most  cases.  Infection  of  the  second 
may  begin  earlier  than  the  signs  in  the  first  lung  would  lead  one  to 
anticipate.  The  rapid  invasion  of  one  lung  compels  compensatory 
emphysema  of  the  other.  The  increased  movement,  with  harsh  or 
puerile  breathing,  without  change  in  fremitus  or  in  pitch  and  tone  on 
percussion,  masks  any  small  consolidations. 

The  expectoration  becomes  more  purulent  as  the  disease  progresses, 
and  may  be  blood-tinged.  It  is  copious  and  possesses  some  fetor.  It 
is  found  to  swarm  with  bacilli  and  to  contain  yellow  elastic  tissue. 
Hemorrhage  may  take  place.  The  general  symptoms  become  more 
alarming.  The  fever  becomes  of  a  hectic  type.  The  patient  rapidly 
emaciates.  Cyanosis  is  shown  in  the  dusky  countenance  and  blue 
finger-tips.  The  exhaustion  becomes  extreme.  Pallor,  with  flushed 
cheeks  and  an  anxious  countenance,  is  seen.  The  sweats  are  profuse. 
The  appetite  is  lost.     Diarrhoea  may  set  in.     Remissions  may  take 


554  SPECIAL  DIAGNOSIS. 

place,  even  in  acute  cases  ;  for  a  time  the  fever  and  more  aggravated 
pulmonary  symptoms  are  in  abeyance.  The  typhoid  state  ensues  in 
some  cases.  Death  takes  place  from  exhaustion  and  heart-clot  or  from 
meningeal  tuberculosis.     The  duration  is  from  two  to  six  weeks. 

Diagnosis.  In  the  earliest  stages,  before  the  invasion  of  new  terri- 
tory is  pronounced,  the  cases  are  involved  in  doubt.  It  may  be  con- 
founded with  pneumonia  until  the  sputum  is  secured  and  bacilli  are 
found. 

In  pneumonia  we  have  the  pronounced  rigor,  the  rapid  rise  of  tem- 
perature, the  altered  pulse-respiration  ratio,  the  hot,  dry  skin,  the  sticky, 
viscid  sputum,  containing  the  pneumococcus,  the  peculiar  changes  in 
the  urine,  leucocytosis,  the  occurrence  of  herpes,  the  termination  by 
crisis,  to  point  to  the  nature  of  the  process.  Emaciation  is  not 
marked ;  there  are  no  such  profuse  sweats  as  the  repeated  drenchings 
we  see  in  pneumonic  phthisis ;  anaemia  is  not  so  pronounced.  Then 
cavity-formation  does  not  take  place,  or  at  least  rarely.  In  pneumonia 
the  fever  is  of  a  continued  type ;  in  phthisis  it  is  often  intermittent 
or  remittent.  The  sputum  is  more  purulent  in  acute  pneumonic 
phthisis.  Finally,  the  history  of  exposure  to  infection,  the  primary 
occurrence  of  tuberculosis  elsewhere,  the  secondary  occurrence  of  tuber- 
culosis in  other  organs  after  the  lung-invasion,  the  longer  duration — 
aid  in  determining  the  true  affection.  Inoculation  of  animals  may  be 
resorted  to  in  doubtful  cases. 

Acute  miliary  tuberculosis  (pulmonary  type)  is  attended  by 
high  fever,  rapid  emaciation,  hurried  breathing,  rapid  pulse,  duskiness 
of  face  and  extremities,  more  or  less  stupor,  delirium,  and  the  develop- 
ment of  the  typhoid  state,  with  prostration  and  the  occurrence  of  pro- 
fuse sweats.  Intestinal  symptoms,  as  flatulency  and  distention,  may 
be  pronounced,  and  diarrhoea  may  form  a  prominent  feature.  Physical 
signs  are  negative  or  are  those  of  bronchitis.  There  is  resonance  or 
hyper-resonance  on  percussion.  The  latter  is  not  uncommon.  The 
onset  is  abrupt  or  may  follow  a  period  of  malaise.  In  some  instances 
the  tuberculous  process  is  more  advanced  in  some  situations  than  in 
others,  giving  rise  to  special  local  symptoms.  Thus,  recently,  a  patient 
was  admitted  to  the  Presbyterian  Hospital  with  stupor  and  moderate 
delirium.  He  had  fever,  rapid  pulse  and  breathing,  and  a  peculiar 
dry,  harsh  skin.  There  were  albuminuria,  casts  and  blood  in  the 
urine,  and  it  was  thought  he  had  uraemia.  The  temperature-range 
was  irregularly  intermittent.  The  diagnosis  was  established  later  be- 
cause of  the  development  of  undoubted  secondary  tuberculosis  in 
other  organs.  At  the  autopsy  general  tuberculosis  was  found,  with 
primary  tuberculous  ulceration  in  the  bladder,  the  ureters,  and  renal 
pelves. 

Diagnosis.  Hurried  breathing  and  cyanosis  are  distinctive  feat- 
ures, out  of  all  proportion  to  the  physical  signs,  and,  on  this  account, 
of  diagnostic  significance.  It  must  be  distinguished  from  typhoid 
fever,  septicaemia  or  pyaemia,  and  malignant  endocarditis.  It  is  dis- 
tinguished from  typhoid  fever  by  the  absence  of  successive  stages  in 
the  course  of  the  disease  ;  in  typhoid  fever  the  evolution  of  the  disease 
is  more  characteristic  than  its  symptoms.     The  headache  of  the  first 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  555 

week  finally  disappearing,  is  noteworthy.  The  special  range  of  tem- 
perature, the  onset,  the  fastigiurn,  and  the  defervescence  at  definite 
periods  in  the  evolution  of  the  disease,  are  of  diagnostic  value.  Cyan- 
osis is  more  constant  and  marked  in  tuberculosis.  The  skin  and  capil- 
laries have  more  tone  in  typhoid  fever  than  in  tuberculosis,  at  least  hi 
the  first  two  weeks.  Hyperemia  follows  irritation  in  typhoid  ;  pallor, 
with  duskiness,  in  tuberculosis.  The  eruption,  with  its  specific  mode 
of  development,  belongs  to  typhoid  fever  alone.  The  stools,  the  en- 
larged spleen,  the  vascular  tone  are  suggestive  of  typhoid  fever.  The 
spleen  enlarges  earlier  in  the  disease  in  typhoid  fever.  Bacteriological 
examination  may  be  of  service.  The  occurrence  of  intestinal  hemor- 
rhage, pointing  as  it  does  to  typhoid  fever,  is  a  welcome  sign  in  cases 
in  which  the  diagnosis  is  obscure.  I  have  never  seen  it  in  tuberculo- 
sis. In  typhoid  fever  the  reflexes  (knee-jerk)  are  never  absent ;  in 
tuberculosis,  if  the  meninges  are  involved,  they  are  variable,  present 
one  day,  absent  the  next.  The  diazo-reaction  in  typhoid  is  of  some 
service,  although  it  also  occurs  in  tuberculosis.  (See  Urine.)  It  does 
not  come  on  until  later  than  the  fifth  clay  in  typhoid  fever.  It  disap- 
pears at  a  certain  time  hi  the  involution  of  typhoid  ;  it  continues  in- 
definitely in  tuberculosis.     (See  Chapter  XIX.,  Part  I.) 

The  distinction  of  tuberculosis  from  septicaemia  or  pyaemia  and 
malignant  endocarditis  is  often  difficult.  We  must  search  for  local 
areas  of  septic  or  pysemic  infection.  The  ears,  the  teeth,  the  bones, 
the  veins,  the  heart,  the  pelvic  organs  in  females,  the  rectum,  the 
genito-urinary  tract  —must  be  carefully  examined.  Hemorrhagic  in- 
farcts, or  metastatic  abscesses,  may  be  found  which  point  to  the  origi- 
nal conditions.  The  eye-ground  may  show  hemorrhages.  The  skin 
and  mucous  membranes  may  exhibit  minute  capillary  hemorrhages  or 
infarcts.  They  are  the  size  of  a  pin-head,  do  not  disappear  on  press- 
ure, and  are  not  elevated.  The  spleen  is  more  likely  to  be  enlarged 
in  the  septic  affections.  The  respirations  are  not  so  rapid  as  in  tuber- 
culosis. Cyanosis  is  a  distinctive  feature  of  tuberculosis.  The  physi- 
cal signs  of  endocarditis  may  be  determined,  and  subsequently  embo- 
lism or  thrombosis  prove  the  nature  of  the  process. 

Cheonic  Tuberculosis,  Cheojstc  Ulceeative  Phthisis.  Chronic 
tuberculosis  or  phthisis  is  much  more  common  than  acute  tuberculosis, 
from  which  it  is  distinguished  by  its  slow  progress  and  by  periods  of 
remission,  during  which  the  disease  may  be  arrested  temporarily  or 
permanently. 

It  may  begin  in  a  variety  of  ways.  The  most  common  mode  of 
origin  is  in  an  ordinary  bronchitis  with  which  pleurisy  is  occasionally 
associated.  Previous  to  this  the  patient  may  have  been  in  good  health, 
but  generally  the  health  has  been  impaired  for  some  time.  The  bron- 
chitis may  be  simple  or  part  of  influenza,  measles,  whooping-cough,  or 
some  other  specific  disease. 

The  bronchitis  usually  proves  obstinate,  and  by  and  by  there  is 
found  at  the  apex  of  the  lung  a  small  area  over  which,  on  percussion, 
there  is  increased  resistance,  with  slight  impairment  of  resonance,  as 
compared  with  the  other  side  ;  the  respiratory  murmur  is  broncho- 
vesicular,   sometimes  jerky  in  rhythm,  and  the  vocal  resonance  and 


556  SPECIAL  DIAGNOSIS. 

fremitus  slightly  increased  or  unaltered.  Such  physical  signs  are  met 
with  more  frequently  at  the  right  apex  than  at  the  left,  and  oftener  in 
the  suprascapular  fossa  than  anteriorly.  The  next  most  frequent  seat 
is  probably  between  the  clavicle  and  second  rib  anteriorly. 

The  patient  will  be  found  to  have  lost  strength,  and  usually  some 
weight.  There  is  often  a  slight  evening  rise  of  temperature,  and  occa- 
sionally nocturnal  perspirations.  The  appetite  is  impaired,  and  ano- 
rexia may  exist.  Cough  is  rarely  absent,  especially  during  the  night 
or  on  waking  in  the  morning  ;  it  may,  however,  be  so  slight  as  appar- 
ently to  have  escaped  the  notice  of  the  patient.  When  characteristic 
it  is  dry  and  hacking.  Expectoration  is  scanty  and  mucoid,  but  occa- 
sionally it  may  be  tinged  with  blood.  It  should  be  remembered  that 
children  and  old  persons  sometimes  do  not  expectorate,  and  that,  as  a 
rule,  women  are  more  inclined  to  suppress  expectoration  than  men. 
No  tubercle  bacilli  may  be  found  in  the  sputum  after  repeated  exami- 
nation ;  but  if  examinations  are  continued,  they  will  appear  sooner  or 
later. 

Instead  of  developing  after  a  bronchitis,  as  we  have  just  described, 
it  may  set  in  suddenly  under  the  guise  of  a  pneumonia,  more  frequently 
of  the  catarrhal  form.  The  symptoms  and  physical  signs  do  not  differ 
essentially  from  those  of  pneumonia,  except  that  the  expectoration  is 
more  likely  to  be  profuse,  mucopurulent,  and  blood-streaked,  and 
bacilli  are  found  in  it ;  the  fever  is  more  hectic  in  type,  and  night- 
sweats  are  common.  The  consolidation  is  found  at  the  apex.  After 
the  patient  convalesces  from  such  an  attack  he  continues  weak,  does 
not  gain  flesh  readily,  still  has  a  cough  with  expectoration,  evening 
fever  with  occasional  night-sweats,  and  an  area  of  consolidation  usually 
at  an  apex  of  the  lung.  Over  this  area,  in  addition  to  the  usual  signs 
of  consolidation  (bronchial  or  feeble  breathing,  dulness,  etc.),  moist  or 
dry  subcrepitant  rales  are  heard. 

In  some  cases  fever,  emaciation,  and  weakness  progress  for  some 
time  before  pulmonary  symptoms  arise. 

In  still  other  cases  the  invasion  of  the  disease  is  by  sudden  haemop- 
tysis, which  is  oftener  copious  than  not.  Several  such  hemorrhages 
may  occur  in  rapid  succession,  or  there  may  be  only  one.  Moreover, 
its  disappearance  may  not  be  followed,  or  at  least  not  immediately,  by 
any  farther  pulmonary  symptoms  or  physical  signs  ;  more  commonly, 
however,  it  is  followed  by  fever,  cough,  expectoration,  and  physical 
signs  of  incipient  consolidation,  usually  at  the  apex. 

In  still  other,  but  rarer  cases,  the  pulmonary  disease  is  latent,  being 
marked  by  gastric  or  peritoneal  symptoms,  or  by  a  general  anaemia. 

By  whatever  path  invasion  conies,  the  physician  should  be  on  the 
lookout  for  it,  especially  in  a  young  adult  predisposed  by  heredity  or 
environment  to  tuberculosis.  The  recognition  of  the  disease  in  its 
early  stage  requires  the  greatest  skill,  which  in  turn  is  recompensed 
with  the  highest  reward,  since  the  disease  is  then  curable. 

The  further  progress  of  a  case  of  tuberculosis  of  the  lungs,  after  con- 
solidation has  once  become  manifest,  is  very  variable.  It  may  be 
arrested  at  this  point  permanently,  cure  resulting  from  cicatrization. 
More  frequently  there  is  temporary  arrest  of  the  process  ;  fever  lessens 


PLATE    XXI. 

FIG.    1. — Anterior  Aspect. 


FIG.    2. — Posterior   Aspect. 


Chronic  Pulmonary  Tuberculosis. 

Consolidation  with  cavity  formation.     Chronic  pleurisy  with  loss  of  respiratory 
movement  of  lung  margins.     Retraction. 


DISEASES  OF  THE  LUNGS  AND  PLEURJE.  557 

or  ceases  entirely,  the  pulse  resumes  its  normal  rate,  appetite  improves, 
and  there  is  a  gain  in  flesh  and  strength.  Cough  and  expectoration 
are  more  likely  to  persist  than  the  other  symptoms,  but  with  the  other 
improvement  they  diminish  in  frequency  and  copiousness.  There  are 
fewer  rales,  but  the  signs  of  consolidation  are  still  present,  though 
there  is  no  further  extension  of  the  process.  Often,  after  a  cavity  has 
been  found,  the  disease  is  arrested,  or  progresses  very  slowly. 

After  a  longer  or  shorter  time,  as  the  result  of  reinfection  from  the 
old  focus  excited  by  acute  bronchitis  or  by  some  depressing  influence, 
the  tuberculosis  is  relighted,  so  to  speak,  and  runs  much  the  same 
course,  the  lung  being  left  more  diseased  and  the  general  health  worse 
after  every  such  attack.  Nevertheless,  there  may  be  long*  intervals 
between  such  attacks,  the  patient  in  the  meantime  continuing  in  fair 
health.  Thus  the  disease  may  linger  or  recur  for  years,  the  patient 
not  ill  enough  to  be  confined  to  the  house,  and  not  well  enough  to 
stand  hard  work  or  great  exposure.  Slowly,  by  ulceration  and  suppu- 
ration, the  lung-tissue  is  wasted  and  cavities  are  formed.  Before  there 
are  large  cavities  at  an  apex  the  base  of  the  same  lung  becomes  consol- 
idated by  the  production  of  tuberculous  material,  and  before  one  lung 
is  extensively  diseased  the  apex  of  the  opposite  lung  is  attacked,  the 
process  being  repeated  in  it  if  the  patient  lives  long  enough.  Instead 
of  reinfection  from  an  old  focus,  new  infection  may  take  place,  giving 
rise  to  the  old  train  of  symptoms,  or  setting  up  more  acute  disease. 
During  this  time  the  patient  is  liable  to  an  attack  of  acute  pneumonia, 
pleurisy,  bronchitis,  or  general  miliary  tuberculosis.  He  is  also  liable 
to  sudden  death  by  hemorrhage.  In  a  number  of  cases  the  intestines 
and  peritoneum  become  affected,  and  abdominal  pain  and  diarrhoea 
are  superadded  as  symptoms. 

As  a  rule,  the  patient  gradually  sinks.  The  later  stages  are  marked 
by  increasing  cough  and  dyspnoea,  which  are  very  distressing  and  pre- 
vent sleep.  Expectoration  is  more  copious,  purulent,  and  is  raised 
with  increasing  difficulty. 

The  appetite  is  poor  and  capricious,  or  anorexia  is  complete.  The 
heart  becomes  more  and  more  feeble,  the  fever  is  hectic  and  accom- 
panied by  exhausting  night-sweats,  the  feet  and  limbs  swell,  and  acute 
cramp-like  pains  are  felt  in  the  legs,  probably  caused  by  thrombosis  of 
the  veins. 

Emaciation  is  extreme,  scarcely  anything  but  skin  and  bone  being 
left.  Death  occurs  from  perforation  of  an  intestinal  or  gastric  ulcer, 
from  hemorrhage,  or  more  commonly  from  exhaustion,  and  from 
asphyxia  caused  by  oedema  of  the  lungs. 

The  physical  signs  (Plate  XXI.)  depend  upon  the  lesions.  It  is  often 
possible  to  detect  all  stages  of  the  tubercular  process,  from  early  consoli- 
dation to  large  cavity,  in  the  same  patient.  The  signs  of  consolidation 
have  been  sufficiently  dwelt  upon.  When  softening  begins,  the  percus- 
sion-note continues  dull  and  the  breathing  bronchial  ;  but  it  is  often 
difficult  to  make  out  the  quality  of  the  breath-sounds  because  they  are 
feeble  and  obscured  by  numerous  moist  crackling  rales  and  moist  sub- 
crepitant  rales  from  disintegration  of  lung-tissue  and  bronchitis.  After 
the  patient  has  coughed  several  times  and  expectorated,  and  then  takes 


558  SPECIAL  DIAGNOSIS. 

a  long  breath,  the  quality  of  the  breathing  becomes  perceptible.  As 
the  lung-tissue  is  further  softened  and  removed  by  expectoration  cavi- 
ties are  formed.  These,  if  large  enough  and  superficial,  give  a  tym- 
panitic note  on  percussion,  and,  if  there  is  communication  with  a  bron- 
chus, a  cracked-pot  sound.  The  breath-sounds  are  hollow  and  the 
rales  are  bubbling  and  gurgling,  or  large  and  mucous. 

The  normal  vocal  resonance  is  replaced  by  bronchophony  and  pec- 
toriloquy. Tactile  fremitus  may  or  may  not  be  increased.  (See  Cavi- 
ties.) 

But  if  the  walls  of  the  cavity  are  thick  from  indurated  tissue,  the 
percussion-note  will  be  dull  and  the  breathing  bronchial.  If  the  tissue 
composing  the  wall  is  less  thick  and  dense,  percussion  produces  a 
wooden  sort  of  resonance.  If  much  normal  lung-tissue  intervenes,  the 
percussion-note  will  be  clear. 

As  tuberculosis  of  the  lungs  progresses,  the  clavicles  and  ribs  be- 
come more  and  more  prominent  from  the  loss  of  fat,  and  local  flatten- 
ing of  the  chest,  with  impaired  expansion,  marks  the  seat  of  the  disease. 

The  Diagnostic  Features.  The  striking  phenomena  of  tuberculosis 
which  are  considered  in  the  diagnosis  are  emaciation,  anaemia,  fever, 
cough,  dyspnoea,  chest-pain,  hemorrhage,  the  expectoration,  and  the 
objective  symptoms.  Of  less  diagnostic  value,  but  important  as  col- 
lateral data,  are  the  aspect,  the  occurrence  of  vomiting  and  diarrhoea, 
and  of  symptoms  of  secondary  tuberculosis  in  other  organs.  Age  and 
occupation  may,  to  a  certain  extent,  aid  in  the  diagnosis. 

Emaciation.  This  is  always  seen,  even  in  acute  forms  of  tubercu- 
losis. It  is  rapid  in  the  acute,  slow  and  progressive  in  the  chronic 
forms.  In  the  latter  there  may  be  a  temporary  improvement  in  this  • 
respect.  It  must  not  be  confounded  with  muscular  atrophy,  and  the 
emaciation  of  carcinoma,  diabetes,  anorexia  nervosa,  and  other  exhaust- 
ing diseases.  Ancemia  is  always  pronounced.  It  may  be  associated 
with  leucocytosis  if  there  is  cavity  formation.  The  reduction  of  red 
cells  and  diminution  of  haemoglobin  are  marked.  Fever.  This  symp- 
tom is  always  present.  The  temperature  should  be  taken  every  two 
hours  for  a  time,  to  determine  accurately  the  degree  and  course.  It 
may  be  intermitting,  remitting,  or  continuous.  It  may  be  intermitting 
in  some  acute  forms,  the  morning  fall  reaching,  or  going  below,  normal. 
The  difference  between  morning  and  evening  temperature  may  not  be 
more  than  a  degree.  In  the  acute  form  it  is  high  and  continuous,  and 
soon  may  be  attended  by  the  typhoid  state.  In  the  more  chronic  cases 
it  may  be  intermittent  at  first,  then  continuous,  and  finally  intermittent 
again.  In  the  later  stages  the  intermitting  fever  is  due  to  a  mixed 
infection,  or  saprremia,  from  the  purulent  contents  (staphylococcus  and 
streptococcus  infection)  of  the  lung  cavities.1  (See  Fig.  148  and  Fig. 
149).  The  intermittent  fever  of  the  early  stages  has  frequently  been 
mistaken  for  malaria.     (See  Fever.)     The  occurrence  of  fever  in  a 

1  Leyden  has  pointed  out  that  intermitting  fever  is  part  of  the  tuberculous  process, 
and  not  a  streptococcus  or  staphylococcus  infection,  as  formerly  held,  because  pus  micro- 
organisms are  not  found  in  the  purulent  contents  of  cavities,  and  because  in  other 
forms  of  tuberculosis,  as  empyema  or  joint-disease,  they  are  notably  absent,  and  yet 
such  form  of  fever  exists. — Deutsche  medicin.  Wochenschnft,  Sept.  14,  1894. 


DISEASES  OF  THE  LUNGS  AND  PLEURAE. 


559 


patient  who  has  been  losing  flesh,  and  is  otherwise  in  poor  health, 
excludes  cancer  and  diabetes  and  other  afebrile  causes,  and  points 
strongly  to  tuberculosis.  It  must  not  be  forgotten  that  in  chronic 
tuberculosis  in  the  aged  the  temperature  may  not  rise  above  100°  ; 
often,  indeed,  it  is  subnormal. 


Fig.  148. 


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Intermitting  fever  of  tuberculosis. 

We  must  consider,  therefore,  that  fever,  the  cause  of  which  is  not 
obvious,  may  be  due  to  tuberculosis  ;  and  that  if,  when  such  probable 
causal  conditions  as  gastro-intcstinal  catarrh  or  infectious  disorders 
(malaria)  and  suppurations  are  eliminated,  the  fever  still  persists,  then 
the  fever  is  probably  of  tuberculous  origin. 

8weats.  Frequent  sweating  may  be  the  first  symptom  complained  of 
by  the  patient.  It  may  occur  with  the  tripod  of  symptoms  of  the 
intermitting  febrile  range — chill,  fever,  and  sweat.  It  would  be  likely 
to  occur  at  night  under  these  circumstances.  It  may  occur  at  any 
time,  however.     "  Night-sweats "  are  alarming  to   the   mind   of  the 


560  SPECIAL  DIAGNOSIS. 

laity,  and  are  really  of  diagnostic  significance.  The  perspiration 
awakens  the  patient  at  night  because  it  is  so  profuse.  It  may  be  only 
moderate,  not  rousing  the  patient  until  morning.  It  may  be  general 
or  local.  Local  sweats  are  confined  to  the  head  and  neck.  Anaemia. 
This  quite  rapidly  becomes  marked.  It  is  recognized  by  the  color  of 
the  surface  and  by  an  examination  of  the  blood.  When  collateral 
inflammation  is  present,  leucocytosis  is  seen.  Cough.  Cough  is  one 
of  the  earliest  symptoms.  It  may  be  the  only  symptom  for  some  time. 
It  is  often  dry  and  hacking  at  first  and  may  continue  so  for  a  long 
time.  Later  it  is  accompanied  by  mucoid  and  then  mucopurulent 
sputa,  which  contain  the  characteristic  elements.  (See  Sputum.)  Dysp- 
noea is  almost  always  present.  The  degree  varies  with  the  association 
of  fever.  When  the  latter  is  present  dyspnoea  is  more  pronounced. 
It  is  more  pronounced  in  acute  cases.  In  miliary  tuberculosis  the 
frequency  of  respirations  that  attends  the  dyspnoea  is  out  of  all  pro- 
portion to  the  physical  signs.  In  this  form  cyanosis  is  more  marked. 
In  chronic  localized  phthisis  the  dyspnoea  may  only  occur  on  exertion, 
after  eating,  or  upon  excitement.  The  bloodless  lips  may  have  a  con- 
stant bluish  hue.  The  fingers  are  dusky  and  become  "  clubbed."  In 
the  later  stages  the  dyspnoea  is  constant  and  in  proportion  to  the  extent 
of  involvement  of  the  lungs  and  the  degree  of  fever.  Although  of 
diagnostic  significance  only  when  associated  with  other  symptoms,  it 
is  most  distressing,  and  is  the  cause  of  constant  demand  for  relief. 

Chest-pain.  This  is  due  to  localized  pleurisy  or  to  myalgia.  The 
latter  may  be  seated  in  muscles  strained  by  coughing.  Pleuritic  pains 
may  occur  in  any  situation,  and  vary  in  position  from  time  to  time. 
They  may  be  due  to  extensive  inflammation  or  to  tuberculous  pleurisy. 
Constantly  recurring  and  unilateral  chest-pains,  with  or  without  signs 
of  pleurisy,  with  cough  and  emaciation,  are  significant  of  the  disorder 
under  consideration.     (See  Pain.) 

Hemorrhage.  This  symptom  is  alarming,  and,  in  the  large  majority 
of  cases,  is  due  to  pulmonary  tuberculosis.  It  may  mark  the  onset  of 
the  acute  disease,  and  continue  irregularly  throughout  its  course  or 
recur  several  times  before  the  advent  of  more  common  symptoms  of 
the  chronic  form.  It  may  occur  at  intervals  of  a  few  months  or  a 
year,  before  emaciation,  cough,  and  characteristic  expectoration  set  in, 
or  before  bacilli  are  found  in  the  sputum.  Each  attack  is  attended 
by  fever,  usually,  and  followed  by  anaemia  and  prostration.  If  hemor- 
rhage of  the  lungs  (see  Symptoms)  occurs  in  a  young  adult  without 
cause  (as  aneurism  or  cardiac  disease,  etc.),  it  must  be  looked  upon 
with  suspicion.  The  likelihood  of  tuberculosis  is  increased  if  the 
bleeding  occurs  in  a  patient  of  tuberculous  aspect  in  whom  a  family 
history  of  tuberculosis  is  found,  and  who  has  been  exposed  to  infec- 
tion. In  the  aged  it  may  occur  from  a  localized  area  of  disease. 
Hemorrhage  is  also  common  in  the  late  stages  of  tuberculosis.  It  is  not 
at  this  period  of  diagnostic  value  as  to  the  primary  cause.  It  is  usually 
due  to  the  erosion  of  an  artery  in  a  cavity.  Hemorrhage  also  occurs 
in  tuberculosis  during  the  quiescent  period.  The  progress  of  the  disease 
is  arrested.  The  discharge  of  blood  is  accompanied  by  the  expectoration 
of  pulmonoliths,  calculi  formed  by  the  degeneration  of  caseous  areas. 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  561 

Vomiting  (see  Gastro-intestinal  Disease)  is  a  symptom  which  is  often 
present  in  the  early  stages  of  tuberculosis  of  the  lungs,  and  frequently 
masks  the  true  condition.  The  vomiting  may  lead  to  the  belief  that 
a  local  gastric  catarrh  or  diarrhoea  is  to  blame  for  the  general  symp- 
toms. The  occurrence  of  fever  with  the  gastric  symptoms  should  lead 
to  an  examination  of  the  lungs. 

The  occurrence  of  diarrhoea  and  symptoms  of  tuberculosis  in  other 
organs  may  thoroughly  establish  the  diagnosis  in  tuberculosis  of  the 
lungs  with  otherwise  obscure  pulmonary  symptoms.  The  intestinal 
discharges  may  contain  tubercle  bacilli,  or  they  may  be  found  in  the 
urine,  in  joint-suppuration  or  glandular  enlargement. 

The  Sputum  (q.  v.).  The  diagnosis  is  absolute  when  tubercle  bacilli 
are  found  in  the  expectoration.  Nummular  sputa  are  more  common 
in  phthisical  excavation.  The  sputum  is  discharged  in  tough  coin- 
shaped  masses,  which  sink  when  expectorated  into  a  vessel  containing 
water.  Fragments  of  lung-tissue  (yellow  elastic)  point  to  tuberculo- 
sis but  are  possible  under  other  circumstances. 

The  Physical  Signs.  The  aspect  of  the  patient  is  always  suggestive, 
and  is  an  aid  to  the  recognition  of  the  condition.  The  tuberculous  or 
phthisical  chest,  the  long  neck  and  arms,  the  pale  face,  the  occasional 
hectic  flush,  the  clubbed  fingers,  the  emaciation  of  the  many  subjects 
Ave  see  in  our  infirmaries,  fix  in  our  minds  a  composite  picture  the 
recognition  of  which  goes  far  to  diagnosticate  the  insidious  disease. 

The  objective  signs  point  to  an  invasion  of  air-containing  structure 
by  solid  material,  with  collapse  of  lobules,  leading  to  consolidation, 
followed  by  cavity-formation,  and  in  both  stages  by  the  occurrence  of 
pleurisy.  Local  contraction  (flattening)  and  impaired  movement  at  an 
apex,  with  inspiratory  depression  above  the  clavicles,  with  suppressed 
breath-sounds  and  prolonged  expiration,  with  impaired  resonance,  are 
the  earliest  signs  of  tuberculosis.  In  the  chronic  cases,  contraction, 
impaired  movement,  dulness  and  increased  resistance  from  thickened 
pleura  may  override  the  signs  of  consolidation.  No  one  physical  sign 
is  of  diagnostic  significance.  The  combination  of  signs,  and  the  orderly 
procession  by  which  they  advance  as  the  physical  conditions  progress, 
are  the  most  diagnostic. 

The  Size  of  the  Lung.  In  the  diagnosis  of  pulmonary  tuberculosis 
the  physical  examination  must  be  directed  to  a  determination  of  the 
size  of  the  lung,  and  of  the  extent  of  its  expansion,  by  which  we  judge 
of  the  amount  of  air  entering  the  lung,  as  well  as  to  the  presence  of 
consolidation. 

The  tuberculosis  process  is  associated  with  diminution  in  the  bulk 
of  the  lung  usually.  We  can  estimate  the  size  and  the  degree  of  ex- 
pansion by  inspection,  palpation,  and  percussion.  The  so-called  dia- 
phragm-phenomena is  studied  and  the  X-rays  employed.  Any  dimi- 
nution in  the  excursion  in  the  shadow  of  the  diaphragm  is  evidence  of 
diminished  bulk  of  the  lung  or  of  diminished  expansion.  By  palpa- 
tion, with  mensuration,  measurements  are  taken.  By  percussion  we 
estimate  the  lung  boundaries.  The  degree  of  expansion  can  be  deter- 
mined by  securing  the  limits  of  liver  dulness  and  cardiac  and  splenic 
dulness  in  ordinary  breathing,  and  then  at  the  end  of  full  inspiration 

36 


562  SPECIAL  DIAGNOSIS. 

and  expiration.  Valuable  information  is  thus  secured.  Of  course, 
employing  inspection  and  palpation  the  two  sides  of  the  lung  must  be 
compared.  Percussion  enables  one  to  determine  fairly  early  the  pres- 
ence of  consolidation.  In  thin  subjects  the  change  in  the  note  is  more 
readily  elicited  than  in  fat  or  muscular  subjects. 

On  auscultation  in  the  early  stage  of  tuberculosis  roughness  of 
respiratory  murmur  with  prolonged  expiration,  feeble  respiratory  mur- 
mur, and  jerking  or  cog-wheel  respiration  are  common  signs.  These 
signs  change  gradually  into  bronchovesicular  and  then  bronchial  types 
of  breathing.  Crackling  rales  or  clicking  sounds  and  consonatiug  rales 
attending  these  modifications  of  breath-sounds  are  of  the  greatest  diag- 
nostic importance.  They  must  be  brought  out  frequently  by  cough 
and  then  full  inspiration. 

The  Site  of  the  Lesion.  The  situation  of  the  physical  signs  is  diag- 
nostic. Percussion  should  be  directed  especially  over  those  parts  of 
the  lung  in  which  an  infection  is  liable  to  occur,  as  the  clavicular  and 
subclavicular  spaces,  the  anterior  border  of  the  upper  lobe,  the  tongue- 
like part  of  the  left  upper  lobe,  which  overlaps  the  heart,  the  supra- 
spinous space,  the  upper  interscapular  region,  and  the  upper  borders 
of  the  lower  lobes  posteriorly.  The  latter  is  best  secured  by  having 
the  patient  place  the  hand  of  the  arm  of  the  side  percussed  on  the 
shoulder  of  the  opposite  side.  The  scapula  is  thus  removed  from  the 
surface  of  the  lung  to  be  examined. 

It  is  necessary  also  to  consider  carefully  the  general  conditions. 
We  inquire  the  age,  adolescence  and  early  adult  life  being  the  common 
periods  in  which  pulmonary  tuberculosis  develops.  The  occupation,1 
the  history  of  exposure  to  the  disease,  the  history  of  predisposition  to 
tuberculosis  in  the  family,  the  history  of  previous,  now  arrested,  tuber- 
culosis, as  in  joint-disease,  or  glandular  tuberculosis  (scrofula),  are 
data  deserving  special  consideration,  as  they  may  furnish  corroborative 
evidence  of  the  presence  of  the  disease. 

Diagnosis.  The  presence  of  tuberculosis  is  presumed  upon  in  a 
patient  with  pulmonary  symptoms — as  a  hereditary  predisposition, 
abnormalities  in  the  form  of  the  chest  and  imperfect  development,  or 
hypoplasia  of  the  circulatory  organs.  If  the  patient  is  under  weight 
and  has  a  poor  appetite,  and  at  the  same  time  is  undergoing  unusual 
strain  or  anxiety,  the  possibility  of  tuberculosis  is  increased.  Often, 
before  the  physical  signs  of  tuberculosis  can  be  established,  the  shrewd 
physician  will  fear  recurrence  of  tuberculosis  if  there  are  signs  of 
anaemia,  progressive  loss  of  weight,  slight  fever,  disturbed  digestion,  a 
frequent  pulse,  and  persistent  and  localized  bronchial  catarrh.  The 
examination  of  the  lungs,  the  examination  of  the  sputa,  and  the  tuber- 
culin test  must  be  employed  as  soon  and  as  often  as  practicable.  (See 
Diagnosis  of  Tuberculosis,  Chapter  XX.,  Part  I.) 

The  diagnosis  is  established  by  finding  tubercle  bacilli  in  the  sputum. 
Their  absence,  in  spite  of  the  most  careful  search,  is  against  the  tuber- 

1  Several  undoubted  instances  are  recorded  in  which  hospital  residents  and  young 
physicians  working  in  laboratories  in  which  tuberculosis  is  studied,  or  constantly  ex- 
amining sputum,  have  been  infected  in  the  course  of  their  studies. 


DISEASES  OF  THE  LUNGS  AND  PLEUEJE.  563 

culous  origin  of  the  disease.  (See  Diagnosis  of  Tuberculosis,  Chapter 
XX.,  Part  I.) 

In  subsequent  chapters  the  differential  diagnosis  of  tuberculosis  and 
other  diseases  will  be  pointed  out.  It  must  not  be  forgotten  that  the 
disease  may  set  in  as  the  terminal  affection  in  many  diseases.  Tims, 
in  diabetes,  in  insanity,  in  chronic  cerebral  or  spinal  disease,  and  in 
other  affections,  tuberculosis  may  develop  insidiously,  and  finally  cause 
death. 

It  must  be  distinguished  from  chronic  gastric  disorders,  and  partic- 
ularly anorexia  nervosa.  It  must  not  be  confounded  with  malaria. 
It  must  be  distinguished  from  simple  anaemia,  the  cause  of  which  may 
be  recognized  with  difficulty.  It  must  be  distinguished  from  chronic 
bronchitis  with  bronchiectasis,  from  pulmonary  gangrene  and  carci- 
noma. Finally,  it  must  not  be  mistaken  for  cancer  of  the  oesophagus 
and  aneurism  of  the  aorta,  two  divergent  conditions  which  may  have 
pulmonary  symptoms  simulating  phthisis. 

Gangrene  of  the  Lung.  Gangrene  is  a  rare  disease  of  the  lung, 
and,  like  abscess,  always  secondary.  It  may  be  produced  by  any  cause 
which  so  obstructs  the  circulation  that  a  portion  of  the  lung  dies  in 
bulk.  The  gangrene  may  be  circumscribed  or  diffused ;  it  results 
most  frequently  from  pneumonia,  but  may  be  due  to  injury,  to  a  gen- 
eral septic  condition,  or  to  embolism.  It  is  rather  frequently  met  with 
in  the  insane,  possibly  owing  to  particles  of  food  which  have  found 
their  way  into  the  lung.  Aspiration  bronchopneumonia,  bronchiectatic 
and  tuberculous  cavities,  sometimes  lead  to  gangrene.  Gangrene  in 
the  lung,  as  elsewhere,  occurs  in  diabetes. 

Symptoms.  When  it  occurs  in  the  insane,  or  is  of  embolic  origin, 
it  may  remain  latent,  and  in  septicaemia  it  may  be  overlooked,  on 
account  of  the  general  symptoms.  In  well-marked  cases,  however, 
the  symptoms  are  characteristic.  Symptoms  and  physical  signs  of 
pulmonary  disease  precede  the  specific  symptoms  of  gangrene.  With 
the  onset  of  a  moderate  fever  haemoptysis  may  occur  at  once  or  be 
preceded  by  the  expectoration  of  a  brownish,  purulent  sputa  having  a 
most  intense  and  persistent  gangrenous  odor.  It  contains  fragments 
of  lung-tissue,  altered  blood,  and  putrid  debris.  (See  Sputum.)  It 
separates  into  the  three  characteristic  layers  in  a  conical  glass.  The 
fetor  of  the  breath  and  the  characteristic  sputum  is  diagnostic. 

The  disease  usually  occupies  the  lower  or  middle  lobe  of  the  lung. 
The  physical  signs  are  those  of  cavity.  The  disease  could  with  diffi- 
culty be  distinguished  from  abscess  were  it  not  for  the  characteristic 
sputum,  though  in  gangrene  there  is  greater  tendency  to  a  general 
septic  condition,  with  profuse  sweats  and  collapse. 

Abscess  of  the  Lung.  Abscess  of  the  lung  may  originate  in  causes 
outside  the  lung,  or  in  causes  within  the  lung.  To  the  former  class 
belong  those  produced  by  suppurating  bronchial  glands,  abscess  of  the 
mediastinum  opening  into  the  lung,  cancer  of  the  oesophagus  with 
ulceration,  and  abscess  of  the  liver,  suppurating  hydatid  cyst,  or  sub- 
diaphragmatic abscess  in  general,  bursting  into  the  lung.  Intra-pul- 
monary  causes  are  tubercle,  septic  emboli,  in  which  case  the  abscesses 
are  multiple  and  subpleural,  and  pneumonia.     In  the  aspiration  form 


564  SPECIAL  DIAGNOSIS. 

of  lobular  pneumonia  abscesses  occur.     Rarer  causes  are  the  presence 
of  tumors  and  obstruction  of  the  bronchi. 

Abscess  of  the  lung  is  therefore  always  secondary.  Its  diagnosis 
depends  upon  the  demonstration  of  a  consolidation  in  which  a  cavity 
subsequently  forms,  taken  in  connection  with  the  history  pointing  to  a 
definite  cause.  The  sputa  are  copious,  purulent,  often  odorless,  some- 
times offensive,  but  always  without  the  fetor  of  gangrene.  They 
contain  elastic  fibre,  but  no  bacilli  except  in  tuberculous  cases.  (See 
Sputum.)  In  embolic  abscess  the  signs  of  pleural  friction  can  only  be 
detected  at  times.  Of  course,  the  constitutional  symptoms  of  suppura- 
tion are  present. 

The  Degenerations. 

Emphysema.  Emphysema  consists  in  an  "  excessive,  permanent, 
and  unnatural  distention  of  the  air-cells,"  or  in  "  extravasation  of  air 
into  the  interlobular  or  subpleural  cellular  tissue."     (Lsennec.) 

Emphysema  may  be  unilateral  or  bilateral.  Local  and  unilateral 
forms  are  usually  compensatory.  Bilateral  emphysema  may  be  hyper- 
trophic or  atrophic. 

It  is  more  common  in  men  than  in  women.  Its  symptoms  are  more 
common  in  childhood  and  after  middle  age.  Two  factors  are  essential 
in  its  causation.  First,  defective  development  of  the  elastic  tissue  of 
the  lungs.  Second,  increased  intra-alveolar  air-pressure.  The  latter 
is  due  to  a  number  of  causes.  In  childhood,  no  doubt,  nasal  and  naso- 
pharyngeal obstructions  are  operative.  In  adults  occupations  which 
necessitate  continuous  and  severe  muscular  effort,  especially  if  coupled 
with  forced  expiration  with  closed  glottis,  act  as  causes.  Such  occupa- 
tions are  blacksmithing  and  playing  upon  wind  instruments.  Diseases 
which  cause  much  coughing  or  respiratory  effort,  such  as  chronic  bron- 
chitis and  whooping-cough,  act  in  the  same  manner.  Chronic  mitral 
valvular  disease  and  the  lessened  elasticity  of  the  lung-tissue  of  ad- 
vancing age  both  favor  congestion  of  the  lung,  and  thereby  predispose 
to  emphysema.  The  disease  is  hereditary  ;  several  members  of  a 
family  are  affected.  It  occurs  in  many  in  childhood,  is  in  abeyance 
in  adult  life,  and  reappears  in  old  age. 

Symptoms.  The  prominent  symptoms  in  hypertrophic  emphysema 
are  dyspnoea,  cyanosis,  and  cough,  with  expectoration  from  associated 
bronchitis.  There  is  no  fever.  The  dyspnoea  is  in  proportion  to  the 
degree  of  emphysema,  and  is  aggravated  by  the  coexistence  of  bron- 
chitis, asthma,  and  eccentric  hypertrophy  of  the  right  ventricle,  which 
are  very  frequent  complications  in  cases  of  long  standing.  When 
the  degree  of  emphysema  is  only  moderate,  dyspnoea  is  not  complained 
of  except  upon  climbing  or  walking  briskly,  or  after  a  hearty  meal. 
But  when  the  degree  of  emphysema  is  great,  dyspnoea  is  constant  ;  it 
interferes  with  all  exertion,  frequently  necessitates  orthopnoea,  and 
prevents  continuous  speech,  so  that  patients  speak  in  broken  sentences 
or  syllables. 

Cyanosis  is  marked.  The  livid  lip  is  common  in  the  asylums  for 
old  men.  The  face  is  of  a  dingy  pale  color,  but  becomes  bluish  on 
exertion.     The  extremities  are  also  dusky,  and  the  blueness  is  general 


PLATE   XXII. 

FIG.    1. — Anterior  Aspect. 


FIG.    2. — Posterior  Aspect. 


Emphyzema. 

Hyperresonanee.     Enlargement  of  lungs  and  diminished  respiratory  movement 
of  margins.     Diminished  fremitus.     Signs  of  bronchitis. 


DISEASES  OF  THE  LUNGS  AND  PLEURJE.  565 

in  severe  cases.  This  cyanosis,  the  round  shoulders,  and  the  drawn, 
chronically  anxious  expression,  if  I  may  so  term  it,  make  it  easy  to 
pick  out  the  emphysematous  subjects  in  a  ward  of  chronic  cases. 

Respiration  is  not  accelerated,  and  may  be  diminished  in  frequency. 
It  is  often  accompanied  by  wheezing  when  chronic  bronchitis  coexists. 

The  cough  varies  greatly  in  frequency  ;  it  may  be  altogether  absent, 
since  its  presence  simply  indicates  an  associated  bronchitis.  This  bron- 
chitis may  for  years  be  present  only  in  the  winter.  In  children  it  may 
be  associated  with  asthma.  It  may  arise  on  changes  of  the  weather  ; 
finally  it  becomes  chronic.  The  expectoration  is  that  of  chronic  bron- 
chitis (q.  v.).     It  is  rarely  stained  with  blood. 

Physical  Signs.  (Plate  XXII. ).  The  physical  signs  of  emphysema 
depend  upon  its  degree  and  upon  whether  it  is  complicated  with 
chronic  bronchitis  or  not. 

Inspection:  In  well-marked  cases  the  chest  is  barrel-shaped  (see 
under  Inspection).  There  is  little  movement  of  the  chest  in  respi- 
ration, because  the  lung  is  already  in  a  condition  of  full  inspiration 
(expiratory  dyspnoea).  Vocal  fremitus  and  resonance  are  usually  dimin- 
ished. Percussion :  The  percussion-note  is  abnormally  clear,  and  may 
even  be  tympanitic.  Hyper-resonance  is  typical  of  the  disease.  When  the 
distention  is  extreme  the  note  may  be  woodeny.  The  lungs  are  enlarged. 
The  heart-dulness  becomes  obliterated  by  the  overlapping  lung.  The 
upper  margin  of  the  liver  falls  one  or  two  interspaces  below  the  normal. 
The  resonance  extends  higher  above  the  clavicles  than  normal. 

On  auscultation  the  inspiration  is  found  to  be  distant  and  feebler 
than  normal,  while  the  expiration  is  prolonged,  and  may  become  three 
or  four  times  the  length  of  the  inspiration.  Grazing  or  rubbing 
sounds  have  been  described  and  attributed  to  the  friction  of  distended 
vesicles  against  the  pleura.  Other  adventitious  sounds  are  due  to  an 
associated  bronchitis,  pleurisy,  or  tuberculosis.  But  bronchitis  is  such 
a  common  accompaniment  of  emphysema  that  the  rales  of  the  former 
become  almost  symptomatic  of  the  latter.  Their  character  in  emphy- 
sema does  not  differ  from  that  in  chronic  bronchitis  (q.  v.). 

The  Heart.  The  apex-beat  is  absent.  There  is  epigastric  pulsation 
or  systolic  shock.  The  normal  area  of  heart-dulness  is  encroached 
upon  by  the  distended  lung,  and  the  heart  itself  is  pushed  to  the  right, 
the  apex-beat  being  frequently  at  the  xiphoid  cartilage.  If  the  em- 
physema attain  a  very  high  degree,  there  may  be  no  perceptible  dulness, 
except  on  very  strong  percussion  over  the  cardiac  region.  The  heart- 
sounds  appear  feebler  and  more  distant  than  normal.  The  right  ven- 
tricle becomes  dilated  and  hypertrophied,  as  the  result  of  the  pulmo- 
nary congestion  produced  by  emphysema.  The  pulmonary  second 
sound  is  accentuated.  A  tricuspid  regurgitant  murmur  may  be  heard. 
Venous  congestions  are  common  in  the  later  stages.  Albuminuria  is 
common.  QEdema  of  the  feet  and  limbs  may  occur,  but  general  ana- 
sarca is  rare. 

The  general  health  suffers  by  loss  of  strength  and  capacity  for 
physical  and  mental  work,  rather  than  by  loss  of  flesh .  The  patients 
are  large-chested,  stoop-shouldered,  and  short-breathed,  and  have  an 
anxious  expression  of  countenance. 


566  SPECIAL  DIAGNOSIS. 

Diagnosis.  This  is  based  upon  the  history  (heredity,  occupation, 
long  duration),  the  occurrence  of  dyspnoea  and  cyanosis,  and  of  winter 
cough  or  chronic,  bronchitis,  and  upon  the  physical  signs. 

Emphysema  can  be  distinguished  from  pleural  effusion  and  from 
aneurism,  which  may  cause  dyspnoea,  by  the  universal  hyper-resonance 
ou  percussion.  Pleural  effusion,  which  also  causes  bulging,  is  usually 
unilateral,  and  the  percussion-note  is  flat.  The  area  of  dulness  of  the 
heart  and  aorta  is  diminished  in  emphysema, 

Pneumothorax,  which  most  resembles  emphysema  in  its  physical 
signs,  develops  suddenly,  affects  one  side,  and  has  a  hollow,  tympan- 
itic note  on  percussion.  The  succussion-splash,  metallic  tinkling,  and 
coin-test  have  no  counterpart  in  emphysema  ;  moreover,  the  antecedent 
history  and  mode  of  development  are  different. 

Atrophic  emphysema  is  due  to  the  degeneration  of  age.  The  lung  is 
reduced  in  size.  The  diameters  of  the  chest  are  lessened.  The  ribs 
are  oblique.  There  is  atrophy  of  the  chest-muscles.  The  patients 
have  dyspnoea,     There  are  other  signs  of  senility. 

In  interlobular  emphysema  the  physical  signs  are  the  same  as  those 
of  vesicular  emphysema,  but  it  develops  suddenly  and  is  liable  to  be 
followed  by  emphysema  (intercellular)  of  the  neck,  which  on  palpation 
gives  a  peculiar  crepitation.  The  friction-sound  and  crackling  which 
have  been  described  as  occasional  adventitious  sounds  in  vesicular 
emphysema  are  more  commonly  heard  in  the  interlobular  form. 

It  is  caused  by  rapture  of  the  air-cells,  and  hence  occurs  in  diseases 
in  which  a  great  strain  is  put  upon  them — especially,  therefore,  in 
whooping-cough,  but  also  occasionally  in  pulmonary  hemorrhage  and 
pneumonia  ;  violent  coughing  and  laughing,  and  great  straining,  as  in 
child-labor,  are  capable  of  producing  it. 

Bronchiectasis.  Dilatation  of  the  bronchi  occurs  secondarily  to 
affections  which  tend  to  weaken  the  walls  of  the  tubes  and  to  lessen 
their  elasticity.  Hence,  it  is  found  in  chronic  bronchitis  with  emphy- 
sema, in  chronic  phthisis,  in  catarrhal  pneumonia  in  children,  in 
chronic  obstruction  from  external  pressure  or  foreign  bodies.  (See  Ob- 
structions.) It  also  occurs  when  the  lungs  contract  in  fibroid  pneu- 
monia, or  in  pleural  thickening.  It  occurs  in  two  principal  forms  : 
the  simple,  in  which  the  affected  tubes  are  uniformly  dilated  ;  and  the 
saccular,  in  which  larger  or  smaller  pouches  are  formed.  It  is  com- 
moner in  males  than  in  females,  and  probably  begins  most  frequently 
in  adult  or  middle  life.  One  lung  only  is  affected  in  about  one-half 
the  cases,  and  when  both  lungs  are  affected  (chronic  bronchitis  and 
emphysema)  it  is  not  often  to  the  same  degree. 

The  subjective  symptoms  consist  of  cough,  expectoration,  and  a 
variable  amount  of  dyspnoea.  Eventually  there  may  be  some  loss  of 
flesh  and  strength. 

The  cough  is  usually  paroxysmal.  It  may  occur  only  in  the  morn- 
ing after  the  dilated  tube  fills.  It  may  follow  change  in  position.  A 
paroxysm  is  followed  by  copious  expectoration,  sometimes  amounting 
to  a  pint  and  a  half  in  twenty-four  hours.  It  is  grayish-brown  and 
mucopurulent,  faintly  or  extremely  fetid.  The  sputa  contain  mucus, 
pus,  casts  of  the  tubules,  and  various  salts.     Charcot-Leyden  and  fatty 


PLATE    XXIII. 


FIG.    1. — Anterior  Aspect. 


FIG.    2.  — Posterior   Aspect. 


Bronchiectasis. 

Chronic  pleurisy  with,  induration  of  the  right  lower  lobe  and  bronchiectasis. 
Vicarious   emphyzema    of  the    left   lung.     Bronchitis. 


DISEASES  OF  THE  LUNGS  AND  PLEURjE.  567 

crystals,  vibrios,  leptothrix,  and  bacteria  (Fox)  can  be  found  on  micro- 
scopical examination.  Elastic  fibres  are  found  only  if  the  tubes  are 
ulcerated.  In  a  conical  glass  the  sputum  separates  into  three  layers — 
a  frothy  brown  top,  a  thin  mucoid  layer  in  the  middle,  and  a  granular 
layer  below.  Hemorrhage  is  rare,  but  may  occur  even  when  tubercu- 
losis is  absent. 

Dyspnoea  is  not  usually  severe,  except  when  the  dilatation  is  compli- 
cated by  disease  of  the  heart  or  lungs,  or  during  an  acute  attack  of 
bronchitis. 

Physical  Signs.  (Plate  XXIII.)  The  physical  signs  differ  according 
ti>  the  extent  and  variety  of  the  dilatation.  In  simple  dilatation  there 
may  be  nothing  different  from  the  signs  found  in  chronic  bronchitis, 
except  a  tendency  to  more  bronchial  respiration,  with  rales  having  a 
metallic  quality.  Percussion  will  vary  according  to  the  degree  of  altera- 
tion of  the  lung-tissue  surrounding  the  affected  bronchi,  and  according 
to  the  extent  of  the  dilatation  and  its  proximity  to  the  surface.  In  the 
simple  forms  the  percussion-note,  if  altered,  is  somewhat  less  resonant 
and  higher  in  pitch,  whereas  in  saccular  dilatations,  favorably  situated 
for  percussion,  the  note  is  tympanitic  if  the  pouch  is  empty.  On  aus- 
cultation in  simple  dilatation  the  breathing  approaches  the  bronchial, 
and  is  accompanied  by  bronchial  rales.  In  saccular  dilatation  the 
sounds  are  practically  those  of  a  cavity,  respiration  varying  from  bron- 
chial to  amphoric.  Vocal  resonance  and  tactile  fremitus  are  usually 
both  increased,  but  the  latter  may  be  diminished. 

Diagnosis.  The  diagnosis  of  simple  dilatation  from  chronic  bron- 
chitis may  be  impossible,  but  copious  and  fetid  expectoration  indicates 
the  former.  The  diagnosis  of  the  saccular  form  from  tuberculosis  of 
the  lung  with  cavity  is  difficult.  Wilson  Fox  says  the  severe  cases 
are  usually  associated  with  consolidation  of  the  lung  or  with  tubercle  ; 
but  even  without  the  presence  of  the  latter  they  often  present  phthisi- 
cal symptoms — retraction  of  the  chest,  with  the  physical  signs  of  exca- 
vation, pains  in  the  side,  haemoptysis,  pyrexia,  nocturnal  perspiration, 
and  diarrhoea — which  may  all  coexist  with  only  an  induration  of  the 
lung  and  dilatation  of  the  bronchi.  The  diagnosis  must  be  made  by 
noting  the  persistency  of  the  physical  signs,  which  change  but  little 
and  are  not  progressive  as  are  those  of  tuberculosis  ;  the  protracted 
course  of  the  disease  ;•  the  character  of  the  sputum  ;  and  the  compara- 
tively slight  impairment  of  the  general  health. 

The  Morbid  Growths. 

Cancer  and  Other  New  Growths  of  the  Lung.  The  new  growths 
may  be  primary  or  secondary.  The  latter  arc  most  common.  Of 
primary  cancer,  the  epithelioma  is  most  common  ;  encephaloid  and 
scirrhus  come  next.  Sarcoma  is  sometimes  primary.  Secondary  new 
growths  succeed  disease  in  the  abdominal  organs,  the  genito-urinary 
tract,  the  bones,  the  breast,  and  the  eye. 

Symptoms.  The  general  symptoms  of  malignant  growths  accom- 
pany the  thoracic  symptoms.  Chest-pain,  dyspnoea,  cough,  and  a 
peculiar  expectoration  belong  to  the  latter.     The  pain  is  due  to  asso- 


568  SPECIAL  DIAGNOSIS. 

ciate  pleurisy  ;  the  dyspnoea  is  paroxysmal.  (See  Dyspnoea  from  Press- 
ure on  Bronchi.)  The  expectoration  is  dark,  like  prune-juice.  Signs 
of  intrathoracic  pressure  are  seen.  The  external  thoracic  veins  are 
enlarged.  The  face  and  arms  may  be  cyanosed,  or  one  arm  only  may 
be  affected.  The  heart  may  be  dislocated,  the  trachea  changed  in  its 
course  ;  compression  of  trachea  and  bronchus  causes  dyspnoea. 

Physical  Signs.  In  primary  cancer  the  affection  is  unilateral ;  in 
secondary  forms,  bilateral.  The  physical  signs  are  those  of  pleural 
effusion  or  of  local  consolidation.  The  consolidation  may  be  massive 
and  not  partake  of  the  shape  of  a  lobe.  Often  signs  of  effusion  and 
consolidation  are  combined  (enlargement,  immobility,  absent  fremitus, 
but  bronchial  breathing).  In  the  secondary  forms  the  disease  is  bilat- 
eral. The  signs  are  mixed.  They  indicate  diminished  air  in  the  lung 
structure.  Care  must  be  taken  not  to  overlook  the  pleural  effusion 
which  accompanies  the  process,  the  removal  of  which  gives  temporary 
relief.  In  both  forms  external  lymphatic  glands,  particularly  the 
cervical,  may  be  enlarged. 

Diagnosis.  The  diagnosis  is  based  upon  :  (1)  The  age  (after  forty)  ; 
(2)  the  occurrence  of  emaciation  ;  (3)  the  duration  of  the  disease,  often 
rapid,  rarely  beyond  eight  months  ;  (4)  the  presence  of  primary  disease 
elsewhere  ;  (5)  the  presence  of  moderate  fever  ;  (6)  the  signs  oi  intra- 
thoracic pressure  ;  (7)  the  involvement  of  lymphatic  glands  ;  (8)  the 
occurrence  of  irregular  areas  of  consolidation  and  of  pleural  effusion, 
alone  or  combined  ;  (9)  the  characteristic  expectoration  ;  (10)  dyspnoea 
due  to  pressure  on  the  bronchus  or  trachea  ;  (11)  the  absence  of  bacilli 
from  the  sputum. 

An  effusion  can  often  be  recognized  only  after  puncture.  Hemo- 
thorax is  not  necessarily  present. 

Gross  Parasites. 

Hydatid  Disease  of  the  Lungs.  The  lungs  are  affected  in  about 
11  per  cent,  of  the  cases  of  hydatid  disease.  The  symptoms,  according 
to  Wilson  Fox,  consist  of  dyspnoea,  pain  hi  the  chest,  cough,  occasional 
haemoptysis,  and  sometimes  the  expectoration  of  hydatids,  the  sputa 
being  otherwise  bronchitic,  or  presenting  the  characteristics  of  pneu- 
monia or  gangrene  when  these  complications  are  present.  Gradually 
weakness  increases,  sometimes  with  pyrexia,  which,  when  combined 
with  emaciation,  may  impart  to  the  case  a  considerable  resemblance  to 
phthisis ;  pressure-symptoms  occasionally  occur,  and  the  physical  signs 
are  either  of  consolidation  of  the  lung  or  of  pleural  effusion,  together 
with  certain  peculiarities  depending  on  the  size  and  site  of  the  tumor. 
Graham  states  that  they  are  more  frequent  in  the  right  lung  and  more 
common  at  the  base,  causing  marked  bulging  of  the  thoracic  wall. 
When  the  physical  signs  are  those  of  pleural  effusion,  localization  of 
the  fluid  to  a  definite  area  takes  place,  and  hence  is  not  related  to  the 
shape  of  the  pleural  cavity.  The  breathing  may  be  tubular  ;  there  is 
condensed  lung  between  the  hydatid  and  the  thoracic  wall.  The  symp- 
toms present — cough,  dyspnoea,  anaemia,  emaciation,  and  clubbing  of 
fingers — too   often   lead  to   the   diagnosis   of    phthisis.      Hsemoptvsi> 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  569 

occurs  in  many  cases.  The  temperature  is  normal — an  important 
point  in  diagnosis.  If  the  cyst  ruptures,  the  sputum  is  diagnostic. 
Complications  often  mask  the  diagnosis.  It  must  be  distinguished 
from  pleurisy,  localized  empyema,  pulmonary  abscess,  phthisis,  actino- 
mycosis, and  mediastinal  tumors. 

Diseases  of  the  Pleura. 

The  large  lymph-structures  which  coyer  the  lung  and  line  the  inside 
of  the  thorax  are  often  the  seat  of  disease.  It  is  usually  of  an  inflamma- 
tory nature.  Hence,  pleurisy,  or  pleuritis,  is  the  most  common  affec- 
tion of  the  pleura.  It  may  be,  as  to  distribution,  bilateral  or  unilateral ; 
as  to  extent,  local  or  general  ;  as  to  the  nature  of  the  inflammation, 
plastic,  serous,  or  purulent.  The  inflammation  may  be  acute  or  chronic. 
It  is  rarely  primary.  It  arises  in  the  course  of  general  disease,  or  is 
the  result  of  the  extension  of  inflammation,  chiefly  of  an  infectious 
nature,  from  neighboring  structures. 

1.  Disease  of  the  ribs  or  vertebrae,  diseases  of  the  mediastinum,  of 
the  aorta,  oesophagus,  and  especially  of  the  lung,  give  rise  to  various 
forms  of  pleurisy,  depending  upon  the  nature  of  the  primary  affection. 

2.  Diseases  below  the  diaphragm.  Abscess  of  the  liver ;  perfora- 
tive inflammation  of  other  viscera  adjacent  to  the  diaphragm  •  abscess 
of  the  spleen  or  pancreas  ;  pus  in  the  pelvis  or  about  the  appendix, 
may  give  rise  to  purulent  pleurisy  by  the  pus  burrowing  upward  or 
by  infection  through  the  lymph-channels. 

3.  Disease  of  the  lungs.  In  the  large  majority  of  cases  pleurisy  in 
some  form  occurs  in  the  course  of  pulmonary  disease.  In  all  surface 
inflammations  of  the  lungs  there  is  associate  pleurisy.  It  is  seen  in 
pneumonia,  in  tuberculosis,  in  gangrene,  and  in  abscess. 

Pleurisy  may  be  simple  or  purulent.  Empyema  is  always  due  to 
infection  from  the  exterior,  as  the  ribs  ;  from  the  lungs  (pneumonia)  : 
suppuration  below  the  diaphragm  ;  or  to  general  infective  processes, 
as  septicaemia,  pyaemia,  and  tuberculosis. 

The  general  diseases  in  the  course  of  which  pleuritis  arises  are 
usually  infective,  or  of  such  nature  as  to  cause  irritating  products  to 
circulate  in  the  blood.  Of  the  former,  the  most  common  is  tuberculo- 
sis ;  the  next  most  common  are  septicaemia  and  scarlatina  ;  Avhile  to  the 
latter  class  belong  Bright' s  disease,  gout,  diabetes,  rheumatism,  and 
scurvy.  Purulent  pleurisy  is  more  common  in  children  than  in  adults  ; 
in  males  than  in  females  ;  and  more  common  in  tuberculous  pleurisy 
and  pyaemia  than  in  rheumatism  and  Bright's  disease. 

Acute  Pleurisy.  Acute  pleurisy  may  be  primary,  or  may  be  sec- 
ondary to  disease  of  the  lung,  or  be  part  of  a  general  infection.  Three 
stages  in  the  morbid  processes  usually  occur,  although  it  may  be 
arrested  in  the  first  stage. 

8ymptoms  of  the  First  Stage.  Dry  Pleurisy.  The  onset  of  the  dis- 
ease is  usually  abrupt,  and  is  marked  by  fever,  which  may  or  may  not 
be  preceded  by  chill,  and  is  followed  by  pain  in  the  side,  dyspnoea, 
and  eough.  The  pain  is  sharp,  stabbing,  or  tearing  in  character,  and 
is  usually,  but  not  always,  referred  to  the  seat  of  pleurisy.      This   is 


570  SPECIAL  DIAGNOSIS. 

mast  frequently  on  a  level  with  the  nipple,  or  a  little  below  this,  and 
more  often  anteriorly  or  in  the  axilla  than  posteriorly.  The  pain  is 
caused  by  the  rubbing  together  of  the  inflamed  surfaces  of  the  pleura, 
and  hence'  is  excited  by  respiration  and  cough.  For  this  reason  the 
patient  is  inclined  to  restrict  the  motion  of  the  affected  side  as  much 
as  possible  ;  he  does  this  by  leaning  over  toward  that  side  and  by 
pressing  his  elboAV  in  against  the  chest-wall.  Pain  is  usually  the  first 
symptom  noticed  by  the  patient.  The  cough  is  dry  and  painful. 
Fever  is  moderate. 

Physical  Signs.  The  physical  signs  in  primary  cases  are  a  friction- 
sound  heard  on  inspiration  and  expiration.  This  friction-sound  may 
be  a  nest  of  fine,  dry,  crepitant  rales,  which  are  very  superficial,  and 
appear  to  be  just  under  the  ear  ;  or  a  coarse  rubbing  sound,  heard  over 
a  larger  surface,  and  resembling  a  bronchial  rhoncus,  from  which  it  can 
be  distinguished  by  its  persistence  after  the  patient  has  coughed.  The 
lungs  themselves  present  nothing  abnormal. 

If  the  inflamed  surfaces '  become  glued  together  by  plastic  lymph, 
recovery  usually  occurs  very  soon,  though  pain  often  persists  for  a 
long  time  in  lessened  degree,  and  the  pleurisy  is  liable  to  be  re- 
lighted. 

Symptoms  of  Second  Stage,  or  Stage  of  Effusion.  If  effusion  takes 
place,  the  two  layers  of  the  pleura  become  separated ;  hence, .  pain  and 
friction-sound  cease,  and  physical  exploration  shows  that  a  collection 
of  fluid  intervenes  between  the  chest-wall  and  the  lung. 

The  physical  signs  (Plates  XXIV.  and  XXV.)  of  this  stage  are 
(1)  enlargement  of  the  affected  side,  increase  in  semi-circumference, 
with  fulness  of  interspaces  ;  (2)  diminution  of  movement ;  (3)  absence 
of  vocal  fremitus  and  resonance ;  (4)  dulness  or  flatness  (deadness)  on 
percussion,  with  great  increase  in  the  resistance  to  the  pleximeter 
finger ;  (5)  absent  or  greatly  diminished  respiratory  murmur ;  (6)  dis- 
placement of  organs. 

The  dead  percussion-note  being  caused  by  fluid,  it  follows  that  its 
upper  level  will  change  with  the  position  of  the  patient  if  the  fluid  is 
free.  If  the  upper  level  is  at  the  third  interspace  when  the  patient  is 
sitting  up,  it  will  fall  to  the  fourth  or  lower  when  he  is  lying  down. 
This  change  of  level  cannot  be  appreciated  when  the  effusion  is  very 
large.  Moreover,  above  the  line  of  dulness  the  percussion-note  is  hyper- 
resonant  or  tympanitic — Skoda's  resonance.  Toward  the  spine  on  the 
affected  side  there  may  be  partial  resonance  and  bronchial  breathing, 
because  here  the  lung  is  compressed  against  the  vertebrae.  In  large 
effusions  the  tympanitic  resonance  in  the  second  interspace  does  not 
change  when  the  mouth  is  opened — that  is,  "  Williams5  tracheal  tone  " 
can  often  be  elicited.  The  upper  limit  of  dulness  in  large  pleural 
effusions  is  higher  at  the  spine  and  slopes  downward,  and  is  lowest  in 
front.  This  parabolic  line  is  only  obtained  when  the  patient  is  in  the 
erect  posture.  In  moderate  effusions  the  line  of  dulness  is  lowest  near 
the  spinal  column,  rises  in  the  middle  of  the  scapula  and  slopes  down- 
ward, assuming  the  shape  of  the  letter  S  as  it  passes  toward  the  front 
(Garland).  The  patient  should  take  deep  breaths  before  the  percus- 
sion  is  performed.     At  the  left  base  in  front  the  semilunar  space  is 


PLATE    XXIV. 

FIG.   1. — Anterior  Aspect. 


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<& 


Pleurisy   with   Effusion   (right-sided). 


PLATE    XXV. 


FIG.    1. — Anterior  Aspect. 


: 


FIG.   2. — Posterior  Aspect. 


V 

Pleurisy  with   Effusion  (left-sided). 


DISEASES  OF  THE  LUNGS  AND  PLEURA. 


571 


obliterated,  dullness  continuing  to  the  margin  of  the  ribs.  In  small 
effusions  the  dulness  may  be  limited  by  the  posterior  axillary  line, 
resonance  being  present  in  the  lateral  and  anterior  regions. 

On  auscultation  below  the  upper  level  of  the  effusion  posteriorly  the 
voice  frequently  has  a  metallic  quality  resembling  the  bleating  of  a 
g0at — cegophony.  It  occurs  usually  when  the  effusion  is  moderate, 
and  may  be  heard  only  over  a  limited  area.  It  is  commonly  heard  at 
or  above  the  angle  of  the  scapula.  Bronchophony  may  be  heard  when 
tubular  breathing  is  present. 

While  the  respiratory  murmur  is,  as  a  rule,  absent,  breath-sounds 
may  be  heard,  and  are  then  weak  and  distant,  or  bronchial.  In  such 
cases  there  may  or  may  not  be  adhesions.  Bronchial  breathing  may 
be  present  along  the  spine  in  small  effusions,  and  in  large  effusions  in 
the  interscapular  region.  Bronchial  breathing,  tubular  in  character, 
is  said  to  be  almost  constant  in  children.  It  may  also  occur  when 
pneumonia  coexists.  In  one  of  the  cases  in  my  ward  the  signs  were 
like  those  of  a  large  cavity  at  the  right  base,  but  the  immobility,  the 
absent  fremitus,  the  enlargement,  and  the  exploratory  puncture  dis- 
proved its  presence. 

At  the  level  of  the  fluid  a  friction-sound  may  persist.  Above  the 
level  of  fluid  anteriorly  the  breath-sound  may  be  bronchial  or  broncho- 
vesicular,  associated  sometimes  with  fine  rales,  due  to  compression  and 
slight  cedenia. 


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Pleurisy  with  effusion.    Recovery.    (Two  days  omitted.) 

Displacement  of  Organs.  If  the  effusion  is  on  the  left  side,  the 
mediastinum  and  heart  become  displaced  to  the  right,  and  the  apex- 
beat  may  be  found  in  the  epigastrium,  or  even  to  the  right  of  it.  The 
occurrence  of  displacement  of  the  heart  must  also  be  judged  by  the 
position  of  maximum  intensity  of  the  heart-sounds,  as  the  heart  may 
be  behind  the  sternum.  At  the  same  time  the  semilunar  space  (Traube's 
line)  is  lower  than  usual  or  entirely  effaced.  On  the  left  side  inaction 
of  the  diaphragm  maybe  observed,  and  the  tissues  at  the  costal  margin 
fall   in  with  each  inspiration.      If  the  effusion  is  on  the  right  side,  the 


572  SPECIAL  DIAGNOSIS. 

diaphragm,  and  with  it  the  liver,  is  depressed,  and  the  mediastinal 
contents  are  moved  to  the  left. 

The  subjective  symptoms  during  this  stage  are  slight  or  moderate 
fever,  sometimes  intermittent  in  character,  with  recurring  chills  ;  con- 
siderable dyspnoea,  occasionally  amounting  to  orthopncea  when  the 
effusion  is  very  extensive  ;  and  dry  cough,  which  adds  greatly  to  the 
dyspnoea.  There  is  frequently  some  evidence  of  insufficient  oxygena- 
tion of  the  blood  ;  when  this  amounts  to  cyanosis,  the  condition  is  one 
of  great  danger.  The  urine  presents  changes  in  amount.  In  ad- 
vancing effusion  the  amount  lessens  very  much  ;  it  increases  in  amount 
with  the  decline  of  the  fluid.  Pleurisy  may  be  complicated  with  bron- 
chitis, pneumonia,  and  pericarditis. 

Empyema.  The  above-mentioned  physical  signs  apply  chiefly  to 
serous  effusions.  They  are  also  present  in  effusions  of  pus.  Other 
physical  phenomena,  however,  and  different  general  symptoms  distin- 
guish the  two  kinds  of  effusions,  although  it  must  be  confessed  that 
aspiration  must  often  be  resorted  to  before  a  positive  diagnosis  can  be 
made. 

Physical  Signs.  The  physical  signs  of  empyema  are  the  same  as 
those  of  other  effusions  within  the  pleura.  In  addition,  especially  in 
children,  local  oedema  of  the  chest-wall  may  be  found.  Another  sign 
was  pointed  out  by  Bacelli,  and  is  held  by  others  to  be  of  diagnostic 
significance.  In  purulent  effusions  the  fremitus  produced  by  the  whis- 
pering voice  is  not  transmitted  to  the  hand  laid  over  the  effusion, 
whereas  in  serous  effusions  such  vibrations  are  transmitted.  In  locu- 
lated  empyema  the  diagnosis  is  very  difficult.  In  one  of  my  cases 
dulness  continuous  with  that  of  the  heart  extended  to  the  second  rib 
and  laterally  to  the  post-axillary  line.  The  dulness  occupied  three 
interspaces.  Additional  physical  signs  were  immobility,  prominence 
of  interspaces,  localized  above  the  heart,  absent  fremitus  and  resonance. 
There  were  no  breath-sounds,  but  an  abundance  of  rales,  apparently 
very  superficial.  The  rales  complicated  the  physical  signs.  Martin 
operated  for  me  and  removed  two  ounces  of  pus  from  a  small  abscess 
above  the  heart  and  between  the  lobes. 

In  empyema  a  local  area  may  become  more  prominent  and  the  sur- 
face assume  an  inflammatory  appearance.  It  is  an  indication  of  dis- 
charge of  the  abscess  through  the  chest-wall.  It  is  usually  found  in 
the  fifth  interspace  in  front,  or  below  the  angle  of  the  scapula,  behind 
— empyema  necessitatis.  (For  a  microscopical  and  chemical  description 
of  the  "  Effusion  within  the  Pleural  Sac,"  and  of  the  morphological 
elements  of  the  purulent  effusions,  see  Chapter  XXL,  Part  I.) 

General  Symptoms.  The  general  symptoms  are  more  marked  hi 
empyema  than  in  simple  serous  effusion.  The  temperature  is  higher 
from  the  onset.  It  soon  becomes  intermittent  or  remittent.  Chills 
or  chilliness  may  attend  the  beginning  of  each  febrile  paroxysm,  and 
sweats  occur  with  the  daily  fall  of  temperature,  or  at  irregular  periods 
during  the  twenty-four  hours.  The  heart's  actum  is  more  rapid  and 
the  pulse  more  feeble,  soon  becoming  dicrotic.  Examination  of  the 
wrine  may  aid  in  the  distinction  of  the  two  forms  of  the  effusion. 
Albumosuria  occurs   in  purulent  pleurisy.     It   must   be   remembered 


DISEASES  OF  THE  LUNGS  AND  PLEURAE. 


573 


that  albumosuria  occurs  in  suppuration  from  other  causes.  Thus,  in 
phthisis  with  suppuration  of  a  cavity  pleural  effusion  may  develop. 
The  albumosuria  that  attends  the  primary  process  must  not  be  mis- 
taken for  that  which  occurs  in  empyema.  Indiean  is  also  present  in 
excess  in  the  urine  in  suppurations.  Before  a  decisive  conclusion  is 
arrived  at  two  or  more  examinations  of  the  urine  should  be  made. 
Examination  of  the  blood  may  aid  in  arriving  at  a  conclusion.  In 
purulent  effusion  there  is  usually  leucocytosis. 

Fig.  151. 


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Empyema  following  pneumonia.    (Fever  absent  from  seventh  to  fourteenth  day.) 

Notwithstanding  the  positive  physical  signs  of  effusion  the  character 
of  the  effusion  may  not  be  recognized  until  perforation  into  the  bron- 
chus has  taken  place.  The  peculiar  character  of  the  expectoration  that 
attends  this  accident  is  described  in  the  section  on  Sputum. 

Hydrothorax.  This  is  an  accumulation  resulting  from  a  transuda- 
tion. (For  character  of  the  fluid,  see  Chapter  XXL,  Part  I.)  It 
occurs  in  the  course  of  diseases  which  produce  anasarca,  as  failing 
organic  heart  disease,  chronic  Bright's  disease,  and  debilitating  diseases, 
as  -curvy.  Locally,  it  may  attend  carcinoma  of  the  pleura  or  obstruc- 
tive disease  of  vessels  within  the  mediastinum. 

The  physical  signs  of  hydrothorax  are  those  of  effusion  in  acute 
pleurisy.  The  general  symptoms  belong  to  the  primary  disorder. 
Dyspnoea  may  develop  gradually  and  even  amount  to  orthopnoea. 
It  is  distinguished  from  inflammatory  effusions  by  the  character  of  the 
fluid,  by  the  absence  of  the  general  symptoms  of  inflammation,  by  its 
insidious  development,  and  by  its  bilateral  distribution. 

Hemothorax.  The  transudation  of  blood  into  the  cavity  of  the 
pleura  occurs  rarely  from  the  rupture  of  an  aneurism  into  the  sac. 
The  fluid  is  then  pure  blood.  Serous  effusions  in  which  a  large  amount 
of  blood  is  found  point  to  primary  carcinoma  of  the  pleura,  or  to  tuber- 
culous disease.  Both  specific  processes  of  this  serous  membrane  may 
occur,  however,  without  the  transudation  of  sero-bloody  fluid. 

Thickened  Pleura.     Chronic  inflammation,  with  thickening  of  the 


574  SPECIAL  DIAGNOSIS. 

pleura  from  excessive  development  of  connective  tissue,  occurs  in 
tuberculosis  and  in  cases  of  combined  pleuritis  and  peritonitis.  The 
thickening  of  the  pleura  is  usually  more  marked  at  the  base. 

The  physical  signs  (Plate  XXVI.)  are  pronounced,  and  are  those 
of  effusion,  but  without  enlargement  of  the  chest.  There  are  marked 
contraction  and  diminution  in  movement  of  the  affected  side.  The 
fremitus  is  absent.  There  is  dulness  on  percussion,  or  even  flatness. 
The  breath-sounds  are  distant  or  are  absent.  Along  the  vertebra?, 
especially  opposite  the  angle  of  the  scapula,  bronchial  breathing  may 
be  heard.  The  subjective  symptoms  of  cough  and  dyspnoea  are  pres- 
ent. The  degree  of  cough  *  depends  upon  the  condition  of  the  lung. 
If  there  is  bronchitis  or  tuberculosis,  the  cough  is  excessive.  The 
amount  of  dyspnoea  depends  upon  the  degree  of  compression  of  the 
lung  by  the  thickened  pleura. 

Tuberculous  Pleurisy.1  The  affection  may  be  acute  or  chronic. 
It  may  occur  primarily,  be  a  part  of  general  tuberculous  infection,  or 
occur  "secondarily  to  disease  of  the  lungs.  It  may  give  rise  to  all  forms 
of  the  inflammatory  process  :  First,  dry  pleurisy  ;  second,  pleurisy 
with  effusion  ;  third,  pleurisy  with  great  thickening.  Often  the  dis- 
tinction between  tuberculous  pleurisy  and  pleurisy  due  to  other  causes 
cannot  be  determined  positively.  If  it  is  associated  with  tuberculosis 
in  other  organs,  or  the  patient  is  of  tuberculous  habit  and  exposed  to 
infection,  or  if  there  has  been  a  history  of  previous  tuberculosis,  the 
pleuritic  infection  is  probably  of  tuberculous  origin.  If  the  affection 
is  bilateral  and  associated  with  peritoneal  inflammation,  and  at  the 
same  time  no  other  cause  exists  for  serous  membrane  inflammation, 
the  probability  of  its  tuberculous  origin  is  very  strong. 

Pulsating  Pleural  Effusion.  Wilson  has  made  the  most  recent 
studies  of  this  rare  affection.  The  effusion  within  the  pleura  pulsates 
synchronously  with  the  ventricular  systole  ;  the  pulsation  is  detected 
usually  by  inspection  and  palpation.  In  some  instances  its  presence 
is  onlv  determined  by  palpation.  It  may  be  confined  to  two  or  three 
interspaces,  or  occupy  the  anterior  aspect  of  the  thorax  and  the  axil- 
lary region  on  the  left  side.  Earely  the  pulsation  is  behind.  It  is 
usually  situated  on  the  left  side.  The  original  effusion  is  purulent  in 
the  large  majority  of  cases.  The  physical  signs  and  general  symptoms 
of  empvema  are  present.  Nevertheless,  the  disease  simulates  aneurism 
of  the  aorta.  The  latter  affection,  however,  is  accompanied  by  vascu- 
lar symptoms  and  physical  signs  in  the  course  of  the  aorta.  Pulsating 
empyema  is  distinct  in  movement  from  the  pulsation  of  the  aorta  and 
occupies  a  different  anatomical  site. 

Diaphragmatic  Pleurisy.  In  diaphragmatic  pleurisy  there  is  in- 
tense pain  in  the  epigastrium.  Gueneau  de  Mussy2  regards  a  paid 
along  the  tenth  rib,  extending  from  the  anterior  extremity  to  the 
sternum  and  xiphoid  cartilage,  as  pathognomonic.  Other  symptoms 
are  nausea,  vomiting,  and  hiccough.  The  dyspnoea  often  amounts  to 
orthopnea,  or  the  patient  sits  stooping  forward.     The  anxiety  of  the 

1  Sec  "Notes  on  Tuberculous  Pleurisy. "  Musser,  American Climatological  Associa- 
tion, 1893. 

2  Arch.  gen.  de  MeU,  1853,  vol.  xi.     Quoted  by  Fox. 


PLATE    XXVI. 


FIG.   1. — Anterior  Aspect. 


\ 


v  '  X.    -i  i 


FIG.  2. — Posterior  Aspect. 


• 


Fibroid  Phthisis  with   Chronic  Pleurisy. 

Heart  drawn  toward  the  right  and  aorta  uncovered    by  retraction  of  lung 
margin.     Vicarious  emphyzema  of  left  lung. 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  575 

patient  is  very  great.  The  fever  is  usually  higher  than  in  ordinary 
pleurisy,  and  there  may  be  delirium.  Effusion  may  lessen  the  pain. 
Peritonitis  may  occur  at  the  same  time,  or  be  secondary  to  the  pleurisy. 

Diagnostic  Features.  The  special  features  of  diagnostic  impor- 
tance that  are  observed  in  the  course  of  pleurisy  are  the  pain,  the 
dyspnoea,  the  cough,  the  fever,  the  physical  signs  of  effusion  within 
the  pleura,  and  the  results  of  exploratory  puncture.  Pain:  The  pain 
is  short,  sharp,  lancinating,  and  is  usually  recognized  quite  readily  by 
its  character  and  location.  It  must  be  distinguished  from  the  pain 
due  to  pleurodynia  and  intercostal  neuralgia.  The  pain  of  pleurisy  is 
associated  with  cough  and  is  increased  by  breathing.  It  causes  dimi- 
nution of  movement  of  the  affected  side.  The  patient  is  compelled  to 
sit  up  in  bed,  or  lie  on  the  side  which  is  the  seat  of  pain.  Cough:  In 
the  first  stage  the  cough  is  short,  suppressed,  dry,  and  painful.  It  is 
constant.  In  the  second  stage  it  changes  in  character.  There  is  no 
pain,  there  is  no  expectoration.  It  is  frequent  and  irritating,  and  of 
a  peculiar  sound  which  is  difficult  to  describe,  and  yet,  when  once 
heard,  is  most  suggestive  in  subsequent  cases.  It  is  short  and  lacks 
resonant  quality,  as  if  the  fluid  hi  the  chest  stopped  the  sound-waves. 
Dyspnoea  in  the  first  stage  is  due  to  pain,  in  the  second  stage  to  the 
large  effusion  which  encroaches  upon  the  normal  air-space.  It  is  not 
diagnostic.  The  physical  signs  of  pleural  effusion  have  been  frequently 
reiterated.  The  most  decisive  are  diminution  or  absence  of  move- 
ment, enlargement  of  the  affected  side,  absence  of  fremitus,  flatness  on 
percussion,  fulness  of  intercostal  spaces,  and  the  displacement  of  organs. 
The  latter  is  of  the  greatest  diagnostic  importance  in  the  distinction 
between  consolidation  and  effusions.  The  results  of  exploratory  punc- 
ture lead  to  decisive  conclusions  usually,  although  it  must  not  be  for- 
gotten that  effusions  may  be  loculated  and  therefore  missed  by  the 
aspirating-needle.  Or  the  enormously  thickened  pleura  may  intervene 
between  the  exudation  and  the  surface  of  the  chest,  and  prevent  with- 
drawal of  the  fluid.  Finally,  effusions  may  complicate  inflammatory 
processes,  as  pneumonia,  tuberculosis,  or  abscess  of  the  lung.  Securing 
fluid  for  diagnosis  by  aspiration,  therefore,  does  not  necessarily  exclude 
these  conditions,  and  hence,  before  the  process  is  decided  to  be  within 
the  pleura  alone,  the  sputum  and  other  conditions  must  be  taken  into 
consideration. 

Differential  Diagnosis.  Acute  plastic  pleurisy  is  diagnosticated  from 
acute  'pneumonia  by  the  friction-sound  and  the  maintenance  of  the  clear 
percussion-note  and  normal  respiratory  murmur,  with  unaltered  vocal 
resonance  and  fremitus.  When  effusion  takes  place  the  chest  is  en- 
larged and  immobile,  especially  on  the  affected  side;  the  interspaces 
are  filled  out  and  the  diaphragm  is  depressed  ;  these  changes  do  not 
occur  in  pneumonia.  Moreover,  the  percussion-note  in  pleural  effusion 
is  flat,  with  greatly  increased  resistance  ;  the  shape  of  the  upper  line 
of  dulness  is  diagnostic  ;  the  respiratory  murmur  is  feeble  and  distant, 
or  entirely  absent,  except  along  the  spine,  where  the  compressed  lung- 
yields  bronchial  breathing,  and  also  above  the  line  of  effusion,  where 
the  lung  yields  exaggerated  breathing.  In  pneumonia,  on  the  other 
hand,  the  percussion-note  is  dull,  without  greatly  increased  resistance, 


576  SPECIAL  DIAGNOSIS. 

and  the  breath-sounds  are  bronchial.  In  addition,  in  pleurisy,  the 
vocal  resonance  and  fremitus  are  usually  almost  if  not  entirely  absent, 
and  posteriorly  at  the  level  of  the  effusion  segophony  may  be  detected. 
In  pneumonia,  on  the  contrary,  vocal  resonance  and  fremitus  are 
increased  in  intensity.  In  pleurisy  with  effusion  the  movable  organs 
are  dislocated  and  Traube's  line  is  obliterated. 

Finally,  the  fever  of  pneumonia  is  much  higher  and  more  continu- 
ous than  that  of  pleurisy,  the  respirations  more  frequent,  the  cough 
looser,  and  in  typical  cases  followed  by  rusty  sputa.  (Compare  the 
temperature  chart  in  article  on  Pneumonia. )  A  crucial  test  is  aspiration 
with  a  hypodermic  needle  :  in  pleural  effusion,  serum  is  withdrawn ; 
in  pneumonia,  a  few  drops  of  thick  blood. 

In  pleurodynia  there  is  also  severe  pain  in  one  side  ;  but  the  pain  is 
more  continuous  than  that  of  pleurisy,  and  consists  of  a  constant  aching 
or  a  burning  sensation.  It  is  made  worse  by  twisting  or  turning,  as 
well  as  by  breathing.  The  side  is  also  tender  to  the  touch.  The  pain 
is  not  so  sharply  localized  as  that  of  pleurisy,  and  may  leave  one  side 
and  affect  the  other.  It  is  unaccompanied  by  fever  or  friction-sound, 
and  is  frequently  found  in  rheumatic  subjects. 

In  intercostal  neuralgia,  there  is  the  same  absence  of  fever  and  fric- 
tion-sound. The  pain,  however,  is  sharply  localized,  as  in  pleurisy, 
but  is  of  the  darting,  neuralgic  character,  and  is  associated  with  tender- 
ness at  the  points  of  exit  of  the  intercostal  nerves.  It  is  most  common 
in  women,  especially  if  they  have  uterine  disturbances.  It  is  more 
frequent  on  the  left  side,  and  just  beneath  the  mammary  gland. 

Chronic  Pleurisy.  Chronic  dry,  or  plastic,  pleurisy  is  the  result  of 
an  acute  attack,  or  develops  insidiously  if  tuberculous.  It  causes 
great  deformity  of  the  chest  from  contraction,  and  compensatory 
emphysema  of  the  healthy  lung.  The  heart  is  dislocated  or  cannot 
be  found  on  physical  examination,  because  it  is  overlapped  by  lung  or 
is  drawn  behind  the  sternum.  There  is  considerable  spinal  curvature, 
dislocation  of  the  scapula,  deformity  of  the  shoulder,  and  indrawing 
and  overlapping  of  the  ribs  at  the  base  of  the  chest. 

('hronic  pleurisy  with  effusion  results  from  an  acute  attack  of  pleurisy, 
in  which  the  fluid  remains  unabsorbed,  or  from  subsequent  attacks. 
The  physical  signs  are  the  same  as  in  acute  effusion.  So  far  as  subjec- 
tive symptoms  go  it  may  remain  latent ;  patients  so  affected  not  infre- 
quently go  about  their  work  with  comparatively  little  dyspncea.  There 
may  be  an  evening  rise  of  temperature  and  acceleration  of  the  pulse. 
Chronic  effusions  are  more  likely  to  be  purulent  in  children  than  in 
adults.  AVhen  empyema  results,  the  fever  becomes  hectic  ;  there  are 
chills  and  sweats,  pyaemia  develops,  and  death  is  likely  to  occur  from 
-nine  intercurrent  suppuration,  as  cerebral  absce>-. 

After  ehronic  effusion  the  chest  is  rarely  restored  to  its  original  shape, 
even  if  the  effusion  is  finally  absorbed.  The  affected  side  becomes 
motionless  and  retracted.  In  process  of  time  the  spine  may  be  bent. 
The  opposite  lung  becomes  hypertrophied.  The  patient  is  usually  in 
precarious  health,  liable  to  acute  attacks  of  pain  hi  the  affected  side, 
and  liable  also  to  be  carried  off  by  phthisis  or  some  intercurrent  affec- 
tion.    Rarely  the   patient   may  maintain  good  health  ;  complete  cure 


PLATE   XXVII. 


FIG.    1. — Anterior  Aspect. 


FIG.    2. — Posterior  Aspect. 

ES3 


Pneumothorax  (left-sided). 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  577 

is  even  possible,  with  restoration  of  the  retracted  side  to,  or  almost  to, 
normal  dimensions,  especially  in  children. 

Pneumothorax.  Pneumothorax  consists  in  an  accumulation  of  air 
in  the  pleural  cavity,  accompanied  or  followed  by  an  outpouring  of 
fluid,  which  may  be  serous  or  purulent,  constituting  respectively  hydro- 
pneumothorax  and  pyo-pneumothorax. 

Pneumothorax  may  originate  :  1.  In  causes  external  to  the  chest, 
by  perforation  of  the  chest-wall  and  pleura.  2.  In  perforation  of  the 
lungs,  bronchi,  or  oesophagus.  3.  It  may  be  caused  by  gases  devel- 
oped from  an  existing  effusion. 

The  most  frequent  cause  is  tuberculous  disease  of  the  lung,  and  next 
an  empyema  ;  out  of  121  cases  collected  by  Saussier,  81  were  due  to 
phthisis  and  29  to  empyema.  It  may  occur  very  early  in  tuberculosis 
of  the  lung,  and  may  even  be  the  first  symptom  of  that  disease. 
(See  cases  referred  to  by  Fox  and  recorded  by  Louis  and  Chomel). 
The  left  side  is  affected  not  quite  twice  as  often  as  the  right ;  the 
disease  is  usually  unilateral.  The  onset  of  the  condition  is  usually 
sudden.  During  a  paroxysm  of  coughing  or  vomiting,  or  without 
immediate  cause,  there  is  an  escape  of  air  into  the  pleura,  and  hi  the 
majority  of  cases  the  patient  at  once  complains  of  acute  pain  in  the 
chest  and  excessive  dyspnoea  with  great  dread  of  impending  suffoca- 
tion. The  patient  often  sinks  into  collapse  from  shock,  but  sudden 
death  is  rare.  If  the  escape  of  air  mto  the  pleura  is  gradual,  there 
will  be  less  pain  and  dyspnoea. 

Physical  Signs.  (Plate  XXVII.)  The  chest  is  distended,  especially 
on  the  affected  side  ;  the  percussion-note  is  a  bell-like  tympany  except 
when  the  distention  is  excessive  and  the  air  contained  is  under  great 
tension,  when  the  note  is  proportionately  duller  and  higher  in  pitch;  the 
diaphragm  is  depressed  and  the  heart  displaced,  unless  adhesions  pre- 
vent it.  In  left  pneumothorax  it  may  beat  on  the  right  side,  the  whole 
mediastinum  being  pushed  to  the  right ;  in  right  pneumothorax  the 
mediastinum  may  be  pushed  to  the  left  nipple  ;  hence  there  is  reso- 
nance over  the  normal  cardiac  region.  The  pitch  of  the  percussion- 
note  may  be  raised  when  the  mouth  is  closed,  and  lowered  when  it  is 
open  (Wintrich's  change  of  note),  and  a  cracked-pot  sound  can  be 
elicited  in  some  cases,  but  this  occurs  only  when  the  communication 
with  the  pleura  remains  open. 

A  valuable  sign  of  pneumothorax  is  the  coin-test,  or,  as  Trousseau 
named  it,  the  Bruit  cFairain.  A  silver  coin  is  laid  upon  the  chest  and 
struck  with  another,  while  the  auscultator  applies  the  stethoscope  oppo- 
site to  the  point  struck,  or  over  any  part  of  the  side  distended  by  air. 
The  ringing  coin-sound  is  reproduced  with  great  intensity.  It  is  path- 
ognomonic, and  the  outlines  of  the  cavity  can  be  traced  by  it. 

When  fluid  is  present,  as  it  usually  is,  there  will  be  the  ordinary 
signs  of  a  pleural  effusion,  which  have  been  sufficiently  dwelt  upon. 
The  fluid  is  more  mobile  in  pneumothorax,  however,  than  in  simple 
pleurisy,  so  that  its  level  changes  more  quickly  with  change  of  posture 
of  the  patient,  and  Hippoeratic  succussion  is  readily  obtained.  This 
movable  dulness  is  a  very  valuable  sign — indeed,  almost  pathognomonic. 

As  the  lung  is  compressed  against  the  spine  by  the  air,  as  it  is  by 

37 


578  SPECIAL  DIAGNOSIS. 

the  fluid  in  pleurisy,  the  breath  sounds  are  feeble  or  absent,  except 
over  the  root  of  the  lung,  where  the  breathing  is  bronchial.  But  if 
the  lung  is  not  completely  collapsed,  amphoric  breathing  may  be  heard, 
the  air-chamber  of  the  pleura  acting  as  a  consonance-box  ;  it  may  be 
heard  with  both  inspiration  and  expiration,  or  only  with  expiration. 

Metallic,  tinkling  is  a  sound  believed  to  be  due  to  the  vibration  of 
bubbling  bronchial  rales  re-echoed  through  the  air-chamber,  or  to 
drops  of  fluid  falling  from  above  upon  the  surface  of  the  effusion.  Re- 
echoing, with  metallic  quality,  may  also  accompany  the  heart-sounds, 
and  in  cases  in  which  the  respiratory  murmur  is  amphoric  the  vocal 
resonance  is  of  the  same  character.  Vocal  fremitus  is  generally 
absent. 

Differential  Diagnosis.  Pneumothorax  is  most  likely  to  be 
confounded  with  (1)  emphysema  ;  (2)  tuberculosis  of  the  lungs  with 
large  cavities  ;  (3)  cases  of  pleural  effusion  in  which  above  the  upper 
level  of  the  fluid  the  lung  is  markedly  hyper-resonant ;  and  (4)  abscess 
below  the  diaphragm  containing  air  (pyo-pneumothorax  subphrenicus). 

1.  Emphysema  can  be  distinguished  by  its  slow  onset,  its  relatively 
slight  impairment  of  the  general  health,  by  the  fact  that  it  is  bilateral, 
whereas  pneumothorax  is  almost  always  unilateral,  and  by  the  exist- 
ence of  feeble  breathing  with  greatly  prolonged  expiration.  Amphoric 
breathing  and  resonance,  metallic  tinkling,  and  signs  of  fluid  are  all 
absent  in  emphysema. 

2.  When  the  pneumothorax  is  circumscribed  the  physical  signs  re- 
semble those  of  pulmonary  cavity.  But  over  a  large  cavity  the  chest 
is  usually  flattened  ;  cracked-pot  sound  and  alteration  in  pitch  upon 
opening  and  closing  the  mouth  are  more  common  in  cavity  than  in 
pneumothorax.  Displacement  of  viscera  does  not  necessarily  occur 
in  phthisical  cavity,  the  coin-test  is  negative,  succussion  cannot  be  pro- 
duced. Fremitus  is  absent  in  pneumothorax  and  increased  over  a 
cavity. 

3.  The  hyper-resonance  above  a  pleural  effusion  develops  with  a  very 
different  clinical  history,  is  accompanied  by  increase  of  fremitus  with 
bronchial  or,  at  times,  amphoric  breathing,  and  changes  when  the 
patient's  mouth  is  open  or  closed.  The  percussion-note  usually  lacks 
the  metallic  quality  heard  in  pneumothorax,  metallic  tinkling  is  absent, 
the  coin-test  is  negative. 

4.  Pneumothorax  must  be  distinguished  from  abscess  below  the  dia- 
phragm containing  air  (pyo-pneumothorax  subjihrenicus).  Often  the 
distinction  is  difficult.  The  constitutional  symptoms  of  suppuration 
are  present.  Leyden  points  out  the  importance  of  remembering  the 
sequence  of  events  in  the  development  of  the  disease.  When  the 
abscess  is  situated  below  the  diaphragm,  abdominal  symptoms  precede 
its  development,  and  early  in  the  course  of  the  disease  there  is  absence 
of  respiratory  symptoms.  If  the  patient  has  had  gastric  ulcer,  this 
would  point  to  subphrenic  abscess,  as  most  of  the  cases  of  subphrenic 
abscess  are  secondary  to  gastric  ulcer.  Moreover,  in  subphrenic  abscess 
the  heart  is  not  displaced  nor  the  interspaces  bulging.  Indeed,  the 
viscera  below  the  diaphragm  are  more  likely  to  be  displaced  than  those 
above  it.     In  pneumothorax,  according  to  Leyden,  the  respiration  is 


DISEASES  OF  THE  LUNGS  AND  PLEURAE.  579 

normal  under  the  clavicle,  and  the  transitions  from  the  normal  to  the 
metallic  and  amphoric  sounds  lower  down  are  abrupt.  In  pyopneu- 
mothorax on  the  left  side  the  semilunar  space  disappears.  In  sub- 
phrenic abscess  the  amphoric  sounds  laterally  or  posteriorly  may  be 
above  and  below  the  diaphragm,  or  they  may  be  loudest  at  the  epigas- 
trium. In  addition,  in  pyo-pneumothorax  subphrenicus,  as  Mason 
points  out,  adhesions  of  the  lung  to  the  diaphragm  and  parietes  can  be 
made  out,  particularly  if  the  case  has  been  under  observation  in  its 
earlier  stages  and  dry  pleurisy  has  been  discovered.  Abscess  in  this 
location  and  slight  fluctuation  are  likely  to  develop  with  associated 
effusion.  The  limited  extent  of  the  effusion  is  of  diagnostic  import  in 
favor  of  sub-diaphragmatic  inflammation. 


CHAPTER    III. 

DISEASES  OF  THE  HEART,  THE  BLOODVESSELS,  AND  THE 
MEDIASTINUM. 

The  symptoms  of  disease  of  the  heart  are  due  to  the  anatomical 
structure  of  the  organ,  to  its  physiological  offices,  and  to  the  morbid 
process.  The  heart  is  a  hollow  muscular  structure  which  hangs  in  a 
cavity  and  encloses  cavities  separated  by  valves.  Both  sets  of  cavities 
are  lined  by  serous  membrane.  The  serous  membranes  are  subject  to 
the  same  diseases,  and  present  the  same  symptoms  as  diseased  serous 
membranes  elsewhere.  In  inflammation  of  the  external  membrane 
the  surfaces  rub  together  and  create  a  sound  of  friction.  The  external 
serous  cavity  may  also  become  filled  with  the  products  of  exudation  or 
transudation.  Physical  signs  are  produced.  They  are  the  physical 
signs  of  a  localized  increase  of  contents  as  determined  by  inspection, 
palpation,  and  percussion,  and  of  physical  interference  with  the  heart's 
action.  The  heart-muscle  is  also  subject  to  the  same  morbid  processes 
as  other  muscular  structures.  They  are  hypertrophy  and  atrophy  ; 
inflammation,  acute  and  chronic,  with  overgrowth  of  connective  tissue ; 
and  degenerations.  The  symptoms  are  likewise  the  same.  Increase 
or  diminution  in  the  power  of  the  muscle  is  associated  with  correspond- 
ing change  in  size,  which  is  determined  by  physical  signs.  Above 
all,  however,  such  change  modifies  the  heart's  action  so  that  strength 
or  weakness  of  the  muscle  shows  itself  in  excessive  or  deficient  vascu- 
lar pressure.  The  latter  is  more  particularly  an  object  of  observation 
because  of  the  congestions,  dropsies,  and  cyanosis  that  ensue. 

The  heart  is  constantly  subjected  to  internal  pressure.  Dilatation 
of  the  cavities  or  a  portion  of  cavity  (aneurism)  follows  previous  dis- 
ease of  the  muscle  or  increase  of  internal  pressure,  and  causes  physical 
signs  of  enlargement.  Degeneration  of  the  heart-muscle,  nearly  always 
secondary  to  deficiency  of  vascular  supply,  is  also  attended  by  symp- 
toms of  weakness  and  physical  signs  of  enlargement  (dilatation),  or  of 
diminution  in  size  (atrophy).  When  dilatation  occurs  the  orifices  of 
the  cavities  enlarge,  the  valves  cannot  close  them,  and  symptoms  of 
incompetency  and  of  blood-regurgitation  result. 

The  serous  membrane  that  lines  the  cavities  of  the  heart  and,  with 
the  subserous  tissues,  makes  up  the  structure  of  the  valves,  is  subject 
to  inflammations,  the  symptoms  of  which  are  common  to  all  serous 
inflammations.  The  swellings  and  outgrowths  that  attend  such  in- 
flammation occlude  the  orifices  and  prevent  closing  of  the  valves.  A 
physical  interference  with  the  heart's  function  is  produced,  recognized 
by  physical  signs.  The  successful  effort  of  the  heart-muscle  to  over- 
come such  obstruction  on  the  one  hand  (hypertrophy),  or  its  failure  on 
the  other  (dilatation),  again  leads  to  the  production  of  symptoms  and 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     581 

signs.  The  serous  membranes,  and  hence  the  valves,  are  exposed  to 
causes  which  excite  inflammation.  By  virtue  of  the  position  of  the 
heart  at  the  centre  of  the  circulation,  the  blood,  infectious  or  irritative, 
as  in  rheumatism  and  Bright's  disease,  constantly  bathes  the  vulnerable 
structure.  For  the  same  anatomical  reason  positive  symptoms  arise. 
not  common  to  serous  membrane  inflammation — that  is,  embolic  phe- 
nomena. (See  Symptoms  of  Morbid  Processes.)  Hence,  the  physical 
signs  (objective  symptoms)  of  cardiac  disease  may  be  due  to  primary 
and  secondary  morbid  anatomical  changes.  They  may  be  due  (1)  to 
valvulitis  as  indicated  by  signs  of  (a)  obstruction  or  regurgitation  at 
the  valve-orifice,  or  (b)  of  embolic  phenomena  ;  (2)  to  secondary  changes 
in  the  heart-muscle  as  seen  in  (a)  change  in  the  size  and  strength  of 
the  organ  (hypertrophy  or  dilatation),  and  (b)  in  consequence  of  the 
latter,  signs  of  congestion,  oedema,  cyanosis,  etc. 

It  is  the  function  of  the  heart  to  propel  the  blood.  It  has  been 
shown  how  interference  with  the  action  of  the  muscle  and  with  the 
consequent  flow  of  blood  through  the  cavities  and  orifices  modifies  the 
function.  The  functional  power  is  increased  or  diminished  by  the 
physical  changes.  The  evidence  of  increased  power  is  increased  force 
of  the  heart-beat,  and  increased  pressure  in  the  arteries  (pulse). 

Diminished  power  shows  itself  in  symptoms  of  diminished  blood- 
supply  to  parts,  and  in  stagnation  of  the  blood  that  is  sent  to  the 
periphery.  The  former  is  more  pronounced  in  cerebral  anasrnia,  and 
physiological  weakness  of  organs  or  the  organism  as  a  whole  ;  the 
latter,  in  congestion  and  dropsies. 

The  functional  activity  of  the  heart  is  controlled  by  a  nervous  mech- 
anism, any  alteration  of  which  alters  cardiac  action  and  consequently 
produces  symptoms.  Just  as  with  the  larynx,  a  break  in  the  cardiac 
mechanism  may  be  in  the  centres  in  the  medulla,  the  centres  in  the 
muscle,  or  in  the  sympathetic  nerves  to  and  from  the  heart.  The  rich 
anastomosis  of  these  nerves  exposes  the  heart  to  disturbance  by  reflex 
influences.  We  should  suppose  such  extensive  innervation  would  in- 
vite frequent  cardiac  perturbation.  In  a  measure  it  does,  but,  fortu- 
nately, so  perfect  is  this  mechanism  that  the  inhibitory  fibres  control 
such  perturbation  to  a  large  extent,  and  we  do  not  see  such  pronounced 
symptoms  as  occur  in  the  larynx.  The  symptoms  which  point  to  dis- 
turbance of  the  cardiac  mechanism  are  alterations  in  the  rhythm  of  the 
heart.  Its  action  may  on  this  account  be  increased  or  diminished  in 
frequency,  or  it  may  be  irregular  or  intermittent.  Such  alterations  of 
rhythm  may  be  due  to  organic  disease  of  the  centres,  notably  the  pneu- 
mogastric  from  apoplexy,  softening,  or  tumor  in  the  medulla,  or  to 
stimulation  or  depression  of  the  centres  by  toxic  substances  in  the  blood, 
as  in  unemia,  aeetomemia,  or  autogenetic  or  other  toxemias,  or  by  nico- 
tine or  other  extraneous  material.  The  altered  rhythm  may  be,  and  most 
frequently  is,  of  reflex  origin.  It  may  be  due  to  disease  of  the  nerves, 
as  the  pneumogastric  or  sympathetic,  from  pressure  upon  the  nerve-trunk 
by  tumor  or  inflammatory  growth.  The  most  pronounced  symptom  of 
altered  rhythm  of  which  the  patient  is  cognizant  is  palpitation.  The 
exciting  cause  of  this,  as  well  as  other  rhythmical  changes,  must,  in  the 
great  majority  of  cases,  be  sought  for  beyond  the  domain  of  the  heart. 


582  SPECIAL  DIAGNOSIS. 

While  the  symptoms  or  signs  of  cardiac  disease  are  often  due  to 
morbid  processes  in  the  organ  or  its  membrane,  it  must  be  remembered 
that  grave  and  persistent  subjective  and  objective  symptoms  may  be 
caused  by,  or  at  least  associated  with,  disease  of  contiguous  structures 
outside  of  the  pericardium.  The  symptoms  are  not  excited  through 
the  nervous  system,  but  are  produced  by  mechanical  encroachment  upon 
the  organ,  as  in  pleurisy  with  effusion,  mediastinal  disease  and  disease 
of  subdiaphragmatic  viscera.  They  will  be  referred  to  in  the  study  of 
objective  symptoms.  Care  must  be  taken  never  to  overlook  the  possi- 
bility of  their  presence. 

In  the  study  of  the  symptomatology  of  cardiac  disease  the  student 
must  bear  in  mind  two  things  :  first,  that  the  cause  of  the  morbid  pro- 
cesses and  of  the  symptoms  (pain  and  palpitation)  may  be  elsewhere 
than  in  the  heart ;  and,  second,  that  the  ultimate  object  of  the  exami- 
nation is  to  determine  the  muscular  power  of  the  heart.  He  will  soon 
learn  that  with  that  power  intact  the  functions  can  be  performed,  not- 
withstanding the  presence  of  marked  physical  abnormalities. 

The  recognition  of  disease  of  the  heart  is  not  usually  attended  by 
much  difficulty,  except  in  some  special  lesions.  The  non-recognition 
of  cardiac  disease  is  due  to  faults  in  the  examination.  The  physician 
is  too  often  satisfied  with  the  recognition  of  the  remote  process,  as  a 
congestion  or  functional  weakness  in  some  organ.  Safety  lies,  as  has 
often  been  said,  in  the  examination  of  all  the  organs  of  the  body. 
Often,  for  instance,  indigestion  from  gastric  catarrh  is  not  relieved,  for 
the  cause,  mitral  regurgitation,  is  not  recognized. 

The  Data  Obtained  by  Inquiry. 

The  Social  History.  The  incidents  in  the  social  history  to  be 
considered  in  the  determination  of  the  presence  of  cardio-vascular  dis- 
ease are  those  which  notably  influence  by  strain,  excitement,  or  wear 
and  tear,  the  cardio-vascular  mechanism — those  which  alternately  in- 
crease and  diminish  cardiac  action,  open  and  shut,  dilate  and  contract 
peripheral  vessels.  Whether  it  be  symptoms  of  functional  disorder  or 
of  organic  disease  we  wish  to  unravel,  we  must  inquire  as  to  the  use 
of  stimulants,  of  tea,  coffee,  tobacco,  and  other  narcotics  or  poisons  ;  as 
to  mental  anxiety  or  physical  strain  ;  as  to  excesses  of  various  kinds. 
Excess  in  any  form  induces  vascular  wear  and  tear.  Tersely  put  by 
one  of  our  most  distinguished  clinicians,  the  devotee  at  the  shrine  of 
Venus,  Bacchus  or  Mars,  is  too  frequently  the  victim  of  vascular  dis- 
ease. Occupations  which  invoke  such  vascular  excitations  are  sugges- 
tive diagnostic  factors. 

The  age  in  which  we  are  wont  to  find  cardio-vascular  affections 
varies  with  the  character  of  the  lesion.  Apart  from  congenital  cardiac 
affections,  acute  inflammations  are  more  common  at  the  age  when  infec- 
tions are  more  operative,  as  in  the  early  decades.  On  the  other  hand, 
and  it  goes  without  saying,  degenerative  lesions  are  found  in  later  life. 
But  as  man  is  no  older  than  his  arteries,  and  as  these  degenerative 
lesions  may  occur  in  comparatively  early  life,  from  a  cardio-vascular 
stand-point,  a  man  may  be  senile  at  thirty-five  or  even  earlier.     Sex 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     5§3 

influences  diagnosis  in  so  much  as  the  one  sex  is  more  exposed  to  the 
causal  influences  of  cardiac  lesions.  Females  are  more  prone  to  acute 
infectious  processes  and  to  the  neuroses  from  immobile  nervous  systems. 
Males  to  degenerative  lesions  and  the  intoxication  neuroses. 

Family  History.  Inquiry  in  this  direction  yields  information  of 
great  diagnostic  value.  The  gouty  and  rheumatic  diatheses,  with 
their  long  train  of  associated  disorders,  which  predisposes  to  cardio- 
vascular affections,  are  notably  inherited.  Moreover,  the  tendency  to 
atheroma  of  vessels  is  itself  pronouncedly  hereditary. 

The  History  of  Previous  Disease.  The  occurrence  of  any  one 
of  the  numerous  infections  may  have  been  the  initial  step  in  the  pro- 
duction of  the  affections  we  are  considering.  The  determination  of 
the  nature  of  a  cardiac  lesion  may  hinge  upon  the  correct  decision  of 
this  question.  The  infection  of  acute  rheumatism  is  of  course  to  be 
eagerly  sought  for.  A  history  of  chorea,  of  various  skin  affections 
related  to  gout  and  rheumatism,  of  eye  affections,  of  tonsillitis,  of  other 
affections  related  to  the  so-called  uric-acid  diathesis,  must  be  sought 
for.     If  found,  such  history  is  more  than  suggestive. 

The  Subjective  Symptoms.  A.  Symptoms  Referred  to  the 
Heart.  Pain.  1.  In  Disease  Outside  of  the  Heart.  Although  pain 
in  the  region  of  the  heart  may  be  a  symptom  of  disease  of  that  organ 
or  of  the  pericardium,  in  the  large  majority  of  instances  it  is  due  to 
other  causes.  The  physician  is  frequently  consulted  by  the  anxious 
patient  on  account  of  pain,  other  than  heart-pain,  but  referred  to  this 
region,  or  more  precisely  to  the  fifth  or  sixth  interspace  on  the  left 
side.  The  causes  of  such  pain  are  various  :  (1)  Xeuralgia  ;  (2)  pleu- 
rodynia; (3)  myalgia;  (4)  local  pleurisy;  (5)  periostitis.  The  neu- 
ralgias may  be  associated  with  points  of  tenderness,  which  are  usually 
the  seat  of  the  greatest  intensity  of  the  pain.  These  points  of  tender- 
ness correspond  with  the  positions  at  which  the  nerves  have  their 
exit  through  the  fascia  to  the  surface,  and  are  found  along  the 
sternum,  in  the  course  of  the  mid-axilla,  and  along  the  vertebra?.  The 
pain  is  paroxysmal,  occurs  at  variable  periods  of  the  day,  and  in 
anaemic  subjects  or  in  the  course  of  neurasthenia.  It  may  precede  the 
development  of  herpes  zoster.  In  these  cases  the  exact  nature  of  the 
pain  is  not  known  until  the  eruption  appears.  In  gout  or  diabetes  we 
may  have  local  neuritis,  which  causes  neuralgic  pain  in  this  situation. 

Pleurodynia,  which  is  thought  to  be  an  affection  of  the  pleural 
nerves,  is  more  general.  The  pain  is  increased  by  pressure  of  the 
finger-tips,  although  it  is  not  localized.  It  is  relieved  by  pressure  of 
the  whole  hand.  In  myalgia,  which  is  seen  so  frequently  in  phthisis, 
on  account  of  severe  coughing,  in  rheumatism  and  in  debilitated  subjects 
generally,  the  pain  is  more  or  less  diffuse,  interferes  more  or  less  with 
movements  of  the  chest,  is  relieved  by  uniform  general  pressure,  and 
is  usually  associated  with  myalgia  in  other  organs.  The  pain  of  pleu- 
risy is  recognized  by  the  fact  that  it  usually  inhibits  the  act  of  breath- 
ing, and  is  associated  with  cough,  and  because  friction-sounds  may  be 
detected.  Periostitis.  In  disease  of  the  ribs  of  the  prrecordia  the  pain 
is  associated  with  tenderness  and  swelling.  One  or  more  of  the  costo- 
sternal  articulations  may  be  extremely  tender.     The  pain  and  tender- 


584  SPECIAL  DIAGNOSIS. 

ness  are  due  to  the  periostitis  of  syphilis  or  to  that  which  follows 
typhoid  fever.  In  one  of  my  cases  the  rib  had  to  be  resected.  It 
may  be  due  to  the  internal  pressure  and  erosion  of  ribs  in  aneurism. 
The  same  affection  may  cause  neuralgic  pains  in  the  nerves.  Abscess. 
Pain  in  this  region  may,  in  rare  instances,  be  due  to  localized  tuber- 
culous abscess  between  the  pericardium  and  the  walls  of  the  thorax. 
One  such  case  was  under  my  care.  The  abscess  developed  secondarily 
to  empyema  and  occupied  the  precordial  region,  causing  bulging. 
The  pain  was  intense,  and  was  only  relieved  after  the  caseating  pus 
wTas  removed  by  incision. 

Pain  in  the  epigastrium  is  often  held  to  be  due  to  cardiac  disease. 
It  is  usually  due  to  gastralgia,  or,  as  it  is  sometimes  termed,  cardial- 
gia.  It  is  recognized  by  the  location  of  the  pain  and  its  association 
with  gastric  symptoms,  as  flatulency,  weight,  fulness,  and  acidity.  In 
gastric  ulcer  the  epigastric  pain  is  localized,  accompanied  by  tender- 
ness on  pressure,  and  is  increased  by  food.  However,  acute,  severe, 
and  excruciating  pain  in  the  epigastrium  may  be  due  to  rupture  of  the 
heart  and  also  to  pericarditis. 

2.  In  Disease  of  the  Pericardium.  Pain  in  the  region  of  the  heart 
is  sometimes  clue  to  affections  of  the  pericardium.  Pericarditis  is  the 
most  common.  While  centralized  in  the  heart-region,  it  may  radiate 
to  the  left  shoulder  and  extend  down  the  arm.  It  is  paroxysmal  and 
may  have  some  of  the  characteristics  of  angina.  It  is  increased  by 
movement,  by  pressure,  and  by  the  action  of  the  diaphragm.  The 
patient  is  often  obliged  to  sit  up  in  bed  and  suffers  from  orthopncea. 
It  may  be  referred  to  the  epigastrium.  A  pericardial  friction-sound  is 
usually  detected.  Pain  due  to  disease  of  the  aorta.  Acute  inflammation 
of  the  aorta  is  also  the  cause  of  cardiac  pain.  The  pain  extends  along  the 
course  of  the  aorta,  may  be  referred  to  the  sternum,  and  extends  along 
the  spine.  The  pain  is  severe,  causing  an  anxious  countenance  and 
an  expression  of  extreme  suffering.  In  gouty  subjects  with  atheroma 
pain  may  occur  in  this  situation  in  paroxysms.  There  is  usually  val- 
vular disease  at  the  aortic  orifice.  Similar  pain  occurs  in  syphilis  and 
in  alcoholic  subjects,  and  may  be  due  to  malaria.  It  is  a  visceral 
neurosis,  or  a  form  of  neuralgia. 

Pain  in  the  region  of  the  heart  is  frequently  due  to  aneurism.  The 
pain  is  usually  due  to  pressure  of  the  aneurism  upon  adjacent  struc- 
tures. If  it  presses  on  the  bone  and  causes  erosion,  the  pain  is  of  a 
boring  character,  localized  at  one  point.  It  has  been  previously  re- 
ferred to.  In  aneurism  alone,  without  pressure,  the  pain  is  of  a  dull 
aching  character,  increased  by  movement,  relieved  by  rest,  or  by 
change  of  position.  When  nerves  are  pressed  upon,  pain  may  be  acute 
and  of  a  neuralgic  nature.  It  may  follow  the  course  of  the  nerves  and 
be  associated  with  numbness  or  sensations  of  tingling.  The  long  dura- 
tion of  the  pain,  its  localization,  and  its  aching  character  are  sufficient 
to  exclude  angina  pectoris.  When  the  pain  is  unilateral  it  may  be 
due  to  pressure  of  an  aneurism  upon  the  nerves  at  their  exit  from  the 
canal ;  the  pain  extends  along  the  course  of  the  intercostal  nerves.  It 
is  severe  and  burning,  but  there  are  no  localized  points  of  greater  in- 
tensity.    The  pain  may  extend  down  the  arms,  and,  when  the  abdomi- 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     585 

nal  aorta  is  affected,  it  may  extend  down  the  legs.  If  rupture  of  the 
aneurism  takes  place,  the  pain  is  sudden  and  sharp.  Death,  however, 
ensues  quickly,  so  that  the  pain  will  rarely  be  complained  of. 

3.  In  Disease  of  the  Heart.  Three  forms  are  seen  :  (1)  Pain  due  to 
disturbances  of  the  rhythm  ;  (2)  pain  due  to  valvular  disease  ;  (3)  pain 
due  to  angina  pectoris. 

Disturbance  of  the  Rhythm.  Palpitation,  intermission,  and  irregu- 
larity of  the  heart  occur  in  the  large  majority  of  cases  without  pain. 
Paroxysms  of  palpitation  are  sometimes  attended  with  severe  precor- 
dial pain  and  distress.  This  occurs  in  the  reflex  palpitation,  which, 
as  will  be  seen,  is  due  to  disease  in  other  situations  ;  in  the  palpitation 
of  Graves'  disease  and  of  anaemia.  The  palpitation  of  organic  disease 
is  induced  by  exertion.  The  rapid  action  of  the  heart  is  painful  and 
the  throbbing  is  complained  of  as  causing  distress. 

While  intermission  and  irregularity  may  continue  without  pain  at 
times,  the  patient  is  conscious  of  this  disturbance  of  the  rhythm,  and 
complains  of  the  stoppage,  which  then  is  attended  by  distress,  some- 
times amounting  to  severe  pain.  This  is  particularly  the  case  when 
the  heart-action  is  tumultuous,  as  the  disturbance  of  rhythm  seen  in 
pericarditis  and  in  valvular  disease. 

Pain  due  to  Valvular  Disease.  In  disease  of  the  aortic  valves  pain 
is  of  more  frequent  occurrence  than  in  other  valvular  lesions.  It  is 
usually  complained  of  in  the  region  of  the  aorta  at  the  base  of  the 
heart,  and  is  aggravated  by  exertion.     (See  Atheroma.) 

Pain  due  to  Angina  Pectoris.  Heberden  was  the  first  to  describe  the 
attacks  of  angina  pectoris,  which,  in  its  typical  form  and  in  association 
with  disease  of  the  heart,  is  not  of  common  occurrence.  The  pain  of 
angina  is  severe  and  is  associated  with  the  most  intense  anguish.  It 
comes  on  suddenly,  and  may  occur  in  paroxysms.  The  patient  real- 
izes that  the  pain  is  in  the  heart,  and  complains  of  feeling  as  if  the 
organ  Avere  held  in  a  vise.  From  the  heart  it  radiates  to  the  neck 
and  down  the  arms.  It  extends  particularly  to  the  left  arm,  and  may 
be  severe  in  the  wrist  or  in  the  ends  of  the  fingers.  With  the  pain 
there  is  a  sense  of  impending  death  with  sinking  and  depression.  The 
pain  lasts  but  a  few  seconds  or  minutes,  and  during  that  time  the  face 
of  the  patient  becomes  pale  or  of  an  ashy  hue,  perspiration  breaks  out 
on  the  forehead,  the  extremities  become  cold,  the  breathing  is  short. 
Prostration  usually  follows  the  attack,  but  the  precordial  distress  dis- 
appears entirely.  The  attack  may  occur  in  patients  who  are  entirely 
free  from  organic  disease  of  the  heart.  It  is  most  commonly,  however, 
associated  with  some  lesion.  The  lesions  frequently  found  are  disease 
of  the  coronary  arteries,  atheroma  of  the  aorta,  aortic  valvular  disease, 
and  myocarditis  with  fatty  degeneration.  It  occurs  after  middle  life, 
and  is  more  frequent  in  males.  It  may  occur  without  exciting/cause, 
or  follow  undue  exertion,  exposure  to  cold,  mental  excitement,  or  pro- 
found emotion. 

The  points  upon  which  the  diagnosis  is  based  are  :  1.  The  seat  of 
the  pain.  This  is  usually  behind  the  middle  or  the  lower  part  of  the 
sternum,  and  more  to  the  left  than  to  the  right.  Thence  it  extends  to 
the  posterior  portion  of  the  axilla  or  it  may  radiate  up  to  the  neck. 


586  SPECIAL  DIAGNOSIS. 

In  some  instances  it  extends  to  the  occiput.  Frequently  the  pain  ex- 
tends to  the  left  arm  as  far  as  the  elbow  or  even  the  fingers.  It  may 
extend  to  the  abdomen  or  to  the  right  arm.  I  have  seen  it  affect  both 
arms.  It  is  not  influenced  by  external  pressure.  2.  The  sense  of 
constriction  with  the  indescribable  torture  are  most  characteristic.  3. 
The  respirations  are  shallow,  or  may  even  cease,  but  there  is  no  dysp- 
noea. 4.  The  patient  is  terrified  and  restless.  5.  The  pale  face,  ex- 
tremely anxious  countenance,  the  cold  sweat  on  the  forehead,  make  a 
striking  picture,  which  when  once  seen  can  never  be  forgotten.  6. 
Such  extreme  depression  and  sensation  of  impending  death  occur  in  no 
other  affection.  Particularly  characteristic  is  the  immediate  relief, 
without  hysterical  manifestations  or  dyspeptic  symptoms  of  any  kind, 
which  follows  an  attack.  7.  During  the  attack  the  frequency  of  the 
pulse  is  not  much  influenced,  and  the  action  of -the  heart  may  be  uni- 
form and  regular.  Rarely  its  frequency  may  be  lessened.  The  tension 
of  the  pulse  is  increased  during  the  attack. 

Some  authors  speak  of  various  grades  of  angina,  and  call  all  forms  of 
precordial  pain  and  oppression,  with  radiation  of  the  pains  to  the  arms 
and  neck,  mild  forms  of  angiua.  Such  attacks  have  often  obvious 
causes  in  disturbance  of  digestion  and  in  emotional  excitement.  When 
associated  with  increased  arterial  tension  and  signs  of  arterio-sclerosis, 
they  may  be  of  an  anginoid  nature.  The  greatest  difficulty  exists  in 
distinguishing  them  from  true  angina.  Hysterical  or  pseudo-angina 
can  be  distinguished  only  with  extreme  difficulty.  It  occurs  much 
more  frequently  than  true  angina.  One  attack  seems  to  predispose  to 
others.  It  occurs  in  females  who  present  other  symptoms  of  hysteria. 
It  occurs  usually  before  forty  years  of  age.  The  attacks  most  fre- 
quently come  on  at  night,  and  may  be  periodical.  They  are  particu- 
larly associated  with  menstrual  disorders.  The  pain  is  less  severe  and 
the  oppression  is  not  so  marked  in  pseudo-angina  ;  coldness  of  the 
hands  and  feet,  with  the  occurrence  of  syncope,  or  a  general  feeling  of 
sinking,  are  common  symptoms.  The  pain  is  of  long  duration  and  is 
associated  with  great  agitation.  It  is  preceded  by  neuralgia,  and 
neuralgic  pains  persist  after  the  attack.  Low  tension,  feeble  second 
sound,  and  soft  arteries  may  be  present,  although  the  opposite  is  also 
seen.  The  disease  is  never  fatal.  In  one  of  my  patients  attacks  of 
hysterical  haemoptysis  alternated  with  the  anginal  attacks. 

Palpitation.  In  palpitation  the  patient  is  conscious  of  the  action 
of  the  heart.  Although  it  may  occur  in  organic  disease,  it  is  more 
frequently  due  to  disease  outside  of  the  heart. 

Symptoms.  The  symptoms  vary  in  degree.  In  mild  forms  the 
patients  may  complain  of  a  fluttering  or  a  sensation  of  sinking  in  the 
precordial  region.  In  the  more  severe  forms  the  heart  beats  violently 
against  the  chest.  The  arteries  throb,  the  action  of  the  heart  is  in- 
creased, and  the  area  of  impulse  against  the  chest-wall  is  enlarged  and 
visible.  The  patient  complains  of  distress  in  the  precordial  region. 
The  pulse  may  be  increased  to  150.  In  nervous  palpitation  the  face 
becomes  flushed,  and  after  the  attacks  large  quantities  of  urine  are 
passed.  Sometimes,  in  this  form  of  palpitation,  exertion  relieves  the 
attack.     On  examination,  the  sounds  are  found  to  be  normal,  but  they 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     587 

are  clear  and  metallic  in  character.  The  diastolic  sounds  are  greatly 
accentuated.  If  anaemia  is  present,  murmurs  due  to  that  condition 
are  increased  in  intensity.  The  attack  may  last  but  a  few  minutes  or 
continue  for  hours. 

(a)  It  is  most  common  in  cases  in  which  the  nervous  system  gener- 
ally is  in  a  state  of  increased  excitability.  Attacks  occur  at  puberty 
and  at  the  menopause.  It  is  very  common  in  hysteria  and  neuras- 
theniac   It  follows  emotional  disturbance.    It  is  more  frequent  in  women. 

(b)  It  is  due  to  the  action  of  the  toxic  substances,  as  tobacco,  tea  and 
coffee,  and  alcohol. 

(c)  From  strain  and  over-exertion,  particularly  if  associated  with  ex- 
citement, palpitation  may  occur  and  continue  for  a  long  period.  This 
is  the  form  of  irritable  heart  described  by  Da  Costa,  common  in  young 
soldiers  during  the  war. 

(d)  In  valvular  disease  of  the  heart  when  compensation  fails,  and 
in  myocarditis,  attacks  of  palpitation  occur,  distinctly  from  exertion. 

Intermission  and  Irregularity.  When  the  patient  feels  the  alter- 
ation in  rhythm,  it  is  usually  due  to  nervous  disturbance.  In  organic 
disease  it  is  not,  as  a  rule,  appreciated  by  the  patient.  Although  not 
a  subjective  symptom  alone,  it  may  be  well  to  speak  of  irregularity  in 
this  connection. 

■  Arrhythmia  is  the  general  term  applied  to  irregularity  of  the  action 
of  the  heart.  When  the  heart  intermits — that  is,  when  one  or  two 
beats  are  dropped  at  intervals  of  half  a  minute,  a  minute,  or  longer  ; 
when  the  beats  are  unequal  in  volume  and  force,  or  occur  at  unequal 
distances  in  time,  the  heart's  action  is  irregular.  The  causes  of  dis- 
turbance of  the  rhythm  have  been  classified  by  Baumgarten1  as  follows  : 

1.  Central  causes  in  the  medulla  either  from  organic  disease,  as 
hemorrhage  or  concussion,  or  from  physical  influences.  2.  Reflex 
influences,  as  in  dyspepsia  and  diseases  of  the  liver,  lungs,  and  kid- 
neys. 3.  Toxic  influences — tobacco,  coffee,  and  tea  are  common  causes  ; 
various  drugs,  such  as  digitalis,  belladonna,  and  aconite.  4.  Changes 
in  the  heart  itself.  Mural  changes,  as  in  dilatation,  fatty  degeneration, 
and  myocarditis  ;  changes  in  the  cardiac  ganglia ;  sclerosis  of  the  cor- 
onary arteries. 

It  must  not  be  forgotten  that  both  irregularity  and  intermittency 
may  occur  in  persons  otherwise  in  good  health,  and  continue  for  a  long 
period  of  time  without  any  evidence  of  arterial  or  cardiac  disease. 
(For  the  varieties  of  arrhythmia,  see  The  Pulse.) 

B.  Symptoms  Referred  to  the  Circulation.  1.  Pulsation  of 
the  Arteries.  Pulsation  of  the  arteries,  especially  the  carotids,  the 
abdominal  aorta,  and  the  brachial  arteries,  occurs  in  anaemia,  and  is 
common  in  emotional  disturbances.  Such  pulsation,  as  of  the  abdomi- 
nal aorta,  may  be  reflex  from  organic  disease  in  the  vicinity.  Similar 
localized  pulsation  in  the  innominate  arteries  may  be  mistaken  for 
aneurism.  The  pulsation  that  attends  organic  heart  disease  may  be 
due  to  hypertrophy  of  the  heart,  but  is  particularly  characteristic  of 
aortic  regurgitation. 

1  See  Transactions  of  the  Association  of  American  Physicians,  vol.  iii. 


588  SPECIAL  DIAGNOSIS. 

2.  Hemorrhages.  In  the  description  of  valvular  lesions  it  will 
be  seen  that  hemorrhages  from  the  lungs  occur  quite  frequently  in 
disease  of  the  mitral  valve.  The  hemorrhage  may  be  due  to  conges- 
tion, to  actual  rupture  of  the  vessels,  or  to  hemorrhagic  infarct.  (See 
Pulmonary  Hemorrhage.)  It  may  simulate  hemorrhage  due  to  tuber- 
culosis. 

3.  Cyanosis.  Cyanosis  is  a  symptom  of  common  occurrence  in  the 
course  of  organic  heart  disease. 

4.  Dropsy.  The  dropsy  of  heart  disease  occurs  after  failure  in 
compensation  in  the  course  of  valvular  disease,  and  in  dilatation  of 
the  heart.  It  may  disappear  entirely,  if  the  conditions  are  improved 
or  become  permanent  and  progressive.  In  general,  it  may  be  said  t< 
be  distinctly  a  phenomenon  of  mitral  regurgitation  and  secondary 
tricuspid  regurgitation.  It  occurs  in  a  lesser  degree  in  mitral  obstruc- 
tion, and  still  less  in  disease  at  the  aortic  orifice. 

C.  Symptoms  Referred  to  the  Luxgs.  The  chief  subjective 
symptom  is  dyspnoea.  Dyspnoea,  due  to  disease  of  the  heart,  is  clini- 
cally divided  into  (1)  dyspnoea  caused  or  increased  by  exertion  ;  (2) 
paroxysmal  dyspnoea ;  (3)  orthopnoea ;  (4)  rhythmical  dyspnoea,  or 
Cheyne-Stokes  respiration.  The  dyspnoea  of  effort  comes  on  after 
the  slightest  exertion.  In  paroxysmal  dyspnoea  the  attack  comes  on 
without  apparent  cause.  It  must  be  distinguished  from  the  paroxys- 
mal dyspnoea  of  uraemia,  asthma,  or  emphysema.  The  physical  signs  of 
lung  disease  usually  point  to  the  latter.  The  paroxysmal  dyspnoea  of 
heart  disease  is  attended  by  more  violent  efforts  in  breathing  than  the 
physical  state  of  the  lungs  admits,  and  the  difficulty  attends  both  in- 
spiration and  expiration.  Wheezing  is  not  so  marked  as  in  forms  of 
asthma.  There  is  some  obstruction  to  the  outgoing:  of  air  :  but,  on 
account  of  air-hunger,  all  the  efforts  of  the  patient  are  exerted  to  fill 
the  chest.  In  paroxysmal  dyspnoea  the  breathing  usually  becomes 
quiet  if  the  patient  is  placed  in  a  comfortable  position,  provided  there 
is  no  lung  or  pleural  complication.  The  position  does  not  modify  the 
severe  dyspnoea  of  asthma  or  emphysema.  Orthopnoea  has  been 
described  previously. 

Cough.  Cough  is  of  frequent  occurrence  in  heart  disease.  The 
causes  are  various.  It  may  be  due  to  pressure  upon  the  bronchus  or 
the  pneumogastric  nerves,  as  in  pericardial  effusion.  It  may  be  due 
to  the  passive  congestion  of  the  lungs  which  occurs  in  failing  compen- 
sation. If  hemorrhagic  infarcts  take  place,  cough  may  be  present.  It 
attends  the  bronchopneumonia  that  follows.  In  cough  from  pressure 
of  an  aneurism  a  metallic  brassy  sound  is  created.  (See  The  Larynx.) 
It  occurs  in  paroxysms,  and  may  be  associated  with  alterations  in  the 
voice.  It  may  result  in  the  expectoration  of  blood-tinged  sputum, 
which  may  be  due  to  the  gradual  rupture  of  the  aneurism. 

D.  Symptoms  Referred  to  the  Nervous  System.  The  symptoms 
are  usually  due  to  disturbance  of  the  cerebral  circulation,  because  either 
an  insufficient  quantity  of  blood  or  improperly  oxygenated  blood  is 
supplied  to  the  brain.  Vertigo,  faintness,  and  languor  are  complained 
of  in  the  first  instance.     Dulness,  stupor,  and  moderate  delirium  (car- 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     589 

bon-dioxicle  poisoning)  may  occur  in  the  later  stages  in  the  second 
instance.  In  the  course  of  organic  heart  disease  epilepsy  or  epileptiform 
convulsions  may  arise,  on  account  of  embolism  or  thrombosis.  Chorea 
is  of  common  occurrence,  and  apparently  of  the  same  cause  as  the 
heart  disease.  Coma  may  be  due  to  hemorrhage  into  the  brain,  to 
embolism,  or  to  thrombosis.  Hemorrhage  occurs  in  patients  in  whom 
there  are  usually  found  hypertrophy  of  the  left  ventricle,  atheroma  of 
the  arteries,  and  renal  disease.  Embolism  occurs  in  valvular  disease, 
particularly  in  aortic  regurgitation  and  mitral  obstruction.  We  may 
have  the  occurrence  of  paralysis  for  the  same  reason,  with  or  without 
coma.  The  Stokes-Adams  syndrome  of  vertigo,  syncope,  loss  of  con- 
sciousness, and  slow  pulse — pseudo-apoplexy — is  seen  in  myocarditis 
and  endarteritis. 

Thrombosis  in  the  course  of  heart  disease  is  usually  due  to  disease 
of  the  bloodvessels  rather  than  to  disease  of  the  heart  itself,  although  a 
weakening  of  the  heart,  as  in  dilatation,  is  a  factor  predisposing  to  the 
development  of  thrombosis. 

E.  Symptoms  Referred  to  the  Alimentary  Canal.  In  the 
course  of  organic  heart  disease  dyspepsia  and  forms  of  catarrhal  gastritis 
and  enteritis  are  of  common  occurrence.  Patients  complain  of  various 
forms  of  indigestion,  or  of  nausea  and  vomiting.  While  water-brash  and 
flatulence  are  caused  primarily  by  the  condition  of  the  heart,  they  may 
in  their  turn  cause  symptoms  of  palpitation  and  cardiac  distress.  These 
gastric  difficulties  are  more  particularly  seen  in  diseases  of  the  auriculo- 
ventricular  valves,  and  are  associated  with  congestion  and  secondary 
cirrhosis  of  the  abdominal  viscera. 

F.  Symptoms  Referred  to  the  Throat.  The  patient  may  com- 
plain of  pain  in  the  throat.  This  may  be  paroxysmal,  and  is  some- 
times said  to  be  due  to  angina  pectoris.  Hoarseness  or  modifications 
of  the  voice  are  occasional  symptoms  of  pericarditis.  They  are  of  fre- 
quent occurrence  in  the  course  of  aneurism  due  to  pressure  upon  the 
recurrent  laryngeal  nerves. 

G.  Symptoms  Referred  to  the  Kidneys.  The  kidneys  are  inti- 
mately related  with  the  heart  at  a  distant  point  in  the  circulation,  and 
are  frequently  the  seat  of  changes  due  primarily  to  disease  of  the  central 
organ  of  circulation.  The  changes  in  the  urine  will  be  referred  to 
again  ;  suffice  it  to  say,  that  in  the  course  of  mitral  and  tricuspid 
disease  and  dilatation,  scanty  urine,  of  high  color,  loaded  with  urates, 
containing  a  small  amount  of  albumin,  is  quite  common  and  indicative 
of  passive  congestion  of  the  kidney.  It  may  result  in  cyanotic  indura- 
tion or  interstitial  nephritis.  On  the  other  hand,  the  urine  may  be  of 
low  specific  gravity  and  pale  in  color.  There  may  or  ma}r  not  be 
traces  of  albumin.  The  change  is  due  to  a  granular,  contracted  kidney, 
which  is  associated  with  hypertrophy  of  the  left  ventricle  and  arterial 
sclerosis.  Bloody  urine  is  usually  due  to  renal  embolism  when  it  occurs 
suddenly  in  the  course  of  organic  heart  disease.  It  may  be  due  to 
the  emboli  that  are  found  in  septic  endocarditis.  Renal  disease  in  all 
forms  may  complicate  disease  of  the  heart.     (See  Kidney  Disease.) 

The  Subjective  Symptoms  of  Arterial  Disease.  The  patient 
may  have  symptoms  of  congestion  or  of  anaemia  of  the  brain.    Headache, 


590  SPECIAL  DIAGNOSIS. 

vertigo,  photophobia,  tinnitus,  and  paresthesia,  due  to  either  cause,  may 
prevail.  (See  also  Cerebral  Thrombosis.)  The  diseased  vessels  prevent 
the  blood  from  reaching  the  extremities,  hence  they  are  cold.  Pain  is 
common  only  when  atheroma  or  aneurism  is  present  (q.  v.).  Throbbing 
or  pulsation  is  complained  of.  It  may  be  a  striking  feature  of  hysteria 
and  neurasthenia.  The  abdominal  aorta  is  frequently  thus  affected. 
The  pulsation  may  be  constant  or  intermittent.  There  may  be  dys- 
peptic symptoms.  The  pulsation  of  the  carotids  may  cause  disagree- 
able sensations  in  the  head,  and  the  beating  transmitted  to  the  ear  be  a 
source  of  extreme  annovance. 


The  Data  Obtained  by  Observation. 

Before  describing  the  methods  of  observation  it  is  well  to  review 
some  of  the  facts  of  anatomy  and  physiology  essential  to  the  accuracy 
of  any  observations. 

Topographical  Anatomy.  (Plate  XIII.)  Outline  of  Heart 
on  Chest- wall.1 

To  have  a  general  idea  of  the  form  and  position  of  the  heart,  map 
its  outline  on  the  wall  of  the  chest  as  follows  : 

(a)  To  define  the  base— i.  e.,  the  part  to  which  its  great  vessels  are 
attached — draw  a  transverse  line  across  the  sternum,  corresponding 
with  the  upper  borders  of  the  third  costal  cartilages  ;  continue  the  line 
half  an  inch  to  the  right  of  the  sternum  and  one  inch  to  the  left. 

(b)  To  find  the  apex,  mark  a  point  about  two  inches  below  the  left 
nipple,  and  one  inch  to  its  sternal  side.  This  point  will  be"  between 
the  fifth  and  sixth  ribs. 

(c)  To  find  the  lower  border  (which  lies  on  the  central  tendon  of  the 
diaphragm),  draw  a  line,  slightly  curved  downward,  from  the  apex 
across  the  bottom  of  the  sternum  (not  the  ensiform  cartilage)  as  far 
as  its  right  edge. 

(d)  To  define  the  right  border  (formed  by  the  right  auricle),  continue 
the  last  line  upward  with  an  outward  curve,  so  as  to  join  the  right 
end  of  the  base. 

(e)  To  define  the  left  border  (formed  by  the  left  ventricle),  draw  a 
line  curving  to  the  left,  but  not  including  the  nipple,  from  the  left 
end  of  the  base  to  the  apex. 

Such  an  outline  shows  that  the  apex  of  the  heart  points  downward 
and  toward  the  left,  the  base  a  little  upward  and  toward  the  right ; 
that  the  greater  part  of  it  lies  in  the  left  half  of  the  chest,  and  that 
the  only  part  which  lies  to  the  right  of  the  sternum  is  the  right  auricle. 
A  needle  introduced  in  the  third,  fourth,  or  fifth  right  intercostal 
space  close  to  the  sternum  would  penetrate  the  lung  and  the  right 
auricle. 

A  needle  passed  through  the  first  intercostal  space  close  to  the  right 
side  of  the  sternum  would  pass  through  the  lung  and  enter  the  supe- 
rior vena  cava  above  the  pericardium. 

1  From  Holden :  Landmarks,  Medical  and  Surgical. 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     591 

The  best  definition  of  that  part  of  the  precordial  region  which  is 
less  resonant  on  percussion  was  given  by  Dr.  Latham  years  ago  in  his 
"  Clinical  Lectures."  "  Make  a  circle  of  two  inches  in  diameter  round 
a  point  midway  between  the  nipple  and  the  end  of  the  sternum.  This 
circle  will  define  sufficiently,  or  for  all  practical  purposes,  that  part 
of  the  heart  which  lies  immediately  behind  the  wall  of  the  chest  and 
is  not  covered  by  lung  or  pleura." 

Valves  of  the  Heart.  The  aortic  valve  lies  behind  the  third 
intercostal  space,  close  to  the  left  side  of  the  sternum. 

The  pulmonary  valve  lies  in  front  of  the  aortic  behind  the  junction 
of  the  third  costal  cartilage  with  the  sternum,  on  the  left  side. 

The  tricuspid  valve  lies  behind  the  middle  of  the  sternum,  about 
the  level  of  the  fourth  costal  cartilage. 

The  mitral  valve  (the  deepest  of  all)  lies  behind  the  third  intercostal 
space,  about  one  inch  to  the  left  of  the  sternum. 

Thus  these  valves  are  so  situated  that  the  mouth  of  an  ordinary- 
sized  stethoscope  will  cover  a  portion  of  them  all,  if  placed  over  the 
sternal  end  of  the  third  intercostal  space,  on  the  left  side.  All  are 
covered  by  a  thin  layer  of  lung  ;  therefore  we  hear  their  action  better 
when  the  breathing  is  for  a  moment  suspended. 

Physiology.  Action  of  the  Heart.  The  heart  beats — that  is,  alter- 
nately contracts  and  dilates  or  relaxes — 65  to  85  times  per  minute  in 
an  adult.  In  females,  the  frequency  varies  from  75  to  85  ;  in  males 
from  65  to  75.  With  each  beat,  blood  is  propelled  throughout  the 
vascular  channels  of  the  body,  and  drawn  from  them  to  the  heart- 
chamber.  The  first  effect  is  produced  by  the  contraction  of  the  heart, 
or  the  systole  ;  the  second  by  the  relaxation,  or  diastole.  Other  events, 
as  the  act  of  respiration,  contribute  to  the  completion  of  the  outflow 
and  inflow  of  blood,  particularly  to  the  latter. 

The  completion  of  the  act  of  contraction  and  the  act  of  dilatation 
make  up  one  revolution  of  cardiac  action,  or,  as  it  is  termed,  a  cycle. 

Events  of  the  Cardiac  Cycle.  The  following  events  make  up  the 
cardiac  cycle.  The  act  of  contraction  is  the  systolic  period  of  the 
cycle  ;  that  of  relaxation  is  the  diastolic  period.  During  the  systole 
(1)  the  ventricles  contract ;  (2)  the  auriculo-ventricular  valves  close  ; 
(3)  the  blood  is  propelled  from  the  ventricles  into  the  vessels,  the 
columns  of  blood  in  the  aorta  and  pulmonary  artery  receive  a  shock 
from  the  impact  of  the  new  volume  of  blood,  and  their  bulk  increases. 
The  movement  of  the  blood-wave  from  this  cause  and  from  the  con- 
traction of  the  large  vascular  trunks  produces  pulsation  of  the  periph- 
eral vessels,  which  is  known  as  the  pulse.  The  contraction  is  imme- 
diately followed  by  relaxation — the  diastole.  (1)  The  blood-columns 
in  the  aorta  and  in  the  pulmonary  artery  fall  back  upon  the  valves 
guarding  their  outlets,  the  aortic  and  pulmonary  valves.  At  the  same 
time  (2)  the  auricles  are  filled  by  the  blood  pouring  in  from  the  veins. 
(3)  The  auricular  muscles  contract  upon  the  blood  in  the  chamber, 
driving  it  into  the  ventricles. 

The  systolic  and  the  diastolic  periods  of  a  cardiac  cycle  are  nearly 
equal  in  the  length  of  time  occupied  in  their  occurrence.  The  systolic 
period  occurs  at  the  same  time,  or  is  synchronous  with  the  apex-beat 


592  SPECIAL  DIAGNOSIS. 

and  carotid  pulse,  and  precedes  by  a  fraction  of  a  second  the  radial 
pulse.  It  is  immediately  followed  by  the  diastolic  period,  which, 
therefore,  follows  the  carotid  and  radial  pulse. 

Inspection.  The  Heart.  The  Method  of  Examination.  The 
patient  should  be  stripped,  and  a  good  light  should  fall  directly,  as  well  as 
obliquely,  on  the  surface.  The  patient  can  be  examined  in  any  position, 
and  indeed  for  accuracy  should  be  examined  both  in  the  upright  and 
recumbent  postures.  This  is  particularly  true  when  the  pulse-rate  is 
taken  and  when  auscultation  is  practised.  The  sounds  vary  frequently 
in  different  positions.  Some  diagnostic  significance  is  attached  to 
these  variations.  It  is  necessary  sometimes  to  have  the  patient  lean 
forward,  to  bring  the  heart  into  more  immediate  contact  with  the 
chest- wall. 

The  examination  should  not  be  confined  to  the  heart  and  vessels. 
The  reader  will  remember  that  in  the  account  of  the  exterior  and 
of  local  areas  it  was  pointed  out  that  various  abnormal  conditions 
may  be  due  to  disease  of  the  heart.  In  the  examination,  therefore, 
of  a  case  of  suspected  heart  disease,  observation  is  made  of  the  gen- 
eral and  of  the  local  color,  as  of  the  lips,  the  fingers,  and  the  con- 
junctivas, to  determine  the  presence  of  cyanosis,  pallor,  or  jaundice ; 
of  the  feet,  to  discover  dropsy ;  the  face,  to  note  the  appearance  of 
the  countenance  ;  the  neck,  to  note  the  state  of  the  vessels ;  the  eyes, 
to  note  their  prominence  ;  the  thorax,  to  ascertain  the  presence  of 
dyspnoea. 

The  Pilecordia.  The  prsecordia  is  the  region  of  the  chest  which 
overlies  the  heart.  In  the  study  of  the  appearance  of  the  preecordia 
we  observe  :  1.  The  degree  of  prominence  or  swelling.  2.  The  impulse 
and  other  pulsations.     3.  The  interspaces.     4.  The  hue  of  the  surface. 

The  Prominence.  The  prsecordia  may  be  unduly  prominent  in 
children  who  have  had  rickets  and  possibly  some  cardiac  hypertrophy 
in  childhood.  It  persists  in  later  life.  The  ribs  as  well  as  the  soft 
tissues  are  prominent.  The  lower  end  of  the  sternum  may  project. 
Swelling  also  occurs  in  hypertrophy  or  dilated  hypertrophy  of  the 
heart,  in  pericardial  effusions,  localized  pleural  effusions  and  pointing 
empyema,  and  in  aneurisms  in  the  region  of  the  heart.  In  pericardial 
effusion  ribs  and  interspaces  project.  The  latter  are  full  or  even  with 
the  surface.  The  prominence  of  cardiac  disease  is  observed  between 
the  third  and  seventh  ribs  on  the  left  side,  and  extends  from  the  left 
nipple  to  the  sternum,  and  even  as  far  as  the  right  nipple.  The  dis- 
tance from  the  middle  of  the  sternum  to  the  mid-axilla  is  greater  on 
the  left  than  on  the  right  side.  Local  bulging  may  be  seen  at  the 
apex  in  cases  of  aneurism  of  the  heart. 

The  prascordia  may  be  sunken.  Old  pericarditis,  bat  more  fre- 
quently old  empyema,  causes  sinking  in  of  the  region.  It  may  be  a 
result  of  rickets  or  of  spinal  curvature. 

The  Impulse.  The  normal  impulse  is  that  portion  of  the  heart 
which  strikes  the  chest- wall,  and  is  improperly  known  as  the  apex-beat. 
It  is  evident  in  health  in  the  fifth  interspace  just  inside  of  the  mid- 
clavicular line.  It  can  readily  be  detected  by  inspection  with  a  good 
light,  in  patients  with  moderately  thick  chest-walls.     It  is  due  to  the 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     593 

impulse  of  the  right  ventricle,  three-fourths  of  an  inch  above  the  apex, 
against  the  chest-wall  when  the  heart  contracts,  and  hence  it  is  systolic 
in  time. 

Changes  of  Position  in  Health.  It  is  not  a  fixed  point  in 
health.  It  moves  with  the  movements  of  the  body,  and  hence,  when 
the  trunk  is  inclined  to  the  left,  the  impulse  falls  toward  the  left 
axilla  as  far  outward  as  the  mid-clavicular  line  or  even  beyond  that 
point.  It  moves  toward  the  right  and  downward  in  full  inspiration, 
or  may  disappear  entirely  toward  the  completion  of  that  act.  It  may 
not  be  observed  if  there  is  a  large  amount  of  subcutaneous  fat,  or  if 
the  mammary  gland  intervenes.  It  becomes  more  conspicuous  at  the 
end  of  expiration  or  when  the  body  is  inclined  forward.  In  children 
it  is  higher  (fourth  interspace)  and  more  to  the  left.  It  is  depressed 
in  old  people.  It  must  be  remembered  that  in  transposition  of  the 
viscera  the  position  of  the  impulse  is  changed. 

Change  of  Position  in  Disease.  The  apex-beat,  or  the  lowest 
point  of  impulse,  may  be  displaced  or  may  be  absent  entirely.-  These 
changes  are  due  either  to  (a)  disease  outside  of  the  pericardium,  to  (6) 
disease  within  the  pericardium,  or  to  (c)  disease  of  the  heart  itself. 

I.  Displaced  to  the  Left.  This  occurs  from  (a)  Alterations 
outside  of  the  Pericardium.  When  the  right  lung  is  the  seat  of  exten- 
sive compensatory  emphysema,  or  the  right  pleura  is  filled  by  a  large 
effusion,  the  impulse  is  displaced  to  the  left.  On  the  other  hand, 
fibroid  phthisis  of  the  apex  of  the  left  lung,  or  pleural  adhesions  which 
have  become  attached  to  the  pericardial  sac,  with,  probably,  coincident 
pericarditis,  pull  the  heart  to  the  left,  thereby  changing  the  position  of 
the  impulse.  In  disease  of  the  mediastinum  the  heart  is  pushed  down- 
ward and  toward  the  left.  An  aneurism,  an  abscess,  or  enlarged  glands 
in  this  situation  may  invade  the  normal  cardiac  territory  and  cause 
dislocation  of  the  heart. 

In  disease  of  the  abdomen  the  impulse  is  displaced.  If  the  liver 
and  spleen  are  enlarged,  or  the  abdomen  distended  by  ascites,  the 
diaphragm  is  raised,  and,  therefore,  also  the  heart.  The  impulse  is 
then  seen  to  the  left  of  the  normal  position,  and  may  be  one  or  two 
interspaces  higher  than  normal.  A  common  physical  change  in  the 
stomach — dilatation — is  a  frequent  source  of  displacement  of  the  im- 
pulse. The  dilatation  may  be  temporary  from  flatulency  or  may  be 
due  to  organic  disease. 

(b)  Alterations  within  the  Pericardium.  In  cases  of  pericardial 
effusion  the  impulse  is  shifted  to  the  left  and  upward.  It  is  seen  in 
the  fourth  and  even  as  high  as  the  third  interspace,  and  sometimes 
only  an  impulse  is  noted  in  the  second  interspace.  This,  however,  is 
not  the  true  apex.  Instead,  we  undoubtedly  see  in  pericardial  effu- 
sions the  impulse  of  the  right  auricle  and  the  conus  arteriosus  against 
the  chest-wall. 

(c)  Diseases  of  the  Heart.  The  impulse  is  diplaced  to  the  left  in 
dilatation  and  hypertrophy  of  the  heart.  In  the  latter  it  is  also  dis- 
placed downward.  It  may  be  as  low  as  the  sixth  or  seventh  interspace 
and  extend  as  far  to  the  left  as  the  anterior  axillary  or  the  mid-axil- 
lary line. 

38 


594  SPECIAL  DIAGNOSIS. 

II.  Displaced  to  the  Right,  (a)  Alterations  outside  of  the  Peri- 
cardium. The  heart  is  dislocated  to  the  right  in  left  pleural  effu- 
sion, and  in  emphysema  of  the  left  lung.  We  find,  moreover,  in 
pleural  contractions  and  fibroid  phthisis  of  the  right  lung  the  heart 
drawn  to  that  side.  Under  these  circumstances  the  impulse  is  noted 
either  in  the  epigastric  region,  along  the  margin  of  the  ribs,  or  even 

Fig.  152. 


Normal  and  abnormal  impulses. 
1.  Normal  position  of  impulse.    2.  Displacement  to  left  and  downward.    3.  Displacement  to  left 
and  upward.     4.  Impulse  from  enlarged  right  ventricle.     5.  Displacement  to  right.     6.  Dilated 
right  auricle.     7.  Displacement  in  fibroid  phthisis.     S.  Impulse  of  conns  arteriosus.    (Errata  : 
"8  "  should  he  in  2d  interspace  parasternal  line.)    9.  Fibroid  phthisis,  right  lung. 

to  the  right  nipple-line,  in  any  interspace  from  the  third  to  the  sixth, 
along  the  right  edge  of  the  sternum.  The  impulse  in  the  epigastric 
region  usually  represents  the  hypertrophied  right  ventricle,  which 
usually  attends  the  lung-changes  that  cause  displacement  of  the  apex- 
beat.  The  impulse  along  the  right  edge  of  the  sternum  may  be  the 
apex-beat,  or  the  right  auricle  and  the  right  ventricle  brought  in  appo- 
sition to  the  chest-wall  by  the  cardiac  dislocation.  The  apex  or  the  tip 
of  the  heart  is,  in  all  probability,  displaced  but  little  beyond  the  mid- 
sternal  line.  (6)  The  impulse  is  not  displaced  to  the  right  in  alter- 
ations within  the  pericardium,  or  (c)  in  disease  of  the  heart. 

III.  Absent.  Following  the  same  order,  we  find  that  the  impulse 
may  be  absent  entirely  in  (a)  disease  outside  the  pericardium,  on  account 
of  which  something  intervenes  between  the  heart  and  the  chest-wall. 
Hence,  in  emphysema  of  the  lungs  and  in  compensatory  emphysema 
of  the  left  lung  the  impulse  is  entirely  effaced  ;  in  (6)  disease  of  the 
pericardium  the  impulse  is  absent  when  there  is  large  effusion.  The 
absence  here  succeeds  the  dislocation  to  the  left,  and  with  its  efface- 
ment  the  impulse  in  the  second  and  third  interspaces  disappears.  In 
(c)  disease  of  the  heart  the  impulse  is  absent  when  the  heart  is  dimin- 
ished in  size,  as  in  atrophy,  or  in  myocarditis,  or  when  weakened  by 
fatty  degeneration  or  dilatation 

The  Extent  of  the  Impulse.  In  health  the  impulse  is  limited 
in  extent  to  about  one  square  inch.     The  area  of  impulse  may  be  in- 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     595 

creased  when  the  individual  leans  forward,  and  at  the  end  of  expira- 
tion. It  is  more  evident  when  the  chest-walls  are  thin,  and  less  when 
they  are  thick. 

Extent  in  Disease.  The  area  of  impulse  may  be  increased.  The 
causes  are :  (a)  Diseases  outside  of  the  pericardium.  The  area  is  in- 
creased in  chronic  phthisis  with  fibrous  adhesions,  and  in  pleural  adhe- 
sions when  the  lung  is  drawn  away  from  the  surface  of  the  heart.  It 
is  increased  when  the  heart  is  pushed  against  the  chest-wall,  as  in 
aneurism  or  in  diseases  of  the  mediastinum,  from  inflammation  or 
cancer,  or  other  mediastinal  growth.  The  impulse  is  seen  not  only  in 
the  third  and  fourth  interspaces,  but  also  as  high  as  the  second,  and  is 
not  limited  to  the  spaces  between  the  sternum  and  parasternal  lines, 
but  may  extend  beyond  the  mid-clavicular  line.  It  may  not  be  systolic  in 
time  only,  but  diastolic,  presystolic,  and  systolic,  and  have  the  appearance 
of  a  peristaltic  wave  from  base  to  apex.  The  time  coincides  not  only 
with  contraction  of  the  ventricles,  but  also  of  the  auricles,  and  of  the 
closure  of  the  semilunar  valves.  (b)  Disease  of  the  -pericardium  tends 
to  increase  the  area  of  impulse  if  moderate  effusion  is  present.  It  will 
be  seen  as  a  diffuse  wave  occupying  the  second,  third,  and  fourth  in- 
terspaces. It  is  also  increased  in  pericardial  adhesions,  without  increase 
in  strength,  (c)  Disease  of  the  heart.  The  heart  must  be  enlarged, 
and  hence  must  either  be  hypertrophied  or  dilated.  The  extent  of 
impulse  varies.  In  hypertrophy  the  impulse  may  be  communicated 
to  the  sternum,  so  that  the  lower  part  heaves  with  each  contraction. 
It  falls  below  the  fifth  interspace  and  toward  the  left,  particularly  if 
the  left  ventricle  is  the  seat  of  the  enlargement.  If  the  right  ventricle 
is  hypertrophied,  the  impulse  is  very  marked  in  the  third,  fourth,  fifth, 
sixth,  and  even  the  seventh  interspaces  near  the  termination  of  the 
cartilages,  or  in  the  epigastrium  along  the  border  of  the  ribs  of  the 
left  side.  It  may  be  seen  in  ansemia  in  this  situation,  particularly  in 
persons  whose  respirations  are  habitually  shallow.  Sometimes,  when 
associated  with  and  displaced  by  lung  disease,  it  is  seen  to  the  right 
of  the  xiphoid  cartilage. 

New  Impulse.  New  areas  of  impulse,  the  heart  not  dislocated, 
arise  from  enlargement  of  one  of  the  cardiac  chambers  or  from  disease 
of  the  bloodvessels.  A  new  area  of  impulse  in  the  second  or  third 
interspace  on  the  left  is  from  the  conus  arteriosus,  or  is  due  to  hyper- 
trophy and  dilatation  of  the  right  ventricle  ;  or  it  may  be  due  to 
retraction  of  the  lung  in  that  region.  It  may  be  due  to  a  dilated  right 
auricle,  and  is  then  seen  in  the  fifth  right  interspace  along  the  sternum. 
If  the  impulse  is  noted  in  the  course  of  or  adjacent  to  the  aorta,  it  is 
indicative  of  aneurism. 

The  INTERSPACES.  They  are  retracted  possibly  from  pericardial 
adhesions  ;  they  are  full  or  bulging  in  effusion.  This  retraction  may  be 
limited  to  the  apex  or  may  occur  in  each  interspace  over  the  precordial 
region.  It  may  occur  with  the  systole  or  with  the  diastole.  It  may 
occur  in  hypertrophy  of  the  heart,  and  is  then  systolic  in  time.  It  is 
of  some,  although  doubtful,  diagnostic  significance  when  it  is  systolic 
in  time,  as  it  is  said  to  indicate  adhesions  of  the  pericardium.  The 
traction  at  the  systole  of  the  heart  causes  the  interspaces  to  be  drawn  in. 


596  SPECIAL  DIAGNOSIS. 

On  inspection  behind,  a  systolic  retraction  of  the  interspaces  is  seen 
in  adherent  pericardium,  known  as  Broadbent's  sign. 

Color  of  Surface.  Only  when  purulent  pericardial  effusion  is 
about  to  rupture,  or  an  empyema  to  discharge,  do  we  note  redness  or 
other  change  in  hue  of  the  surface  of  the  prsecordia,  not  observed  over 
the  remainder  of  the  thoracic  surface. 

The  Arteries.  By  inspection  we  may  be  able  to  determine  pulsa- 
tion or  any  undue  swelling  or  other  change  in  the  course  of  the  vessels. 
With  the  exception  of  pulsation  in  the  carotids,  which  may  temporarily 
increase  under  excitement,  pulsation  of  the  vessels  is  not  usualy  seen 
in  health.  In  old  people  we  can  see  the  pulsation  of  the  aorta  (rarely) 
at  the  episternal  notch,  and  often  in  others,  the  temporals,  the  innomi- 
nate, the  carotids,  the  subclavians,  the  brachial  and  radial  arteries,  the 
abdominal  aorta  in  thin  subjects,  the  femoral  arteries  and  the  posterior 
tibials. 

The  Arteries  in  the  Neck.  Temporary  pulsation  of  the  carotid 
arteries  from  excitement  has  been  mentioned.  It  is  commonly  seen 
in  anosmia,  and  is  quite  marked  in  exophthalmic  goitre.  It  is  striking  in 
aortic  regurgitation.  It  often  attends  the  vascular  changes  of  old  age. 
It  may  be  due  to  atheroma  or  aneurism.  It  is  always  suggestive  of 
aortic  valvular  disease.  The  innominate  artery,  as  well  as  the  carotids, 
often  pulsates  visibly  in  the  neck,  and  may  be  so  large  as  to  simulate 
aneurism.  The  subclavians  may  pulsate  for  the  same  reasons ;  they 
may  also  be  seen  to  pulsate  if  the  lungs  are  consolidated  or  shrunken 
by  disease.  If  the  patient  is  young,  the  throbbing  is  more  likely  to  be 
of  neurosal  or  hsemic  origin.  In  later  life,  if  such  pulsation  is  asso- 
ciated with  a  more  or  less  defined  swelling  or  tumor,  with  other  phys- 
ical signs  of  aneurism,  that  disease  is  doubtless  present. 

The  Thoracic  Aorta.  An  impulse  of  the  thoracic  aorta  is  usually 
from  aneurism.  The  pulsation  is  not  always  due  to  disease.  The  aorta 
may  be  pushed  against  the  chest-wall,  or  the  lung-structure  which  over- 
laps it  normally  may  be  withdrawn. 

Tumor.  An  enlargement  or  swelling  in  the  course  of  the  aorta  may 
be  due  to  aneurism  of  that  vessel.  It  must  be  distinguished  from 
the  tumor  of  mediastinal  disease,  and  of  empyema. 

The  Abdominal  Aorta.  Pulsation  of  the  abdominal  aorta  is 
often  the  cause  of  serious  distress.  The  violent  throbbing  keeps  the 
patient  awake  at  night,  and  makes  him  more  and  more  nervous  and 
irritable.  The  pulsation  is  usually  seen  in  the  epigastrium.  It  is 
more  frequent  when  the  vessel  is  not  diseased,  in  neurasthenic  subjects. 
It  occurs  reflexly  in  patients  with  dyspepsia  or  organic  disease  in  the 
tipper  abdominal  tract.  The  shock  of  the  pulsation  is  transmitted  to 
the  hand  with  considerable  violence.  The  impulse  is  diffused,  but 
not  expansile. 

Epigastric  pulsation  also  may  be  due  to  the  transmission  of  the  im- 
pulse of  the  aorta  by  enlargement  of  the  pancreas,  or  tumors  of  the 
stomach  or  the  omentum.  The  transmitted  pulsation  is  distinct.  The 
impulse  is  a  transmitted  one  when  the  tumor  can  be  defined  and  when 
a  sensation  of  lifting  is  transmitted  to  the  hand.  The  physical  signs 
of  ansurism  are  absent.     If  the  patient  lies  on  the  abdomen,  or  in  the 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     597 

knee-chest  position,  the  tumor  falls  away  from  the  aorta,  and  the  im- 
pulse is  not  readily  transmitted.  Epigastric  pulsation  is  also  caused 
by  aneurism  of  the  abdominal  aorta.  The  pulsation  is  distensile  or 
expansile,  and  the  aneurismal  sac  can  be  denned  at  times.  The  other 
physical  signs  of  aneurism  are  usually  present — namely,  thrill,  dulness 
over  the  tumor,  a  murmur  on  auscultation.  In  these  conditions,  how- 
ever, we  cannot  always  rely  on  the  physical  signs  alone  ;  the  history 
of  the  subjective  symptoms  and  of  disease  of  other  structures  must  be 
carefully  inquired  into.  Aneurism  rarely  occurs  without  some  evi- 
dence of  arterial  sclerosis  or  some  physical  effect  upon  the  circulation. 
Accentuation  of  the  aortic  second  sound,  variations  in  the  femoral 
pulse,  high  arterial  tension,  and  the  usual  evidences  of  sclerosis  favor 
aneurism.  While  functional  epigastric  pulsation  usually  occurs  in 
neurotic  subjects,  and,  hence,  in  the  earlier  periods  of  life,  yet  such 
pulsation  is  frequently  seen  at  the  climacteric  and  in  the  neurasthenia  of 
old  age.  Late  in  life,  with  such  impulse,  fibrous  thickening  about 
the  pylorus,  or  contraction  of  the  omentum,  may  easily  be  confounded 
with  malignant  disease.  Cancer  of  the  stomach  has  been  diagnosticated 
under  these  circumstances  when  the  pulsation  was  simply  reflex  from 
chronic  gastritis.  Some  time  ago  a  private  patient  in  the  Presbyterian 
Hospital  had  extreme  pulsation  of  the  abdominal  aorta,  with  great 
local  discomfort,  on  account  of  the  throbbing.  She  was  sixty-five  years 
of  age,  and  had  within  the  past  two  years  nursed  her  son  through 
tuberculosis.  She  failed  in  health,  and  came  to  the  hospital  emaciated, 
with  some  chronic  gastritis  and  diarrhoea.  On  examination,  a  distinct 
tumor  was  felt  above  the  umbilicus,  which  she  had  been  told  was  due 
to  carcinoma.  It  was  hard  and  painless  ;  the  physical  signs  of  aneurism 
were  not  present ;  the  pulsation  was  extreme.  A  second  tumor,  not  so 
large,  was  felt  in  the  right  hypochondriac  region.  Both  tumors  were 
dull  upon  percussion  and  surrounded  by  tympanitic  areas.  They  were 
also  movable.  While  it  was  impossible  to  be  sure  of  the  nature  of  the 
tumors,  it  seemed  to  me  they  were  tuberculous,  or  simply  fibrous,  and 
would  not  influence  the  patient's  immediate  welfare.  Under  treat- 
ment, the  pulsation  disappeared  ;  the  gastro-intestinal  symptoms  were 
relieved  entirely  ;  the  patient  rapidly  gained  in  weight  and  strength  ; 
the  tumors  continued,  but  they  are  not  so  distinctly  outlined  because 
the  previously  scaphoid  abdomen  has  become  distended  (two  years 
under  observation).  The  questions  arose  for  decision  :  Was  the  epi- 
gastric pulsation  due  to  a  throbbing  aorta  or  transmitted  by  an  ob- 
scurely defined  probable  tuberculous  mass  in  that  region  ?  No  doubt 
it  was  the  vessel  alone  that  caused  the  impulse.  The  diagnosis  must 
be  made  by  carefully  weighing  all  concomitant  circumstances  and  phe- 
nomena that  surround  cancer.  (See  Symptomatology  of  Morbid  Pro- 
cesses.) Fecal  accumulations  in  the  colon  may  be  made  to  heave  by 
the  beat  of  the  aorta  and  cause  exaggerated  epigastric  impulse.  The 
bowels  must  be  emptied  before  definite  conclusions  are  arrived  at. 

An  epigastric  impulse  due  to  one  of  the  above-mentioned  causes 
must  not  be  confounded  with  the  impulse  of  hypertrophy  of  the  right 
ventricle,  or  to  the  shock  of  the  hypcrtrophicd  heart  transmitted  to 
the  left  lobe  of  the  liver.     In  hypertrophy  of  the  right  ventricle  or 


598  SPECIAL  DIAGNOSIS. 

dislocation  of  the  heart  from  disease  within  the  chest,  the  impulse  may 
be  seen  to  the  right  or  left  of  the  xiphoid  cartilage.  The  symptoms 
and  signs  of  right-ventricle  hypertrophy  explain  the  pulsation. 

The  Smaller  Arteries.  By  inspection  of  the  arteries  beyond 
the  abdominal  aorta  we  can  often  recognize  more  distinctly  the  condi- 
tion known  as  arterio-sclerosis.  Examination  of  the  femoral,  poplit- 
eal, tibial,  brachial,  and  radial  arteries  reveals  dilated,  tortuous,  hard, 
often  pulsating  vessels  in  endarteritis.  Elongation  of  the  artery,  so 
that  instead  of  a  straight  tube  it  becomes  a  sinuous  canal,  turning 
and  twisting  at  short  intervals,  is  seen.  (See  Arterio-sclerosis.)  But 
pulsation  of  the  above-mentioned  peripheral  arteries  may  be  due  to 
other  causes.  In  hypertrophy  of  the  left  ventricle  arterial  pulsation 
is  prominent,  although  more  marked  in  the  vessels  near  the  heart,  as 
the  carotids.  In  regurgitation  at  the  aortic  orifice,  pulsation  is  also 
frequently  seen. 

Capillaey  Pulse.  The  capillary  pulse  is  seen  under  the  finger- 
nails or  in  the  skin  after  hyperemia  is  induced  by  firmly  stroking  the 
skin  with  the  nail.  It  may  be  seen  inside  the  lips,  if  a  piece  of  glass  is 
pressed  against  them.  There  is  rhythmical  pulsation  of  the  capillaries, 
from  which  the  surface  becomes  alternately  white  and  red.  It  is  a 
sign  of  aortic  insufficiency. 

The  Veins.  Diseases  of  the  veins  are  largely  surgical  and  do  not 
frequently  come  under  the  notice  of  the  physician.  Alterations  in  the 
veins  from  physical  causes  in  the  circulation,  local  or  general,  are  of 
frequent  occurrence,  and  are  of  the  greatest  diagnostic  significance. 
The  "  venous  phenomena  "  are  physiological  and  pathological  evidences 
of  the  circulation  of  the  blood  in  the  veins. 

Examination  is  limited  largely  to  the  jugular  veins  in  general  affec- 
tions of  the  circulation  ;  to  other  subcutaneous  veins  in  addition  in 
local  affections.  The  examination  is  made  by  inspection,  to  determine 
the  size  and  degree  of  pulsation  of  the  veins  ;  by  palpation,  to  confirm 
the  results  of  inspection  and  to  determine  the  presence  of  a  thrill ;  by 
auscultation,  to  determine  the  presence  of  murmurs. 

By  inspection  we  note  the  presence  of  :  A.  Enlargement  of  the  veins. 
The  change  in  size  may  be  general  or  local.  In  both  instances  there 
is  interference  with  the  venous  return  of  blood. 

1.  General  enlargements  may  be  observed  in  all  the  veins,  but 
is  more  readily  studied  in  the  jugular  veins  of  the  neck.  Associated 
with  the  enlargement,  general  venous  engorgement  is  observed,  and 
hence  oedema  (which  obscures  external  veins),  cyanosis,  effusions  in 
serous  cavities,  and  congestion  of  internal  organs  attend  the  pathologi- 
cal venous  phenomena.  It  must  follow  that  a  central  disturbing  influ- 
ence upon  the  circulation  is  present,  and  so  we  find  interference  with 
the  circulation  in  the  right  heart  to  be  the  causal  factor.  This  inter- 
ference is  due  to  dilatation  of  the  right  auricle  and  ventricle,  which  in 
turn  may  have  arisen  from  valvulitis,  myocarditis,  pericarditis,  or,  on 
account  of  increased  pulmonic  blood-pressure,  from  emphysema  and 
other  pulmonary  obstructions.  In  rare  instances  pressure  upon  the 
cavse  by  a  mediastinal  tumor  may  cause  general  over-fulness  of  the 
veins. 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.    599 

The  jugular  veins,  both  internal  and  external,  are  seen  to  be  dis- 
tended, even  in  stout  people.  The  observation  can  better  be  made  by 
viewing  the  head  when  it  is  turned  to  the  opposite  side  from  the  vein 
which  is  under  examination.  The  external  jugular  can  almost  always 
be  seen;  the  internal  jugular  frequently  when  engorged.  They  may 
also  be  felt  under  these  circumstances.  The  position  of  the  veins  can 
be  more  readily  distinguished  by  observing  their  relation  to  the  sterno- 
cleido-mastoid  muscle.  The  internal  jugular  vein  is  seen  in  the  inter- 
sterno-cleido-mastoid  fossa,  just  behind  the  sterno-clavicular  articula- 
tion. Here  the  jugular  bulb  is  seen,  and  at  this  point  in  the  veins 
the  bulbar  valves  are  situated.  When  abnormally  full  it  may  project 
beyond  the  surface  and  rise  one-fourth  or  one-half  inch  above  the 
articulation.  The  over-fulness  is  more  marked  in  the  dorsal  than  in 
the  upright  posture. 

Local  Enlargements.  Local  increase  in  fulness  of  the  veins  is  due 
to  narrowing  or  closure  of  the  venous  trunk  by  pressure  or  by  throm- 
bosis. A  mediastinal  tumor  pressing  upon  the  cava  will  cause  abnor- 
mal fulness  of  the  jugulars.  The  veins  of  the  scalp  become  distended 
and  tortuous  in  thrombosis  of  the  longitudinal  sinus.  Enlargement 
of  the  veins  of  the  arm  or  leg  points  to  compression  or  thrombosis 
of  the  axillary  or  femoral  vein  respectively.  The  enlargement  is 
associated  with  oedema  of  the  respective  extremity.  Enlargement  of 
the  superficial  veins  of  the  thorax  is  seen  in  intrathoracic  pressure 
from  tumor  or  aneurism,  rarely  in  dilatation  of  the  heart.  En- 
largement of  the  veins  of  both  legs  may  be  due  to  obstruction  of 
the  vena  cava  or  both  iliac  veins.  The  latter  is  liable  to  occur  in 
pelvic  tumors.  When  there  is  engorgement  of  the  portal  vein  collat- 
eral circulation  is  frequently  carried  on  through  the  abdominal  veins. 
The  veins  are  enlarged  ;  and,  in  some  instances,  the  veins  about  the 
navel  enormously  distended,  because  of  a  permanent  patulous  umbilical 
vein.  The  crown  of  veins — caput  Medusa — is  significant  of  cirrhosis 
of  the  liver  and  of  pyelo-thrombosis.  Enlargement  of  the  veins  of 
the  extremities,  from  the  causes  above  mentioned,  must  not  be  con- 
founded with  the  unilateral  or  bilateral  varicosity  that  occurs  during 
and  after  pregnancy,  after  prolonged  intra-abdominal  pressure  from 
other  causes,  or  in  inflammation  of  the  veins  in  the  course  of  septic 
diseases,  as  typhoid  fever. 

B.  Pulsation  of  the  veins.  The  circulation  in  the  veins  differs  from 
that  in  the  arteries.  The  blood-flow  is  continuous.  Two  circumstances 
modify  it — respiratory  movements  and  cardiac  action. 

Pulsation  due  to  Respiratory  Movements.  The  modification  is  par- 
ticularly seen  in  the  veins  of  the  neck.  During  inspiration  all  of  the 
veins  empty  rapidly,  while  in  forced  expiration,  or  with  strong  effort, 
as  seen  in  coughing,  the  discharge  from  the  veins  is  checked  and 
they  become  full  and  even  over-distended.  When  the  fulness  of  the 
veins  is  normal  the  respiratory  alterations  are  not  observed,  except 
the  swelling  that  occurs  in  severe  coughing,  as  in  whooping-cough. 
When  they  arc  abnormal,  as  from  right-sided  cardiac  dilatation  (q.  v.), 
they  show  a  corresponding  to-and-fro  swelling  synchronous  with  respi- 
ratory movements.     Upon  coughing,  the  jugular  bulb  may  appear  as 


600  SPECIAL  DIAGNOSIS. 

a  rounded  pulsating  bunch  between  the  heads  of  the  sterno-mastoid 
muscle.  The  internal  jugular  may  also  swell  and  contract.  Increased 
pulsation  with  fulness  of  the  veins  is  seen  during  the  labored  expira- 
tion of  asthma  and  emphysema. 

Alteration  of  the  respiratory  movements  of  the  veins  is  observed  in 
cases  of  pericarditis  or  of  mediastino-pericarditis.  Normally  the  vessels 
are  drawn  upon  and  bent  during  the  act  of  inspiration — inspiratory 
collapse.  In  the  above  pathological  conditions  they  swell  up  in  inspira- 
tion and  empty  during  expiration,  directly  opposite  to  the  normal  state. 

Pulsation  due  to  Cardiac  Movements.  The  Venous  Pulse.  The  car- 
diac movements  also  modify  the  movements  of  the  blood  in  the  veins. 
They  cause  rhythmical  pulsation,  or  the  venous  pulse.  This  may  be 
communicated  from  the  carotids  underneath  or  occur  in  the  veins. 
The  so-called  true  avid  false  pulses  are  thus  produced.  The  true  venous 
pulse  is  divided  into  the  (1)  negative  and  (2)  positive  pulse,  the  former 
being  the  pulse  of  health,  the  latter  the  pathological  venous  pulse. 

1.  The  normal  or  negative  venous  pulse  is  so  designated  because  it  is 
not  due  to  positive  action  of  the  heart,  causing  retrogression  of  blood. 
It  can  be  demonstrated  by  pressure  of  the  finger  on  the  middle  of  the 
veins.  Pulsation  ceases  below  because  the  blood  does  not  regurgitate 
from  the  heart ;  it  does  not  pulsate  above,  or  the  pulsation  lessens 
materially,  indicating  non-transmission  from  the  carotid.  The  negative 
venous  pulse  is  presystolic  in  time,  and  can  only  be  seen  in  the  external 
jugulars.  The  vein  collapses  during  the  systole  and  distends  or  pul- 
sates before  the  systole,  hence  is  presystolic.  This  may  be  observed 
by  inspection,  keeping  in  view  also  at  the  same  time  the  apex  or 
carotid  pulse.  The  systolic  collapse  occurs  quickly.  The  presystolic 
pulsation  follows  slowly,  with  an  appreciable  interval  between  the 
two.  The  presystolic  distention  occurs  during  the  time  that  the  auri- 
cle is  filled  with  blood  ;  the  collapse  occurs  when  the  auricle  is  empty 
— that  is,  during  the  ventricular  systole.  When  the  auricle  is  dis- 
tended the  flow  of  blood  from  the  veins  is  impeded,  and  hence  the 
jugulars  are  overfilled.  "When  the  auricle  is  empty  the  flow  of  blood 
from  the  veins  is  favored,  hence  the  vein  collapses  (the  systole). 

Diagnosis  It  may  be  distinguished  from  pulsation  in  the  artery 
by  the  time,  by  the  greater  size  of  the  surface-pulsation  on  account 
of  the  greater  size  of  the  vein,  by  the  impression  of  undulation  rather 
than  shock  received  by  the  finger,  by  the  impression  of  passive  force 
rather  than  of  active  power.  Sometimes  it  is  extremely  difficult  to 
recognize  the  normal  or  negative  venous  pulse  on  account  of  undula- 
tions in  the  veins  produced  by  the  blood-flow  and  transmitted  carotid 
impulse. 

2.  The  positive  venous  pidse  is  systolic  in  time.  It  is  due  to  positive 
action  of  the  heart.  It  is  pathognomonic  of  tricuspid  regurgitation 
(q.  v.).  When  the  right  ventricle  contracts  the  regurgitant  blood- 
wave  is  transmitted  into  the  cava  through  the  incompetent  valves. 
It  appears  first  in  the  internal  jugulars  or  their  bulbs,  because  of  the 
direct  course  of  the  innominate  and  right  jugular  from  the  cava.  Sub- 
sequently the  left  may  become  affected.  If  the  valve  in  the  vein  is 
competent,  the  systolic  regurgitant  wave  is  seen  there  only.     The  pul- 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     601 

sation  of  the  enlarged  bulb  is  seen  in  the  inter-sterno-cleido-mastoid 
fossa.  Usually  the  valve  is  insufficient,  or  rapidly  becomes  so,  and 
the  systolic  back-wave  therefore  extends  upward.  The  same  wave  is 
transmitted  to  the  viens  of  the  liver,  causing  systolic  swelling  and  dias- 
tolic collapse  of  the  liver.  These  conditions  are  produced,  as  pre- 
viously mentioned,  in  right-sided  dilatation  of  the  heart,  providing 
there  are  moderate  force  and  slowness  of  the  heart's  action.  When 
the  heart  becomes  very  weak  and  rapid  the  pulsations  disappear. 

Diagnosis  1.  The  negative,  true,  or  normal  pulse  is  distinguished 
from  the  pathological  or  positive  pulse,  and  from  the  transmitted  pul- 
sation, by  its  time.  It  is  timed  by  the  apex-beat,  or  the  carotid  pulse 
of  the  opposite  side.  The  negative  pulse  (normal)  is  presystolic,  the 
collapse  of  the  vein  systolic  ;  the  positive  pulse  (pathological)  is  sys- 
tolic in  time.  The  patient  should  hold  his  breath,  as  increased  respi- 
ratory movement  will  modify  the  venous  pulsation.  2.  The  imparted 
or  false  puke  is  transmitted  from  the  carotids,  and  can  be  recognized 
by  stopping  the  flow  of  blood  by  pressing  the  finger  or  barrel  of  the 
stethoscope  on  the  vein  in  the  middle  of  the  neck,  after  it  has  been 
emptied  by  pressure  upward.  If  the  pulsation  is  communicated  (false 
pulse),  the  vein  remains  empty  in  the  portion  nearest  the  heart,  and 
fills  up  in  the  peripheral  portion,  while  the  pulsation  ceases  toward  the 
centre  (below)  and  increases  in  the  periphery  (above  the  finger).  If 
the  carotid  artery  is  pressed  upon  as  near  the  heart  as  possible,  the 
transmitted  pulse  will  cease.  In  the  positive  pulse  the  portion  near 
the  heart  slowly  fills  from  below  upward. 

In  congenital  heart  disease  with  patulous  foramen  ovale  the  positive 
venous  pulse  may  sometimes  be  seen,  but  is  extremely  rare. 

Diastolic  collapse  is  seen  in  pericarditis,  as  observed  by  Friedreich. 
The  collapse  occurs  at  the  time  of  the  cardiac  diastole.  It  is  distin- 
guished from  the  true  pulse  as  follows  :  compress  the  jugular  vein, 
pulsation  ceases  above  and  below  the  seat  of  compression. 

Pulsation  of  other  veins.  Quincke  has  described  venous  pulse  in 
the  hand  and  back  of  the  foot,  with  the  capillary  pulse  in  aortic  re- 
gurgitation and  in  anaemia.  It  is  probably  only  the  arterial  pulse 
propagated  through  the  capillaries.  The  positive  pulse  may  be  seen 
in  the  veins  of  the  face,  in  the  cutaneous  veins  of  the  arm  and  hand, 
and  in  the  superficial  mammary  veins,  and  in  the  veins  of  the  legs. 

Palpation.  The  Heart.  Palpation  confirms  inspection  as  to  the 
shape  of  the  prsecordia,  the  position  and  the  extent  of  the  impulse,  and 
the  condition  of  the  intercostal  spaces.  In  addition,  we  determine  by 
palpation  the  character  and  strength  of  the  impulse,  and  the  presence 
or  absence  of  valv&shock  and  of  thrills  or  of  friction.  Palpation  also 
reveals  oedema  of  the  surface  and  fluctuation. 

The  [mpulse.  In  a  normal  chest  with  moderate  walls  a,  slightly 
prolonged,  moderately  strong  shock  is  transmitted  to  the  hand  when 
placed  over  the  pra?cordia.  It  is  synchronous  with  the  cardiac  and 
precedes  the  radial  pulse.  It  is,  therefore,  systolic  in  time.  It  is 
stronger  when  the  patient  leans  forward,  exhales  freely,  removing  the 
lung  from  the  surface,  and  when  the  chest-walls  arc  thin  ;  it  is  weaker 
in  opposite  conditions. 


602  SPECIAL  DIAGNOSIS. 

Character  and  Strength  of  Impulse.  A.  Strength  increased.  1. 
Overaction.  In  the  violent  action  of  the  heart  that  attends  palpita- 
tion, and  in  the  increased  action  in  the  early  stages  of  fevers  or  of  in- 
flammation, the  force  of  the  cardiac  impulse  is  much  increased.  2. 
Disease,  (a)  Alterations  outside  of  the  pericardium.  Increase  in  the 
extent  of  the  impulse  is  attended  by  increased  strength  when  the  heart 
is  hypertrophied  or  the  lung  retracted.  (6)  Alterations  within  the  peri- 
cardium. In  pericardial  adhesions  the  heart  is  held  more  firmly 
against  the  wall  and  may  give  the  appearance  of  strength  to  the  im- 
pulse, (c)  Disease  of  the  heart.  True  increase  in  force  of  the  impulse 
is  seen  in  disease  of  the  heart.  When  the  organ  is  hypertrophied  or 
the  seat  of  dilated  hypertrophy  the  force  of  the  impulse  is  increased, 
sometimes  to  an  almost  unbearable  degree.  Uplifting  of  the  precor- 
dial area  or  even  of  the  lower  half  of  the  anterior  part  of  the  chest  is 
seen.  The  hand  or  the  head  laid  over  the  heart  is  forcibly  lifted  with 
each  systolic  contraction.  This  great  force  is  most  pronounced  in 
the  enormous  hypertrophy  that  occurs  in  cases  of  aortic  obstruction. 
It  is  the  impulse  and  force  of  the  so-called  cor  bovinum.  In  dilatation 
the  impulse  is  diffused  and  wavy. 

Fro.  153. 


Abnormal  palpable  impulse  and  thrills. 
1.  Diastolic  impulse  palpable  from  closure  of  pulmonic  valve.  2.  Presystolic  impulse  in  mitral 
obstruction  in  third,  fourth,  and  fifth  interspaces.  3.  Thrill  at  aortic  orifice  ;  systolic,  obstruction  ; 
diastolic,  regurgitation.  4.  Thrill  at  pulmonary  orifice ;  systolic,  obstruction;  diastolic,  regurgi- 
tation. 5.  Thrill  at  mitral  orifice  ;  systolic,  regurgitation  ;  diastolic,  obstruction  ;  presystolic,  ob- 
struction." 6.  Thrill  at  tricuspid  orifice. 

B.  Strength  lessened.  This  occurs  from  causes  which  diminish  the 
extent  of  the  impulse  or  cause  it  to  be  absent  entirely,  as  when  mate- 
rial intervenes  between  the  heart  and  the  chest-wall,  or  the  heart 
is  weakened  by  disease.  Hence  (following  the  classification  above)  (a) 
in  emphysema  of  the  lung  ;  (6)  in  pericardial  effusions  ;  (c)  in  fatty 
heart,  or  myocarditis,  in  dilatation,  and  simple  weakness  of  the  heart, 
the  strength  of  impulse  is  lessened. 

Valve-shock.  The  shock  of  the  closure  of  the  valves  can  be  felt 
by  the  hand  when  placed  evenly  over  the  proecordia.     The  shock  from 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     603 

the  pulmonary  aud  aortic  valves  is  best  transmitted.  It  is  felt  most 
distinctly  in  persons  with  thin  chest-walls,  and  when  there  is  height- 
ened tension  either  in  the  aorta  or  pulmonary  artery.  The  shock 
follows  the  impulse.  It  may  be  localized  more  accurately  with  the 
finger-tips  in  the  third  or  fourth  interspace  along  the  left  edge  of  the 
sternum.  The  shock  of  the  auriculo-ventricular  flaps  is  also  trans- 
mitted. The  shock  is  synchronous  with  the  first  sound.  It  is  felt  in 
the  left  fourth  interspace  near  the  sternum,  sometimes  over  it.  It  is 
due  to  dilatation  of  the  heart,  and  is  more  readily  felt  in  thin-chested 
persons. 

Thrills.  A  thrill  is  produced  when  the  blood  is  thrown  into 
vibration  by  passing  over  a  rough  surface.  It  may  be  created  with 
the  systole  or  during  the  diastole.  It  can  only  be  created  at  the  time 
blood  is  passing  through  the  orifices.  1.  The  most  common  seat  of 
the  thrill  is  the  apex.  If  the  hand  is  placed  in  close  proximity  to  the 
surface  of  the  chest  at  this  point,  a  vibration  or  tremor  is  transmitted 
to  it  in  most  cases  of  mitral  obstruction.  The  blood  is  passing  from 
the  auricle  to  the  ventricle  ;  as  this  takes  place  before  the  systole,  the 
thrill  is  felt  before  the  impulse  or  carotid  pulse.  It  is  2^'esystolic  in 
time.  It  is  sometimes  difficult,  however,  to  distinguish  it  from  the 
impulse.  Its  character  cannot  well  be  described.  The  hesitating, 
jogging  manner  of  the  vibrations  or  the  thrill  is  clearly  transmitted  to 
the  hand.  2.  The  next  most  frequent  seat  of  thrill  is  the  second  costal 
cartilage  on  the  right.  Here  the  thrill  or  vibration  is  systolic  in  time 
and  is  caused  by  obstruction  at  the  aortic  orifice.  It  may  be  felt  away 
from  the  heart,  in  the  aorta,  or  in  the  carotids.  The  aortic  cusps  are 
thickened,  contracted,  and  stiffened  by  a  sclerotic  endocarditis,  or  the 
orifice  is  occluded  by  valvulitis.  3.  Sometimes  a  thrill  is  felt  at  the 
apex  with  the  systole — -first  sound.  This  occurs  rarely,  but  must  not 
be  confounded  with  the  before-first-sound  thrill.  It  is  never  so  dis- 
tinct, and  is  not  made  up  of  a  series  of  vibrations.  It  is  due  to  re- 
gurgitation at  the  mitral  orifice.  4.  Rarely  a  thrill  is  felt  at  the  second 
costal  cartilage  on  the  right,  with  the  second  sound.  It  may  be  felt 
along  the  course  of  the  sternum  also,  and  is  due  to  regurgitation 
through  the  aortic  orifice.  The  systolic  thrill  must  not  be  confounded 
with  the  thrill  elicited  over  the  aorta  or  at  the  aortic  cartilage,  which 
is  due  to  aneurism.  5.  At  the  second  costal  cartilage  on  the  left  a 
thrill  is  sometimes  felt.  It  is  systolic  in  time  and  is  not  transmitted. 
It  is  due  to  obstruction  at  the  pulmonary  orifice.  6.  At  the  lower 
portion  of  the  sternum  a  thrill  systolic  in  time  is  also  felt,  due  to  tri- 
cuspid regurgitation.  Care  must  be  taken  not  to  confound  the  above- 
mentioned  thrills  with  those  due  to  aneurism.     (See  Aneurism.) 

Pericardial  Friction.  In  addition  to  the  thrills,  a  friction  or 
to-and-fro  rubbing  is  transmitted  to  the  hand  in  cases  of  pericarditis, 
in  the  first  stage.  The  friction  may  be  felt  all  over  the  heart  region, 
but  is  pronounced  in  the  third  or  fourth  interspace.  It  may  be  de- 
tected on  slight  pressure  or  only  when  the  tips  of  the  fingers  are  pressed 
firmly  against  the  interspaces. 

It  is  important  to  remember  that  the  posiiioyi  of  the  patient  weakens 
or  modifies  the  thrill  or  friction.     When  the  patient  is  lying  down  it 


604  SPECIAL  DIAGNOSIS. 

may  not  be  felt.  The  upright  posture  or  leaning  forward  makes  it 
evident,  and  hence  the  patient  should  be  instructed,  if  possible,  to 
assume  this  position  in  the  examination. 

The  Arteries.  The  results  of  inspection  are  confirmed.  In  addi- 
tion, the  artery  is  examined,  to  determine  its  tension,  the  character  of 
the  coats,  and  the  presence  of  thrills.  Pulsation  of  organs.  It  is  said 
that  in  aortic  regurgitation  an  arterial  liver-pulse,  similar  to  the  venous 
liver-pulse,  can  be  felt  when  the  hands  are  placed  over  that  organ. 
Similar  pulsation  may  be  felt  in  the  spleen. 

In  examining  the  arteries  it  is  important,  as  will  be  detailed  in  the 
chapter  devoted  to  the  pulse,  to  compare  the  arteries  of  the  two  sides. 
Often  the  pulse-wave  is  found  to  be  unequal  in  force,  in  volume,  and 
in  time.  This  is  almost  always  due  to  obstruction  to  the  passage  of 
the  blood.  "When  not  due  to  endarteritis  or  to  aneurism,  it  is  due  to 
the  pressure  of  a  tumor  on  the  vessel  somewhere  in  its  course.  A 
thrombus  or  embolus  in  the  artery  may  likewise  cause  the  condition. 
A  difference  in  the  radial  and  the  femoral  pulse  points  to  obstruction 
in  the  thoracic  or  abdominal  aorta.  Anatomical  variations  must  be 
remembered. 

The  Pulse.  The  pulse  is  an  index  to  the  force,  frequency,  and 
rhythm  of  the  heart's  action  and  of  the  pressure,  or  tension,  which  is 
maintained  in  the  arteries. 

General  Observations.  The  frequency  of  the  pulse  before  birth 
is  from  120  to  140  beats  in  the  minute.  From  this  time  it  is  dimin- 
ished in  frequency  up  to  adult  life,  72  being  then  accepted  as  an  aver- 
age ;  the  number  of  beats,  however,  is  often  under  72,  and  sometimes 
over  that.  In  old  age  the  pulse-rate  is  again  increased.  Sex  has  some 
influence.  The  rate  is  slightly  higher  in  females  than  in  males  of  the 
same  age. 

The  frequency  of  the  pulse  is  subject  to  diurnal  variations,  at  times 
corresponding  with  the  diurnal  rise  and  fall  of  temperature.  The  rate 
will,  therefore,  be  highest  in  the  afternoon  and  evening  and  lowest  in 
the  earlv  mornino;  hours. 

The  position  of  the  body  has  also  a  modifying  influence.  The  pulse 
is  more  frequent  when  a  person  is  standing  than  when  he  is  sitting, 
and  more  frequent  when  he  is  sitting  than  when  he  is  lying  down. 
Walking,  running,  bodily  and  mental  exertion,  fear,  and  excitement 
all  tend  to  accelerate  the  pulse. 

During  and  for  one  or  two  hours  after  a  meal  the  pulse-rate  is  higher, 
especially  if  an  alcoholic  or  other  stimulant,  such  as  coffee,  has  been 
taken. 

How  to  Take  the  Pulse.  To  make  a  correct  count  of  the  fre- 
quency of  the  pulse,  the  conditions  just  mentioned,  as  normally  modi- 
fying its  rate,  should  be  borne  in  mind.  If  the  object  of  the  count 
is  to  determine  the  rate  which  is  normal  for  a  particular  individual, 
several  counts  will  be  necessary  at  different  times  and  under  different 
conditions,  such  as  sitting  and  standing.  The  best  time  for  the  physi- 
cian to  take  the  pulse  will  have  to  be  determined  by  his  own  judgment 
in  each  case.  If  the  patient  comes  to  his  office  and  is  excited  by  the 
prospect  of  an  examination,  it  will  be  well  to  wait  until  he  becomes 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     605 

calm.  On  the  other  hand,  if  he  is  calm  at  first,  a  count  at  that  time 
is  to  be  preferred  to  one  made  after  the  patient  has  been  disturbed  by 
a  physical  examination.  In  the  same  manner,  on  visiting  a  patient  at 
his  house,  the  judgment  of  the  physician  must  decide  whether  to  count 
the  pulse  immediately  on  his  arrival  or  to  postpone  it  until,  by  general 
conversation,  all  apprehension  and  alarm  on  the  part  of  the  patient 
have  been  allayed.  In  general,  it  may  be  said  that  if  the  physician 
finds  upon  his  arrival  that  the  pulse  is  more  frequent  than  the  condi- 
tion of  the  patient  would  lead  him  to  expect,  he  should  wait  a  while, 
endeavor  to  find  out  whether  anything  has  served  temporarily  to  dis- 
turb the  circulation,  and  then  make  the  count  when  the  conditions  are 
most  favorable.  Some  patients  are  so  nervous  that  the  mere  act  of 
placing  the  finger  upon  the  wrist  sends  the  pulse-rate  up  ten  or  twenty 
beats  in  the  minute.  In  such  cases  an  effort  should  be  made  to  obtain 
a  count  without  the  patient's  knowledge  by  observing  the  pulsations 
of  the  temporal  or  carotid.  In  other  cases  it  may  be  well  to  entrust 
the  counting  of  the  pulse  to  the  nurse  or  to  a  member  of  the  family. 
In  infants  and  young  children,  count  while  they  are  asleep.  In 
febrile  conditions  the  count  is  more  likely  to  be  too  high  than  too  low. 

In  hospital  practice,  or  when  a  nurse  is  constantly  in  attendance,  the 
pulse  and  respiration  should  be  taken  at  the  same  time  as  the  temper- 
ature. But  the  nurse  must  be  warned  against  taking  them  under 
dissimilar  conditions  upon  successive  days.  For  example,  the  pulse 
should  not  be  taken  one  day  while  the  patient  is  lying  down,  quiet 
and  comfortable,  and  compared  with  the  count  of  the  next  day  when 
the  j^atient  is  sitting  up  or  has  just  had  some  hot  liquids,  or  a  spell  of 
coughing,  or  been  subjected  to  some  other  disturbing  influence. 

The  preferable  position  is  the  recumbent  one  in  the  case  of  patients 
in  bed,  and  in  the  sitting  position  in  those  not  confined  to  bed.  Care 
should  be  exercised  in  all  cases  to  see  that  the  patient's  position  is 
comfortable  and  that  nothing  obstructs  the  artery  or  interferes  with 
the  unimpaired  flow  of  the  blood. 

The  wrist  is  the  place  usually  selected  at  which  to  feel  the  pulse. 
At  this  point  the  radial  artery  passes  over  the  radius,  and  can  readily 
be  compressed  and  its  character  made  out.  An  old-fashioned  rule 
prescribes  that  three  fingers  should  be  applied  to  the  artery,  the  index- 
finger  of  the  physician  being  nearest  the  heart.  In  particular  cases  it 
may  be  advisable  to  count  the  pulse  at  the  temporal  or  carotid  artery. 
The  fingers  should  be  applied  so  that  the  beats  can  be  most  distinctly 
felt.  The  beats  are  counted  for  fifteen  seconds  by  the  second  hand  of 
a  watch  when  only  an  approximate  count  is  desired,  or  when  time  is 
a  factor,  and  then  multiply  by  four.  It  is  better  to  count  the  pulse 
for  half  a  minute,  and  still  better  for  a  full  minute. 

The  arteries  of  the  two  sides  must  be  compared.  Difference  in  the 
force,  volume,  and  time  may  be  due  to  the  anomalous  distribution  of 
arteries.  In  disease,  it  may  occur  in  aneurism  and  atheroma,  in  press- 
ure on  the  trunk  from  external  disease,  and  in  embolism  and  throm- 
bosis. 

Condition  of  the  Walls  of  the  Artery.  The  condition  of 
the  artery  is  often  of  more  importance  than  the  pulse-rate.     A  health)" 


606  SPECIAL  DIAGNOSIS. 

radial  artery,  in  a  person  not  advanced  in  }7ears,  can  be  compressed 
easily  against  the  radius  without  the  finger  being  able  to  differentiate 
the  artery  from  the  other  tissues.  But  as  age  advances,  and  as  the 
result  of  certain  constitutional  diseases — syphilis,  gout,  chronic  endar- 
teritis, alcoholism,  and  others — the  artery  tends  to  become  thicker,  so 
that  in  pronounced  cases  it  cannot  be  obliterated,  but  is  rolled  like  a 
cord  or  pipe-stem  between  the  compressing  fingers  and  the  bone. 
Small  specks  or  plates  of  atheroma,  feeling  like  hard  particles  in  the 
coats  of  the  artery,  may  be  detected.  The  artery  has  a  beaded  feeling. 
Fatty  degeneration  of  the  organs  is  likely  to  occur  when  the  arteries 
are  in  this  condition,  and  apoplexy  is  to  be  feared. 

Tensiox.  Tension  is  the  word  used  to  express  the  degree  of  blood- 
pressure — that  is,  of  distention  of  the  arteries.  Normally,  the  pulse 
nearly  or  quite  subsides  between  the  beats,  but  little  pressure  being 
required  to  obliterate  it.  High  tension  may  be  said  to  exist  when  the 
artery  remains  continuously  full  between  the  beats  (Broadbent).  It  is 
produced  by  plethora ;  increased  heart-action ;  contraction  of  the 
arterioles,  as  by  chill ;  and  obstruction  in  the  capillaries.  The  condi- 
tions which  bring  about  obstruction  in  the  capillaries  in  the  order  in 
which  they  are  enumerated  by  Broadbent  are  :  1.  Age.  The  liabil- 
ity to  high  arterial  tension  increases  with  the  age,  especially  after 
middle-life.  2.  Heredity.  There  is  in  some  families  a  marked  ten- 
dency to  high  tension.  The  younger  members  show  its  effects  in  head- 
aches and  bilious  attacks,  while  the  older  ones  develop  chronic  heart 
disease  and  apoplexy.  3.  Disease  of  the  kidney.  Parenchymatous, 
but  especially  interstitial  nephritis,  is  associated  with  high  arterial 
tension  ;  this,  with  accentuation  of  the  aortic  second  sound,  is  one  of 
the  early  and,  therefore,  one  of  the  most  valuable  indications  of  chronic 
Bright's  disease.  4.  Gout.  Gout  and  lithsemia  are  almost  always 
accompanied  by  high  arterial  tension.  5.  Diabetes  in  old  persons 
associated  with  gout.  6.  Lead-poisoning.  7.  Pregnancy.  8.  Anaemia. 
9.  Emphysema  and  chronic  bronchitis.     10.  Mitral  stenosis. 

As  regards  arterial  tension  in  persons  presenting  signs  of  angina 
pectoris,  Sansom  asserts  that  if  the  tension  is  increased,  even  though  the 
signs  are  not  typical,  the  fear,  present  or  remote,  of  true  angina  is  justified. 
On  the  other  hand,  if  there  is  persistent  low  tension,  especially  during 
the  painful  crisis,  it  is  almost  certain  the  affection  is  a  false  angina. 

Low  tension  of  the  pulse  is  characterized  by  a  softness  and  a  com- 
pressibility in  excess  of  the  normal.  This,  like  the  high  tension  pulse, 
may  be  'a  family  peculiarity.  It  is  met  with  in  conditions  of  great 
depression  and  exhaustion,  and  wherever  there  is  a  marked  cardiac 
weakness.  It  is  most  common  in  fever,  particularly  in  typhoid,  in 
which  also  an  accompaniment  of  low-tension  pulse — namely,  dicrotism 
—  is  met  with  in  a  marked  degree.  Fat  persons  are  apt  to  have  low- 
tension  pulses,  and  it  may  occur  in  any  person  temporarily  under  the 
influence  of  external  warmth  and  moisture,  such  as  a  hot  bath,  or  after 
taking  hot  drinks,  or  under  the  influence  of  depressing  emotions,  and 
after  diarrhcea,  or  copious  urination. 

Volume.  The  volume  of  the  pulse  should  be  noted.  It  is  usually 
large  in  conditions  of  pyrexia  and  when  the  tension  is  low.     A  small 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     607 

pulse  is  met  with  in  many  conditions  other  than  weakness  of  the 
heart-muscles.  In  aortic  stenosis  the  pulse  is  small,  and  in  mitral 
stenosis  it  is  small,  of  high  tension,  and  frequently  irregular.  In  gen- 
eral contraction  of  the  arterioles,  as  happens  under  the  influence  of  a 
chill,  the  pulse  is  small.  In  Bright's  disease  it  is  sometimes  very 
small,  slow,  and  hard.  Some  care  will  be  required  to  differentiate  such 
a  pulse  from  a  weak  pulse.  In  acute  peritonitis  the  pulse  is  apt  to  be 
small  and  hard. 

Rhythm.  The  rhythm  of  the  pulse  is  of  diagnostic  importance. 
In  health  one  beat  succeeds  another  at  equal  intervals  of  time,  and  the 
successive  beats  are  of  the  same  force  and  quality.  Here,  also,  how- 
ever, as  in  other  conditions,  there  are  variations  within  physiological 
limits.  In  some  persons  the  pulse-rate  is  somewhat  accelerated  during 
respiration  and  becomes  slower  in  the  pauses  which  follow  breathing. 

In  disease,  disturbance  of  the  rhythm  occurs  as  intermission  or  as 
irregularity.  Intermission  signifies  a  dropping  of  a  pnlse-beat ;  sev- 
eral normal  pulse-beats  succeed  each  other,  and  then  the  pulse  is  absent 
during  the  time  occupied  by  one  or  two  beats.  The  intermission  may 
occur  at  regular  or  at  irregular  intervals — that  is  to  say,  every  third, 
fifth,  or  sixth  beat  may  be  wanting,  or  the  intermission  may  be  irregu- 
lar— now  a  second,  the  next  time  a  fifth  or  a  third  beat  being  absent. 
Moreover,  the  intermittent  pulse  may  be  constant,  or  it  may,  and  more 
frequently  is,  only  occasional.  It  is  not  characteristic  of  any  one  dis- 
ease or  condition,  and  it  may  exist  without  the  patient's  knowledge 
and  without  producing  any  perceptible  effect  upon  his  health.  Some- 
times it  is  met  with  in  a  fatty  heart,  and  this  disease  may  be  suspected 
if  the  intermittent  pulse  is  associated  with  a  weak  first  sound  of  the 
heart  without  valvular  lesion,  and  evidences  of  failing  circulation,  such 
as  oedema  of  the  feet.  More  frequently,  however,  the  intermittency 
is  a  symptom  of  nervous  depression,  or  is  caused  by  tea,  coffee,  tobacco, 
or  digitalis.  So  far  as  prognosis  is  concerned,  it  is  much  less  serious 
than  irregularity.  Broadbent  says  he  has  met  with  it  at  the  age  of 
eighty,  when  it  was  known  to  have  existed  for  forty  years. 

Irregularity  is  characterized  by  differences  in  time,  force,  or  volume 
of  successive  beats.  A  full  beat  is  succeeded  by  another,  which  is 
smaller  and  weaker,  or  successive  beats  occur  at  irregular  intervals 
of  time.  Irregularity  may  or  may  not  be  associated  with  intermission. 
In  advanced  cases  of  mitral  stenosis  the  pulse  is  both  irregular  and 
intermittent.  The  irregularity  may  be  habitual  or  occasional  ;  the 
former  is  due  most  frequently  to  mitral  lesions,  but  sometimes  occurs 
without  assignable  cause,  and  is  attributed  to  disturbance  of  the  nerve- 
supply  ;  the  latter  is  due  to  digestive  disturbances  and  to  the  effect  of 
nicotine  and  digitalis.  Irregularity  is  not  incompatible  with  health, 
but  is  much  more  likely  to  be  of  serious  import  than  intermission.  It 
occurs  in  diseases  of  the  brain,  in  degeneration  of  the  heart  as  well  as 
in  valvular  lesions,  and  in  grave  cases  of  febrile  diseases,  such  as 
typhus  and  typhoid,  when  the  heart-muscle  is  involved.  Some  cases 
of  Graves'  disease  arc  characterized  by  great  irregularity  instead  of 
excessive  rapidity  of  the  pulse.  Irregularity  may  occur  in  rheumatoid 
arthritis  also,  though  increased  frequency  is  the  rule. 


608  SPECIAL  DIAGNOSIS. 

Frequency.  The  frequency  of  the  pulse  is  of  aid  in  diagnosis. 
Increased  frequency.  1.  The  pulse  is  increased  in  frequency  in  all 
the  febrile  diseases,  and  generally  in  the  proportion  of  eight  to  ten 
beats  for  each  degree  of  rise  in  temperature  above  98.3°.  But  there 
are  important  exceptions.  In  typhoid  fever  the  pulse  is  slower  in  pro- 
portion to  the  temperature  and  the  gravity  of  the  disease  than  in  most 
of  the  other  acute  febrile  diseases.  It  may  not  beat  above  85  in  mild 
cases,  and  in  severe  cases  frequently  does  not  rise  above  100.  Conse- 
quently a  pulse  of  120  is  of  much  graver  import  than  it  would  be  in 
other  diseases.  It  may  be  more  frequent  during  convalescence  than 
during  the  febrile  stage.  This  pulse-rate  helps  to  differentiate  it  from 
tuberculosis,  malignant  endocarditis,  and  septicaemia. 

2.  The  pulse  of  scarlet  fever  often  aids  materially  in  diagnosis.  A 
pulse  of  120  to  160  is  the  rule  from  the  development  of  the  sore-throat 
to  the  completion  of  the  eruption.  In  measles,  rubella,  diphtheria, 
and  follicular  tonsillitis  it  is  much  slower  during  the  early  stages. 

3.  In  Graves'  disease  great  frequency  of  the  pulse  is  the  essential 
and  most  constant  symptom  of  the  disease.  The  pulse  may  be  con- 
stantly considerably  over  100,  and  in  attacks  of  palpitation  200  or 
more.  In  these  attacks  there  may  or  may  not  be  precordial  distress 
and  mental  anxiety.  Here  belong  the  cases  described  as  paroxysmal 
hurry  of  the  heart,  etc.,  the  thyroid  and  ophthalmic  symptoms  being 
absent. 

4.  Cases  have  been  reported  of  extreme  frequency  of  the  pulse 
(160  to  240)  without  palpitation,  dyspnoea,  or  any  signs  of  Graves'  dis- 
ease. Some  of  the  patients  have  been  able  to  perform  much  bodily 
and  mental  labor,  notwithstanding  that  the  rate  mentioned  was  main- 
tained persistently  for  weeks.  To  this  class  of  cases  the  name  tachy- 
cardia has  been  provisionally  applied  until  their  pathology  is  under- 
stood. 

5.  In  all  forms  of  valvular  disease,  except  aortic  stenosis  with  fail- 
ing compensation,  the  pulse  may  be  increased  in  frequency.  In  col- 
lapse ;  in  weakening  of  the  heart ;  and  in  central  or  peripheral  vagus 
disease,  the  pulse  is  increased.  Mitral  stenosis  may  be  latent  until 
great  excitement,  overexertion,  and  particularly  running  or  forced 
marches  bring  on  palpitation,  or  simply  abnormal  and  persistent  fre- 
quency of  the  heart's  action,  with  or  without  dyspnoea. 

6.  Attention  has  been  called,  especially  by  Dr.  J.  Kent  Spender,  to 
acceleration  of  the  pulse  as  an  early  symptom  of  rheumatoid  arthritis. 
The  pulse  increases  gradually  until  it  reaches  a  range  of  110  to  120,  and 
it  persists  at  that  rate  with  little  diurnal  variation,  even  after  the 
arthritic  symptoms  subside. 

7.  In  locomotor  ataxia  permanent  moderate  acceleration  of  the  pulse 
(90  to  100)  is  a  frequent  symptom. 

8.  Infections.  In  the  puerperium  increased  frequency  with  irregu- 
larity of  the  pulse  is  a  surer  indication  of  intra-uterine  mischief  than 
is  the  temperature.  So,  too,  in  all  cases  of  inflammation  so  situated 
that  the  products  are  absorbed  into  the  circulation  and  not  discharged 
externally,  the  pulse  shows  by  its  increased  frequency  that  a  septic 
process  is  going  on. 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     609 

Diminished  Frequency.  A  slow  pulse  (bradycardia),  under  60,  like 
a  frequent  pulse,  is  sometimes  habitual,  and  sometimes  a  family  char- 
acteristic. Pathologically,  it  is  met  with  in  conditions  which  increase 
the  resistance  in  the  arteries,  such  as  Bright's  disease,  especially  acute 
glomerulo-nephritis  ;  but  it  is  especially  common  in  jaundice.  The 
bile-acids  have  the  effect  of  retarding  the  action  of  the  heart. 

A  slow  pulse  is  met  with  in  certain  forms  of  heart  disease,  as  aortic 
stenosis,  but  it  is  not  constant  in  any  of  them.  It  occurs  in  fatty  de- 
generation, especially  when  due  to  obstruction,  by  atheroma  or  other- 
wise, of  the  coronary  arteries.  W.  J.  Pettus  has  reported  a  case  of 
bradycardia  associated  with  aneurism  of  the  right  sinus  of  Valsalva, 
involving  the  orifice  of  the  right  coronary  artery.  When  it  appears 
in  the  late  stages  of  valvular  affections  or  specific  diseases  with  cerebral 
symptoms  it  is  usually  a  sign  of  danger.  It  is  seen  in  articular  rheu- 
matism (Atkinson).  According  to  Riegel,  it  is  most  common  in  con- 
valescence from  acute  disease,  particularly  pneumonia,  typhoid  fever, 
erysipelas,  and  rheumatic  fever.  It  is  also  frequently  encountered  in 
diseases  of  the  digestive  organs  and  of  the  urinary  organs,  particularly 
acute  nephritis.  Moreover,  it  is  generally  slow  in  myxoedema,  and  both 
slow  and  irregular  in  epilepsy.  It  is  slow,  not  uncommonly,  also,  in 
melancholia  and  in  the  early  stages  of  cerebral  meningitis  and  in  tumors 
and  cerebral  hemorrhage. 

The  Sphygmograph.  The  sphygmograph,  as  its  name  implies,  is 
an  instrument  for  recording  in  writing  the  volume,  force,  frequency, 

Fig.  154. 


Dudgeon's  sphygniograph. 


tension,  and  general  characteristics  of  the  pulse.  Many  forms  of  the 
instruments  have  been  devised  since  the  first  one  of  Marey.  The  later 
models  have  the  advantage  of  simplicity  and  ease  of  application.  One 
of  the  most  convenient  is  Dudgeon's.  It  lias  its  faults,  particularly 
in  exaggerating  the  vibrations  when  the  pulse  is  large  and  the  heart  is 
acting  violently  ;  nevertheless,   with  care,  trustworthy  tracing  can  lie 

39 


610  SPECIAL  DIAGNOSIS. 

obtained  in  all  ordinary  cases.  No  matter  what  instrument  is  used, 
the  value  of  the  tracing  depends  very  largely  upon  the  personal  skill 
and  experience  of  the  one  who  takes  the  tracing  ;  hence  the  sphygmo- 
graph  occupies  a  position  very  different  from  the  thermometer  and 
other  instruments  of  precision.  While  it  is  true  that  a  person  can 
learn  to  detect  nearly  all  the  variations  of  the  pulse  by  palpation  alone, 
yet  the  tracing  has  the  great  advantage  of  permanency,  and  many  per- 
sons are  led  to  palpate  the  pulse  more  carefully  by  seeing  in  a  sphyg- 
mographic  tracing  a  dicrotism  or  irregularity  which  had  escaped  their 
attention. 

The  expansile  pulsation  of  the  artery  is  communicated  by  a  system 
of  levers  to  a  needle,  which  graphically  records  the  qualities  of  the 
pulse  upon  smoked  paper. 

Directions  for  Using  Dudgeon's  Sphygmograph.  1.  Wind  up,  by 
the  button,  the  clockwork  contained  in  the  box.  The  clockwork 
carries  the  smoked  paper  under  the  writing-needle. 

2.  See  that  the  patient  is  in  a  comfortable  position,  and  have  him 
hold  toward  you  either  hand  with  wrist  exposed,  fingers  gently  flexed, 
and  muscles  relaxed. 

3.  Apply  the  instrument  by  slipping  the  band  over  the  hand,  the 
free  end  of  the  band  being  passed  through  the  retaining  clamp.  The 
metal  box  is  placed  toward  the  elbow. 

4.  Now  adjust  the  instrument  by  placing  the  bulging  button  which 
connects  the  levers  directly  over  the  radial  artery  at  its  most  accessible 
point. 

5.  Keep  the  instrument  accurately  in  place  with  the  left  hand,  and 
draw  the  band  through  the  clamp  with  the  right  until  the  writing- 
needle  plays  freely  with  each  pulsation  of  the  radial  artery,  then  fasten 
the  band  by  screwing  up  the  clamp. 

6.  Introduce  the  smoked  paper  between  the  rollers  and  under  the 
writing-needle. 

7.  Vary  the  pressure  by  means  of  the  thumb-screw,  which  connects 
with  an  eccentric,  until  the  best  apparent  amplitude  of  vibration  is 
obtained. 

8.  Instruct  the  patient  not  to  move  the  fingers  or  hand,  and  further 
steady  them  for  him  with  your  own  right  hand. 

9.  Start  the  clockwork  by  pushing  the  bar  at  the  top  of  the  clock- 
work box. 

10.  Allow  the  paper  to  run  through,  and  then  stop  the  clockwork. 
The  clockwork  is  so  regulated  that   five  inches  of  smoked  paper 

pass  through  in  ten  seconds,  so  that  six  times  the  number  of  pulsa- 
tions recorded  on  the  paper  represent  the  pulse-rate  per  minute.  Each 
instrument,  however,  should  be  tested  and  its  time  determined.  The 
clockwork  should  be  wound  up  for  every  tracing. 

Considerable  practice  will  be  required  to  take  a  tracing  rapidly  and 
accurately,  in  spite  of  the  simplicity  of  the  mechanism. 

Several  tracings  should  be  taken  at  different  pressures  and  com- 
pared, or,  what  is  better,  as  suggested  by  Sansom,  stop  the  clockwork 
and  alter  the  pressure  two  or  three  times,  so  as  to  have  the  effect  of 
varying  pressures  on  one  tracing. 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     611 

The  technique  of  sphygmography  needs  a  few  words.  Smoked 
paper  is  generally  used  for  the  tracings.  A  paper  glazed  upon  one 
surface  and  rough  upon  the  other  has  some  advantages.  This  paper 
has  to  be  cut  in  strips  about  seven-eighths  of  an  inch  wide  and  six 
inches  or  more  long.  The  cutting  should  be  done  with  care  so  that 
the  edges  are  smooth  and  even,  otherwise  the  paper  sticks  in  the  in- 
strument and  the  tracing  is  spoiled.  The  glazed  surface  is  blackened 
by  holding  it  above  the  flame  of  a  small  piece  of  burning  gum  cam- 
phor. For  convenience  a  strip  of  tin,  bent  upon  itself  at  each  end,  so 
as  to  catch  and  hold  about  an  inch  of  the  ends  of  the  paper,  may  be 
used  to  prevent  the  fingers  from  becoming  blackened  and  to  preserve 
the  ends  of  the  paper  unblackened  for  memoranda.  The  blacking 
should  not  be  too  thick,  otherwise  the  needle  will  not  plough  through 
it  easily,  and  the  white  line  of  the  tracing  will  not  be  distinct.  After 
the  tracing  has  been  made,  the  name  of  the  patient,  the  diagnosis  of 
his  disease,  the  date  of  the  tracing,  and  the  amount  of  pressure  em- 
ployed should  at  once  be  scratched  with  a  fine-pointed  pen  upon  the 
blackened  surface  beneath  the  tracing,  or  written  in  ink  upon  the  un- 
blackened end  of  the  paper.  The  tracing  is  then  ready  for  preserva- 
tion. This  is  done  by  dipping  it  into  a  solution  of  shellac  or  in  tinc- 
ture of  benzoin  (gum  benzoin  oj,  alcohol  f-5vj)  ;  the  alcohol  evaporates 
and  leaves  a  smooth,  glazed  surface.  Dr.  Dudgeon  recommends  as  a 
varnish  a  solution  of  gum  damar  §j,  rectified  benzoline  f§vj.  When 
the  tracing  is  likely  to  be  subjected  to  friction,  a  second  or  third  coat 
should  be  applied  subsequently. 

Explanation  of  the  Normal  Pulse-tracing.  With  each  contraction  of 
the  left  ventricle  a  volume  of  blood  is  forced  into  the  aorta,  which  dis- 
tends it,  the  distended  impulse  being  transmitted  by  a  wave-like 
motion  to  remote  arteries.  This  distending  impulse  lifts  the  button  of 
the  lever  sharply  upward,  forming  the  so-called  percussion  up-stroke, 

Fig.  155. 


a,  b,  percussion  up-stroke;  a,  b,  c,  percussion  wave;  c,  d,  e,  tidal  wave;  e,f,g,  dicrotic  wave  ; 
d,  e,f,  aortic  notch  ;  /,  g,  diastolic  period. 

a  b ;  but  the  distending  impulse  is  exaggerated  by  the  system  of 
levers,  and  having  been  thrown  up  too  high,  the  lever  falls  by  its 
own  weight  too  low,  so  that  it  is  again  caught  and  lifted  by  the  tidal 
blood,  forming  the  tidal- wave,  c  d  e.  The  gradual  descent  of  the  lever 
is  again  interrupted  at  efg,  forming  a  wave,  called  the  dicrotic  wave, 
due  to  the  recoil  of  the  blood  from  the  closure  of  the  aortic  valves. 
(Fig.  155.) 

Roy  and  Adami  believe  that  the  apex  (h,  b,  d)  of  the  percussion- 
wave  is  due  to  the  sudden  pulling  down  of  the  auriculo-ventricular 


612  SPECIAL  DIAGNOSIS. 

valves  by  the  papillary  muscles  during  the  first  rapid  part  of  their 
contraction.     Hence  they  call  the  wave  the  "  papillary  wave." 

The  second  wave  (c,  d,  e)  corresponds  in  time,  they  say,  with  the 
outflow  from  the  ventricle  due  to  the  continued  contraction  of  the 
heart-wall  and  papillary  muscles  after  the  flaps  have  been  pulled  down. 
Hence,  they  prefer  to  call  this  wave  the  "  outflow  remainder,"  instead 
of  "  tidal  "  wave. 

Interpretation  of  Pulse-tracings.  Sphygniographic  tracings 
must  be  interpreted  in  accordance  with  the  known  peculiarities  of  the 
patient,  his  history,  and  the  associated  physical  signs. 

1.  The  Amplitude.  The  height  of  the  percussion-stroke  varies  con- 
siderably in  health.  It  is  increased  in  conditions  which  bring  about 
low  tension  and  rapid  systolic  contraction  of  the  heart.  Hence  the 
febrile  pulse  is  usually  one  of  considerable  amplitude.  It  is  increased 
also  very  markedly  hi  aortic  regurgitation.  Suddenness  of  systole 
rather  than  force  determines  the  height  of  the  up-stroke.     (See  Fig. 

156). 

Fig.  156. 


Tracing  from  a  case  of  aortic  regurgitation. 

2.  Obliquity  of  the  Percussion-stroke.  Normally  the  percussion- 
stroke  ascends  vertically  from  the  base-line.  A  tendency  to  incline 
forward  indicates  a  weak  and  laboring  heart  or  an  aneurism  inter- 
posed between  the  radial  artery  and  the  heart.  In  the  latter  case 
there  is  also  a  tendency  to  rounding  of  the  summit  of  the  percussion- 
wave,  and  the  up-stroke  is  generally  short.  There  is  usually  also 
irregularity  in  successive  pulsations,  some  showing  the  gradual  ascent 
and  rounded  summit  much  better  than  others.  Sometimes,  however, 
when  aneurism  exists,  there  is  no  evidence  of  it  in  the  tracing,  and 
differences  upon  the  two  sides  are  not  always  significant.     (See   Fig. 

157.) 

Fig.  157. 


Tracing  from  a  case  of  aneurism  of  the  aorta. 


Disease  at  the  aortic  orifice  and  the  intervention  of  a  considerable 
quantity  of  subcutaneous  fat  or  of  any  growth  superficial  to  the  vessel 
may  cause  a  marked  obliquity  of  the  percussion-stroke.  Sansom 
asserts  that,  such  causes  excluded,  as  well  as  aneurism  and  organic 
disease  of  the  aorta  and  its  valves,  a  sloping  line  of  ascent,  observed 
under  various  gradations  of  pressure,  indicates  feebleness  of  the  left 
ventricle.  He  considers  it  of  higher  diagnostic  value  than  irregularity, 
which  he  says  is  often  neurotic. 

3.  Increased  Breadth  of  the  Apex  of  the  Percussion-icave.  The 
breadth  of  the  apex  of  .the  percussion-wave  indicates  the  time  during 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     613 


which  the  artery  is  kept  full  by  the  systole  of  the  left  ventricle. 
When  the  left  ventricle  acts  slowly  and  forcibly  the  arteries  will  be 
kept  distended  for  a  longer  time,  and  this  distention  will  be  manifest 
in  broadening  of  the  apex  of  the  tracing.     (See  Fig.  158.)    The  degree 


Fig.  15S. 


From  a  case  of  aortic  stenosis,  showing  increased  tension  and  the  pulsus  bisferiens. 

of  distention  of  the  artery  is  called  tension,  hence  a  broadening  of  the 
apex  is  an  evidence  of  high  tension.  As  the  word  "  high  "  does  not 
indicate  the  duration  of  the  tension,  Sansom  has  very  properly  sug- 
gested that  we  should  speak  of  persistent  high  tension  as  "  prolonged  " 
tension.  This,  then,  is  the  significance  of  the  broad  top  of  the  tracing. 
(See  Fig.  159.) 

Fig.  159. 


From  a  case  of  mitral  stenosis,  showing  increased  tension  and  some  irregularity. 

Prolonged  arterial  tension  occurs  when  there  is  a  strong  heart  acting 
slowly,  a  large  volume  of  blood,  or  obstruction  in  the  capillary  circu- 
lation.    (For  specific  causes,  see  under  Tension.) 

The  amount  of  pressure  required  to  develop  the  characteristics  of  a 
pulse,  and.  still  more,  the  amount  required  to  obliterate  it,  are  good 
indexes  of  the  degree  of  tension  present.  Some  pulses,  however, 
appear  to  the  touch  to  be  of  prolonged  tension,  but  a  sphygmogram 
does  not  show  it.  Such  cases  are  often  explained  by  the  fact  that  the 
heart  has  begun  to  fail  under  the  strain  put  upon  it  by  prolonged 
obstruction  in  the  capillaries.  There  may  be  regurgitation  also  from 
the  mitral  or  aortic  orifice. 

4.  Acute  Angle  of  the  Percussion-wave.  When  the  heart's  action  is 
feeble  or  sudden,  the  volume  of  blood  small,  or  the  resistance  in  the 


Fig.  160. 


Low  tension  with  irregularity,  from  cases  of  mitral  regurgitation. 

capillaries  much  diminished,  the  up-stroke  of  the  tracing  is  vertical, 
and  the  down-stroke  forms  an  acute  ancde  with  it.     The  dicrotic  wave 

• 

is  pronounced,  and  often  descends  unduly  low,  sometimes  to  the  base- 
line. These  are  the  characteristics  of  low  tension.  (See  Fig.  160.) 
When  the  dicrotic  wave  springs  from  a  lower  level  than  the  base-line 


614 


SPECIAL  DIAGNOSIS. 


of  the  tracing  it  is  hyper 'dicrotic.     When  the  dicrotic  wave  is  wholly 
effaced  in  the  succeeding  up-stroke  it  is  monocrotic. 

While  dicrotism  is  commonly  associated  with  low-tension  pulses,  it 
is  occasionally  met  with  also  in  high-tension  pulses.  Sansom  says, 
however,  that  he  has  scarcely  ever  observed  the  conjunction  of  broad 
summit  and  marked  dicrotism  without  the  patient's  manifesting  the 
sign  of  failing  heart. 

5.  Irregularity  of  the  Base-line.  This  occurs  normally  in  some 
persons  as  the  result  of  respiration,  especially  deep  breathing.  It 
occurs  in  respiratory  diseases  also,  and  in  affections  causing  dyspnoea. 
Decided  undulation  of  the  base-line,  the  curves  being  irregular,  occurs 
in  tubercular  meningitis. 

6.  Differences  in  the  Height  of  Successive  Percussion-waves  or  in  their 
Distance  from  Each  Other.  These  are  written  evidences  of  disturb- 
ance in  the  rhythm  of  the  heart.  The  first  expresses  irregularity  in 
volume  of  successive  beats,  and  the  second  irregularity  in  time.  When 
this  latter  amounts  to  the  omission  of  a  beat  it  is  called  intermission. 
All  these  changes  are  shown  in  Fig.  161. 


From  a  case  of  advanced  mitral  stenosis,  showing  extreme  irregularity  and  intermission. 


The  Veins.  Thrombosis.  This  is  usually  detected  by  palpation, 
and  occurs  most  frequently  in  the  femoral  vein.  The  vein  is  trans- 
formed into  a  firm,  round  cord,  and  is  distinguished  from  the  artery 
by  the  absence  of  pulsation.  Thrombosis  in  these  veins  and  in  the  iliac 
veins  higher  up  occurs  in  acute  infectious  diseases  and  in  the  debility 
of  the  aged.  Dropsy  in  the  area  of  distribution  of  the  veins  is  per- 
ceived. 

Percussion  By  means  of  percussion  the  shape  and  size  of  the  heart 
and  changes  in  the  area  of  cardiac  dulness  are  determined.  (See  the 
Lungs  for  discussion  on  percussion.)  To  determine  the  size  of  the 
heart,  both  superficial  or  light,  and  deep,  or  strong,  percussion  must  be 
employed.  By  the  former  we  determine  the  area  of  superficial  or 
absolute  cardiac  dulness  ;  by  the  latter,  the  area  of  deep  cardiac  dulness. 

1.  The  Area  of  Superficial  or  Absolute  Cardiac  Dulness. 
(See  Plate  XVI.)  It  is  the  area  not  covered  by  the  lung  at  the  time 
of  inspiration.  The  lungs  overlap  the  heart,  and,  in  inspiration,  allow 
a  small  area  to  be  in  contact  with  the  chest-wall.  The  percussion-force 
employed  must  be  light,  so  as  not  to  elicit  the  resonance  of  the  extreme 
thin  edge  of  the  lung.  The  area  extends  from  the  fourth  to  the  sixth 
costal  cartilages.  The  right  border  may  be  roughly  defined  by  a  line 
drawn  along  the  left  edge  of  the  sternum  from  the  upper  border  of  the 
fourth  rib  downward  ;  the  left  border  by  a  line  extending  from  the  upper 
border  of  the  fourth  rib  at  the  left  edge  of  the  sternum  to  a   point 


DISEASES  OF  HEAR  T,  WtoOD  VESSELS  AND  MEDIASTIN  UM.     615 

midway  between  the  parasternal  and  the  mammillary  line  in  the  fifth 
interspace.     The  lower  border  is  continuous  with  liver  dulness. 

Method.  The  right  border  is  determined  by  percussing  from  right 
to  left  toward  the  median  line.  Always  begin  to  percuss  far  enough 
from  the  heart  to  get  the  clear  pulmonary  note.  To  insure  uniformity, 
select  a  definite  area  from  which  to  start  in  all  cases.  Apply  the 
finger  vertically  at  first.  The  right  border  may  correspond  with  a 
line  outside  of  or  along  the  right  edge  of  the  sternum,  with  the  median 
line  or  the  left  edge  of  the  sternum,  or  even  beyond  the  latter.  After 
the  edge  of  modified  resonance  is  reached,  percuss  with  the  finger  par- 
allel to  the  ribs,  to  control  the  result  previously  secured,  and  as  each 
interspace  is  percussed  the  upper  limit  of  liver-dulness  and  the  tri- 
angle (Ebstein's)  between  the  liver  and  heart  may  be  determined. 

The  left  edge  is  determined  by  percussing  in  vertical  lines  from  a 
point  near  the  axilla  toAvard  the  heart.  Opposite  the  second  and  third 
interspaces  the  aorta  on  the  right  side,  and  the  pulmonary  artery  on 
the  left,  will  cause  impairment  of  the  normal  pulmonary  resonance. 
The  student  should  acquire  the  habit  of  proceeding  from  definite  fixed 
positions  toward  the  heart,  and  to  observe  the  changes  during  inspira- 
tion and  expiration.  The  lower  border  and  rounded  apex  of  an  en- 
larged heart  cannot  be  defined  if  the  stomach  contains  food  or  fluid. 
It  is  triangular  in  shape,  with  the  apex  pointing  downward. 

The  cardio-hepatic  triangle  is  the  more  or  less  resonant  area  in  the 
right  fifth  interspace  which  separates  the  right  heart  and  the  liver. 
The  apex  of  the  triangle  points  to  the  sternal  edge,  the  base  to  the 
axilla.  The  upper  side  corresponds  to  the  right  border  of  the  heart ; 
the  lower  is  the  upper  limit  of  the  liver. 

Changes  in  Size.  The  superficial  area  of  dulness  or  absolute  dulness 
is  increased  in  pericardial  effusion  in  enlargement  of  the  heart  and 
when  the  heart  is  pushed  against  the  chest-wall.  It  is  replaced  by 
resonance  in  emphysema,  and  hence  absent  entirely,  as  the  lung  over- 
laps or  completely  covers  the  heart.  It  is  absent  when  the  heart  is 
drawn  under  the  lungs  by  adhesions  and  when  there  is  air  in  the 
pleural  or  pericardial  sac. 

Absolute  Dulness  Increased.  The  increase  in  the  area  of  abso- 
lute dulness  in  all  directions  occurs  in  hypertrophy  of  the  heart  and  in 
pericardial  effusions.  The  increase  in  width  at  the  base  of  the  heart 
occurs  in  dilatation,  pericardial  effusion,  and  aneurism  of  the  aorta. 
Change  in  the  position  of  the  heart,  a  general  idea  of  which  is  obtained 
by  inspection  and  palpation,  always  changes  the  shape  and  extent  of 
the  dulness.  The  heart  should  be  accurately  delimited  when  displace- 
ments have  taken  place. 

Increase  of  Dulness  Upward.  In  addition  to  general  increase 
in  cardiac  dulness,  one  of  the  boundaries  or  a  portion  of  the  boundary 
may  be  increased  or  extended  beyond  the  normal  line.  Thus  the  area 
of  dulness  may  extend  upward.  It  may  be  followed  by  extension  of 
the  right  and  left  boundaries.  The  relative  area  of  dulness  is  abol- 
ished. The  change  from  pulmonary  resonance  to  dulness  is  abrupt  and 
decided.  The  area  of  dulness  becomes  pyramidal  or  pyrifonn  in  shape. 
It  is  due  to  effusion  in  the  pericardium.     Upward  increase  of  dulness 


61  (J  SPECIAL  DIAGNOWS. 

may  be  due  to  disease  of  the  vessels.  Increase  in  the  area  of  dulness 
over  the  bloodvessels  is  usually  due  to  aneurism.  It  may  be  general, 
as  in  dilatation  of  the  aorta,  or  local,  as  in  aneurism.  Extension  of 
the  dulness  outward  or  upward  from  the  normal  line  may  be  found  at 
the  right  of  the  sternum  (aneurism  of  the  ascending  aorta),  or  over  the 
first  bone  of  the  sternum  (aneurism  of  the  transverse  aorta),  or  to  the 
left  just  above  the  cardiac  area.  In  the  last  case  the  dulness  is  an 
extension  upward  of  the  normal  area  of  cardiac  dulness  with  rounding 
of  the  area  affected  ;  the  aneurism  is  situated  at  the  beginning  of  the 
aorta. 

Increase  to  the  Left.  Increase  in  dulness  to  the  left  occurs  in 
enlargement  of  the  heart  from  hypertrophy  or  dilatation.  If  the  dul- 
ness extends  outward  to  the  left  and  retains  the  triangular  shape,  with 
the  apex  pointed,  it  is  due  to  hypertrophy  of  the  left  ventricle.  If,  on 
the  other  hand,  it  becomes  quadrilateral  in  shape,  with  the  apex 
rounded,  it  is  due  to  dilatation  of  the  left  ventricle.  The  results  of 
palpation  and  inspection  aid  in  detecting  the  presence  of  one  or  the 
other  of  the  two  conditions. 

Increase  to  the  Right.  The  area  of  dulness  extends  to  the 
right.  It  is  due  to  hypertrophy  and  dilatation  of  the  right  auricle  and 
ventricle.  If  the  auricle  is  dilated,  the  right  edge  is  extended  beyond 
the  normal  in  the  third  and  fourth,  or  as  high  as  the  second  interspace. 
With  this  increase  in  dulness  there  are  also  seen  an  epigastric  impulse, 
venous  turgescence,  and  pulsation  of  the  veins  of  the  neck  or  of  the 
liver. 

Deep  Cardiac  Dulness.  Many  authorities  consider  the  deep  or 
relative  area  of  cardiac  dulness  of  importance  in  diagnosis.  The  percus- 
sion must  be  strong.  The  best  method  is  that  advised  by  Gibson  and 
Russell.  Their  directions  are  as  follows  :  "  Begin  in  the  upper  left 
interspaces  sufficiently  far  out  from  the  sternum  to  secure  pulmonary 
resonance.  For  instance,  in  the  second  interspace  begin  in  the  mid- 
clavicular line  and  percuss  strongly.  As  soon  as  a  slight  alteration  in 
that  sound  is  noted,  the  point  is  indicated  by  a  mark.  The  second  or 
third  and  succeeding  interspaces  are  percussed  in  like  manner,  bearing 
in  mind  that  the  percussion  must  begin  further  out  in  each  interspace, 
in  order  to  get  pure  resonance.  As  dulness  is  secured  in  each  space  a 
mark  is  made.  This  is  continued  to  the  apex  if  that  is  visible,  or  to 
the  base  of  the  chest.  By  joining  the  marks  in  each  interspace  with 
the  line  at  the  base  of  the  heart,  the  left  border  of  the  cardiac  dulness 
can  be  fixed."  The  authors  correctly  point  out  that  in  this  way  the 
true  apex  of  the  heart  is  found,  enabling  auscultation  to  be  conducted 
more  accurately. 

The  right  edge  of  the  vessels  and  of  the  heart  is  defined  in  the  same 
way.  The  difference  in  the  sound,  in  passing  from  the  lung  to  the 
heart,  is  not  so  distinct  along  the  right  border  as  along  the  left.  The 
authors  include  the  dulness  which  is  due  to  the  vessels  at  the  base  of 
the  heart,  and  hence  begin  percussion  in  the  higher  interspaces.  This 
they  deem  is  proper,  because  it  is  impossible  to  delimit  the  two.  The 
dulness  of  the  vessels  is  not  so  marked,  however,  and  may  be  indicated 
by  simple  change  in  pitch  in  the  percussion-note.     The  lower  border 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     617 

of  cardiac  dulness  is  ascertained  with  difficulty,  because  of  its  close 
apposition  with  the  liver.  At  times  there  is  a  difference  in  the  char- 
acter of  the  dulness  between  the  two  organs.  It  can  be  well  made  out 
by  stethoscopic  percussion.  This  may  not  be  so  pronounced  as  we  pass 
from  the  heart  to  the  liver  in  the  median  and  parasternal  lines. 
Toward  the  apex  the  difference  is  more  apparent. 

Pleximeteic  Peecussion.  For  more  accurate  cardiac  percussion, 
Sansom  recommends  the  use  of  a  pleximeter  designed  by  himself,  by 
which  delicate  shades  in  dulness  can  be  readily  heard.  The  pleximeter 
is  a  thin,  flat,  oblong  plate  one  inch  by  half  an  inch,  which  has  on  its 
upper  surface  a  column  rising  from  the  middle,  one  and  a  half  inches 
in  height,  which  is  surmounted  by  a  second  plate  three-eighths  to 
three-fourths  of  an  inch,  set  parallel  with  the  lower  plate.  The  instru- 
ment is  held  between  the  forefinger  and  middle  finger  of  the  left  hand, 
the  sensitive  tips  of  the  fingers  resting  on  the  upper  surface  of  the 
larger  horizontal  plate.  The  lower  surface  of  this  latter  is  held  close 
to  the  wall  of  the  chest,  and  percussion  with  one  or  two  fingers  of  the 
right  hand  with  an  even  and  not  too  forcible  stroke  from  the  wrist  is 
made  upon  the  upper  plate.  The  resulting  vibrations  are  transmitted 
to  the  ear  and  are  also  appreciated  by  the  digital  sense  of  touch,  so 
that  both  senses  aid  in  the  determination  of  the  nature  of  the  sound 
produced. 

Method.  The  pleximeter  is  placed  with  its  long  diameter  parallel 
with  the  sternum,  about  midway  between  the  axilla  and  the  right  ster- 
nal border.  Percussion  is  made  upon  the  summit  of  the  column  by 
one  or  two  fingers,  and  the  pleximeter  is  moved,  always  in  parallel 
lines,  nearer  and  nearer  to  the  sternum.  A  line  is  reached  where  the 
vibrations  are  modified.  Incline  the  pleximeter  so  that  the  vibrations 
come  from  its  left  edge.  This  edge,  or  line,  is  practically  the  line  of 
demarcation  of  the  dulness,  and  should  be  indicated  with  an  aniline 
pencil.  It  corresponds  to  the  outline  of  the  right  border  of  the  heart. 
The  process  must  be  repeated  at  higher  and  lower  levels  until  the  entire 
right  border  of  cardiac  or  aortic  dulness  is  ascertained.  In  passing,  it 
may  be  stated  that  percussing  from  above  dowirward  with  the  long 
diameter  of  the  pleximeter  horizontal  instead  of  vertical  leads  to  the 
upper  limit  of  the  liver  as  indicated  by  modified  vibrations.  At 
about  the  fifth  right  intercostal  space  a  short  curved  line  is  thus 
made  out  along  the  right  edge  of  the  sternum,  which  indicates  the 
outline  of  the  right  auricle  at  the  point  where  it  joins  the  liver- 
dulness.  Above  this,  as  far  as  the  second  rib,  the  line  indicates  the 
outline  of  the  right  border  of  the  auricle  and  the  aorta.  The  outline 
of  the  auricle  may  be  in  the  mid-sternum  ;  of  the  aorta,  at  the  right 
edge.  In  percussing  the  left  side  of  the  chest  the  same  method  is 
adopted.  Begin  at  the  level  of  the  second  rib,  two  or  three  inches 
beyond  the  left  edge  of  the  sternum,  and  move  to  the  right.  Join  the 
lines  of  modified  vibrations,  and  in  this  manner  the  left  border  of  car- 
diac and  aortic  dulness  is  secured.  The  outline  of  the  apex  of  the 
heart  is  readily  mapped  out.  Over  the  tympanitic  stomach  light  per- 
cussion is  necessary.  To  narrow  the  area  of  percussion  about  the  apex, 
the  percussion  may  be  performed  on  the  larger  plate,  while  the  smaller 


618  SPECIAL  DIAGNOSIS. 

is  applied  to  the  chest.  The  vibrations  over  the  liver  and  over  the 
right  ventricle  are  difficult  to  distinguish,  although  sometimes  so  differ- 
ent that  demarcation  of  the  border  of  the  ventricle  presents  no  difficulty. 
Between  the  apex  of  the  left  ventricle  and  the  left  lobe  of  the  liver  the 
space  is  easily  marked  out. 

A  correct  outline  of  the  heart  and  of  the  vessels  is  thus  obtained. 
The  upper  limit  of  dulness  is  formed  by  the  right  auricle,  the  aorta, 
and  the  pulmonary  artery.  Any  bulging  or  undue  expansion  is  due 
to  aneurism  or  aneurismal  dilatation  of  the  aorta.  The  space  be- 
tween the  apex  and  the  left  lobe  of  the  liver  defines  the  lower  border. 
Sansom  points  out  that  by  this  method  of  percussion  the  following 
absolute  data  can  be  obtained  :  "  A  projection  to  the  right  of  the  area 
of  the  upper  part  over  the  second  and  third  interspaces  points  to  aneu- 
rism of  the  aorta  or  of  the  innominate  artery.  It  may  be  traced  to  the 
left  side  of  the  sternum,  on  account  of  saccular  dilatation  of  the  aorta. 
If  the  dulness  at  the  upper  part  extend  greatly  to  the  left,  an  increase 
in  size  of  the  pulmonary  artery  may  be  suspected.  Along  the  mid- 
sternal  region,  extension  beyond  the  right  side  joining  the  line  indi- 
cating the  upper  border  of  the  liver  indicates  distended  inferior  cava. 
This  distention  occurs  in  right-sided  dilatation  of  the  heart,  and  the 
dulness  may  also  be  due  to  dilatation  of  the  adjoining  auricle.  The 
outline  of  dulness  obtained  over  the  apex  of  the  heart,  if  pointed,  indi- 
cates hypertrophy  ;  a  more  rounded  outline  shows  dilatation.  In  un- 
complicated hypertrophy  the  line  of  the  right  ventricle  forms  a  much 
less  obtuse  angle  with  the  liver-dnlness  than  in  dilatation.  Of  great 
diagnostic  value  is  the  diminution  of  the  area  of  dulness  from  atrophy 
of  the  heart  as  observed  in  wasting,  as  in  cancer,  and  in  tuberculosis  ; 
it  may  also  be  observed  in  typhoid  fever.  In  the  above-mentioned 
conditions  it  is  a  bad  prognostic  sign." 

Adjacent  Dulness.  Care  must  be  taken  not  to  confound  the 
dulness  of  pleural  effusion  or  consolidated  lung  with  the  cardiac 
dulness. 

Repercussion.  Modification  of  the  vibrations  felt  by  the  fingers 
on  the  pleximeter,  as  pointed  out  by  Sansom,  may  indicate  an  abnormal 
change  in  physical  condition  impossible  to  detect  in  any  other  way. 
It  is  to  be  remembered  that  over  the  lungs  the  vibrations  are  exces- 
sive ;  over  solid  structures  they  are  modified  or  lessened.  Xow,  the 
change  from  vibrations  to  absence  of  vibrations  may  be  gradual  or 
abrupt.  Sansom  determines  this  by  percussion,  after  the  heart  has 
been  outlined  in  the  above-mentioned  manner.  In  percussing  from 
the  lung  to  the  heart  area,  if  the  modified  vibrations  occur  abruptly, 
it  is  very  probable  that  there  is  pericarditis  with  effusion  or  thickened 
pericardium ;  or  if,  on  percussing  from  above  downward,  there  is 
pericardial  effusion,  no  vibrations  are  to  be  elicited  over  the  area  de- 
limited— that  is,  the  absence  of  vibrations  is  noted  over  the  whole 
area — whereas,  in  ordinary  conditions,  when  the  pericardium  is  unaf- 
fected, in  percussing  from  above  downward  over  the  area  which  had 
been  delimited  on  the  right  and  left  sides  respectively,  a  line  will 
be  reached  where  the  vibrations  become  modified.  This  line  com- 
mences a  little  above  the  ensiform  cartilage  and  inclines  toward  the 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     619 

left  border  of  the  cardiac  dullness  at  the  level  of  the  fourth  rib  and 
third  interspace.  Vibrations  are  more  marked  above  than  below  the 
line.  The  line  at  which  the  lessened  vibrations  begin  points  out  the 
commencement  of  the  thick  wall  of  the  ventricles  ;  the  portion  above 
(more  vibratory)  indicates  the  position  of  the  right  auricle  and  vessels. 
If  the  pleximetric  percussion  is  employed,  areas  of  superficial  and  deep 
dulness  need  not  be  estimated. 

The  Apex  Impulse.  Whichever  method  of  percussion  is  em- 
ployed, it  will  be  often  observed  that  the  spot  marked  by  inspection 
and  palpation  as  the  apex  impulse  is  far  outside  of  the  left  border  of 
cardiac  dulness.  In  hypertrophy  of  the  left  ventricle  it  may  be  a  con- 
siderable distance  to  the  left.  In  dilatation  the  difference  is  not  so 
marked.  The  percussion-lines  are  made  when  the  heart  is  away  from 
the  chest,  and  hence  are  within  the  systolic  apex -beat. 

Method  of  Graphic  Record.  (See  also  page  536.)  We  are  indebted 
to  Sansom  and  Ewart  for  a  method  of  recording  the  outlines  of  the 
areas  of  dulness  and  the  position  of  the  apex-beat  and  other  pulsations, 
which  is  of  great  value  for  class-demonstration,  and  for  permanent 
records  to  compare  with  other  records  taken  from  time  to  time.  The 
points  of  pulsation  and  border-lines  of  dulness  are  marked  by  a  derma- 
tographic  pencil.  Various  colors  may  be  used  in  order  to  indicate  the 
different  data.  The  landmarks,  etc.,  are  outlined  by  a  camel's-hair 
pencil  dipped  in  olive  oil.  The  episternal  notch,  the  clavicles,  the 
intercostal  spaces,  the  ensiform  cartilage  and  nipples,  etc.,  the  percus- 
sion-outlines, and  other  recorded  marks  are  passed  over  with  the  oiled 
pencil.  A  sheet  of  tissue-paper,  or  of  copying-paper,  is  then  gently 
placed  over  the  whole,  so  that  the  oil-marks  are  imprinted.  After  the 
paper  is  removed  the  oil-outline  is  colored  with  the  dermatographic 
pencil,  and  a  permanent  record  is  preserved.  By  this  plan  of  record- 
ing a  maximum  of  precision  is  attained.  Outlines  can  be  measured 
and  positions  defined  by  mathematical  data.  The  name  of  the  patient, 
the  date  of  observation,  with  a  brief  history  of  the  case,  should  be 
attached  to  the  chart.  If  the  colored  pencil-marks  on  the  patient's 
chest  are  objectionable,  the  outline  may  be  made  with  the  colorless 
oil-pencil  at  the  various  steps  of  the  examination.  After  they  are  trans- 
mitted to  the  paper  they  may  be  made  more  distinct  with  the  colored 
pencils.  Packard  fits  to  the  chest  a  square  of  coarsely  woven  muslin 
and  outlines  the  ribs  and  sternum,  etc.,  which  are  seen  through  the 
meshes.  With  colored  pencils,  dull  areas,  etc.,  the  site  of  organs,  the 
position  of  murmurs,  are  then  designated. 

Ewart  has  shown  that  after  long  intervals  the  size  of  the  chest  and 
abdomen  is  apt  to  alter  from  various  circumstances— growth,  muscu- 
lar development,  habit  of  sitting,  etc.  He  therefore  points  out  the 
advisability  of  using  the  sternum,  which  is  immovable,  for  the  sake  of 
future  comparison. 

Sense  op  Resistance.  Ebstein  delimits  the  heart  by  the  sense  of 
resistance,  change  in  size  being  noted  by  increase  or  diminution  of  the 
area,  which  in  health  gives  a  sense  of  resistance  to  the  percussing  finger. 

Auscultation.  Method.  Either  method  of  auscultation  may  be 
employed.     By  the  immediate  method  we  may  form  a  general  notion 


620 


SPECIAL  DIAGNOSIS. 


as  to  the  condition  of  the  heart-sounds.  The  mediate,  however,  is  pref- 
erable, because  it  is  essential  to  localize  the  sounds  that  are  heard,  and 
because,  if  the  double  stethoscope  is  used,  we  can  percuss  the  cardiac 
area.  The  patient  should  be  in  a  comfortable  position.  The  muscles 
should  not  be  strained.  The  general  directions  for  performing  auscul- 
tation must  be  followed.  Before  he  begins  the  observer  has,  if  pos- 
sible, determined  the  presence  of  the  impulse,  or  found  the  radial  or 
carotid  pulse.  By  this  means  the  time  of  the  heart  is  taken  and  the 
relation  of  the  events  of  the  cardiac  cycle  to  each  other  is  ascertained. 
With  each  normal  impulse  or  carotid  pulse  a  systole  takes  place  ;  hence 
they  are  synchronous.     The  systole  occurs  just  before  the  radial  pulse. 

By  auscultation  we  determine  (1)  the  normal  sounds  of  the  heart, 
including  their  rhythm,  their  character  and  the  seat  of  maximum  in- 
tensity ;  (2)  modifications  of  the  normal  sounds  as  regards  (a)  loudness 
and  (6)  rhythm  ;  (3)  the  presence  of  abnormal  sounds  or  murmurs. 

I.  The  Normal  Sounds.  The  stethoscope  is  placed  over  the  heart 
and  the  finger  on  the  impulse  or  the  radial  pulse  ;  a  sound  will  be  noted 
at  the  time  of  the  impulse  or  the  systole,  followed  almost  immediately 
by  another  sound  and  then  a  period  of  silence.  The  sounds  that  attend 
the  systole  are  known  as  the  systolic,  or  first  sounds.  The  sounds  that 
follow  are  known  as  the  diastolic,  or  second  sounds.     The  sounds  and 


Fig.  162. 


Diagrammatic  representation  of  the  movements  and  sounds  of  the  heart.  (After  Sharpey.)  This 
diagram  shows  merely  the  general  relations  of  the  several  events,  and  does  not  represent  exact 
measurements. 

In  a  heart  beating  seventy-two  times  a  minute,  Foster  estimates  each  entire  cardiac  cycle  as 
occupying  about  0.8  sec,  of  which  0.3  sec.  represents  the  duration  of  the  systole  of  the  ventricle, 
0.4  sec.  the  diastole  of  both  auricle  and  ventricle,  or  the  "  passive  interval,"  and  0.1  sec  the  systole 
of  the  auricle. 

Only  one  '•  pause  "  is  marked  here— sometimes  called  the  "  long  pause  "  ;  some  writers  describe 
a  "short  pause"  also— indicated  in  the  diagram  by  the  small  space  between  the  first  and  the 
second  sound. 


silence  mark  the  completion  of  a  cardiac  cycle  as  far  as  the  ear  is  con- 
cerned. (Fig.  162.)  A  definite  relationship  in  time  exists  in  the  car- 
diac cycle.     Cause.     Four  sounds  are  created  during  a  cycle,  one  at 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     621 

each  valve.  The  sounds  created  with  the  systole  (systolic  sounds)  are 
due  to  contraction  of  the  right  ventricle  and  closure  of  the  tricuspid 
valve  ;  and  on  the  opposite  side,  of  the  left  ventricle  and  the  mitral 
valve.  The  rash  of  blood  along  the  course  of  the  vessels  and  the 
shock  of  the  heart  may  contribute  somewhat  to  the  systolic  sound. 
The  sounds  heard  in  the  beginning  of  the  diastole  (diastolic  sounds) 
are  due  to  closure  of  the  aortic  and  pulmonary  valves.  They  are  due 
to  the  tension  produced  on  the  valves  as  the  respective  arteries  con- 
tract upon  the  columns  of  blood.  The  closures  of  the  valves  make 
up  most,  if  not  all,  of  the  sounds.  To  review  :  two  sounds  occur  with 
the  systole,  one  from  closure  of  the  mitral,  another  from  closure  of 
the  tricusjrid  valve  ;  two  with  the  diastole  from  closure  of  the  aortic 
and  pulmonary  valves,  respectively.  In  health  the  sounds  of  the  sys- 
tole blend  because  synchronous,  giving  the  impression  at  a  common 
point  of  one  sound.  Analysis  of  the  sound  in  the  respective  valve 
areas  will  show  that  the  systolic  sound  is  made  of  two  sounds.  The 
sounds  of  the  diastole  may  or  may  not  blend.  Often  there  is  an  appre- 
ciable difference  between  the  two. 

Recognition  of  the  Respective  Sounds.  To  distinguish  the  sounds  we 
study  their  rhythm  or  time,  their  character,  their  position  of  maximum 
intensity,  and  their  direction  of  transmission.  We  distinguish  the  first 
from  the  second  sounds  by  their  rhythm  and  character,  and  then  differ- 
entiate the  sounds  respectively  of  the  systole  and  of  the  diastole  by 
their  point  of  maximum  intensity. 

(a)  The  Rhythm  or  Time.  The  sounds  that  are  heard  at  the  time  of 
the  normal  impulse  or  just  before  the  radial  pulse  are  the  systolic  or 
first  sounds ;  the  sounds  that  follow  the  impulse  are  the  second  sounds. 
The  sounds  that  follow  the  long  silence  are  the  systolic  or  first  sounds  ; 
those  that  precede  the  long  silence  are  diastolic  or  second  sounds. 

(b)  Character  of  the  Sounds.  The  systolic  sounds  are  pro- 
longed, somewhat  dull  in  character,  low  in  pitch,  and  resemble  the 
sound  produced  by  the  pronunciation  of  the  syllable  "  ubb."  The 
diastolic  sounds  are  short,  sharp,  and  quick,  and  resemble  the  sound 
produced  by  the  pronunciation  of  the  syllable  "  dupp."  The  syllables 
ubb,  dupp  indicate  the  character  of  the  sounds  in  health.  Modifica- 
tions in  the  intensity  of  the  sound  are  due  to  changes  in  the  tension  of 
the  valve-curtains,  and  are  dependent  upon  the  force  of  muscular  con- 
traction, which,  if  strong,  renders  the  valves  more  tense.  Experiment 
and  the  results  of  disease  have  aided  in  proving  these  points. 

(c)  Position  op  Maximum  Intensity.  In  general  the  first  sounds 
are  loudest  at  the  lower  part  of  the  prsecordia,  the  second  at  the  upper. 
But  we  especially  distinguish  the  independent  valve  elements  which 
make  up  the  systolic  and  the  diastolic  sounds  in  the  following  manner. 
The  sounds  produced  by  the  closure  of  the  valves  are  created,  as  the 
topography  of  the  heart  shows,  quite  near  to  each  other,  but  by  con- 
duction of  the  sound  they  are  transmitted  away  from  the  respective 
valves  in  particular  directions,  and  heard  loudest  in  definite  areas  on 
the  chest. 

The  Systolic  or  First  Sounds.  Two  sounds  are  created.  The 
valves  which  cause  the  sound  are  near  to  each  other.     Because  of  their 


622 


SPECIAL  DIAGNOSIS. 


anatomical  relations  the  sounds  are  conducted  into  different  areas,  by 
virtue  of  which  they  are  differentiated.  The  Mitral  Valve  Sound. 
The  sound  produced  by  the  closure  of  the  mitral  valve  is  created  oppo- 
site the  fourth  interspace  near  the  sternum.  It  is  transmitted  to  the 
surface  of  the  chest  by  the  thickened  left  ventricle,  and  hence  is  heard 

Fig.  163. 


Areas  of  cardiac  murmurs  (Gairdner  for  the  areas;  and  Luschka  for  the  anatomy).  The  out- 
lines of  organs,  which  are  partially  invisihle  in  the  dissection,  are  indicated  by  very  fine  dotted 
lines ;  while  the  areas  of  propagation  of  valvular  murmurs,  as  described  in  the  text,  have  been 
roughly  marked  by  additional  much  coarser  and  more  visible  dotted  lines— the  character  of  the 
dots  being  different  in  each  of  the  four  areas  A  capital  letter  marks  each  area — viz.,  A,  the  circle 
of  mitral  murmurs  corresponding  with  the  left  apex ;  B,  the  irregular  space  indicating  the  ordi- 
nary limits  of  diffusion  of  aortic  murmurs,  corresponding  mainly  with  the  whole  sternum,  and 
extending  into  the  neck  along  the  course  of  the  arteries ;  C,  the  broad  and  somewhat  diffused 
area  occupied  by  tricuspid  murmurs,  and  corresponding  generally  with  the  right  ventricle  ;  D,  the 
circumscribed  circular  area  over  which  pulmonic  murmurs  are  commonly  heard  loudest. 

Reference  letters :  r.  au.  =  right  auricle  :  a.  o.  =  arch  of  aorta  ;  v.  i.  =  the  two  innominate  veins  ; 
v.  c.  =  vena  cava  descendens ;  p.  =  pulmonary  artery ;  1.  au.  =  left  auricle ;  1.  v.  =  left  ventricle  ; 
r.  v.  =  right  ventricle.    (Finlayson.) 


loudest  where  that  is  nearest  the  chest,  namely,  at  the  apex — the  mitral 
area.  The  Tricuspid  Valve  Sound.  The  sound  produced  by  the 
closure  of  the  tricuspid  valve  is  transmitted  by  the  right  ventricle,  and 
is  heard  loudest  over  the  lower  portion  of  the  sternum — the  tricuspid 
area. 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     623 

The  Diastolic  or  Second  Sounds.  Two  sounds  are  created. 
The  valves  at  which  they  are  produced  are  also  in  close  proximity. 
To  distinguish  the  two  sounds  it  is  necessary  to  auscult  over  areas  into 
which  they  are  transmitted.      They  may  often   be  distinguished  by 

Fig.  164. 


The  valve  areas. 
1.  Mitral  area.    2.  Tricuspid  area.    3.  Aortic  area.    4.  Pulmonary  area. 


their  slight  difference  in  time,  the  aortic  preceding  the  pulmonic  by  a 
fraction  of  a  second.  The  Aortic  Valve  Sound.  The  sound  produced 
by  the  closure  of  the  aortic  valve  is  heard  loudest  at  the  second  costal 
cartilage  on  the  right,  because  the  aorta  which  conducts  the  sound  is 
nearest  the  surface  of  the  chest  at  this  point — the  aortic  area.  This 
cartilage  is  known  as  the  aortic  cartilage.  The  Pulmonary  Valve 
Sound.  The  sound  produced  by  the  closure  of  the  pulmonary  valve  is 
conducted  to  the  left  and  heard  loudest  in  the  second  interspace  near 
the  left  edge  of  the  sternum — the  pulmonary  area. 

(d)  The  Direction  of  Transmission.  The  first  sounds  are  trans- 
mitted toward  the  axillae.  They  may  be  heard  all  over  the  cardiac 
area,  but  the  position  of  maximum  intensity  is  in  the  lower  portion  and 
toward  the  left.  The  second  sounds  are  loudest  at  the  base  of  the  heart. 
They  may  be  propagated  beyond  the  prsecordia  toward  the  neck,  and 
be  heard  loudest  in  the  vessels  of  the  neck. 

Precise  Location  and  Differentiation  of  Each  Sound. 
This  may  be  determined  by  listening  with  the  bell  of  the  stethoscope 
over  each  area.  Then  move  the  bell  of  the  stethoscope  gradually  from 
one  area  into  the  other.  As  the  sound  of  the  original  area  lessens  the 
sound  of  the  approached  area  is  observed.  The  change  from  one  to 
the  other  is  often  very  marked.  1.  Mitral  first  or  systolic  sound,  heard 
loudest  at  the  apex,  inward  to  the  parasternal  line,  upward  to  the  third 
interspace.  2.  Tricuspid  first  or  systolic  sound,  heard  loudest  at  the 
lower  part  of  the  sternum  and  toward  the  left  to  the  parasternal  line  as 
high  as  the  third  rib.  3.  Aortic  second  or  diastolic  sound,  heard  loudest 
at  the  aortic  cartilage,  propagated  into  the  vessels  of  the  neck,  and  also 


624  SPECIAL  DIAGNOSIS. 

heard  at  and  outside  of  the  apex-beat.  It  is  louder  than  the  pulmo- 
narv  second  sound  in  health.  4.  Pulmonary  second  or  diastolic  sound, 
localized  to  the  second  interspace  and  the  third  rib. 

II.  Modifications  of  the  Sounds.  The  sounds,  singly  or  com- 
bined, may  be  increased  or  diminished  in  intensity  or  accentuation. 
They  may  be  altered  in  rhythm. 

Sounds  Increased,  a.  Games  outside  of  the  pericardium.  1.  Any- 
thing which  brings  the  heart  closer  to  the  ear  of  the  observer.  Thus, 
in  patients  with  thin  chest-walls,  when  the  heart  is  pushed  to  the  sur- 
face of  the  chest  (mediastinal  tumor)  or  the  lung  removed  (pleural 
contraction).  2.  Anything  which  conducts  the  sounds,  as  consolidated 
lung  in  the  vicinity,  or  a  pneumothorax,  or  pulmonary  cavities.  6. 
Affections  of  the  pericardium,  as  pericardial  adhesions,  c.  Conditions  of 
the  heart.  1.  Hypertrophy.  2.  Overaction,  as  in  palpitation,  fevers, 
anaemia,  exophthalmic  goitre. 

Sounds  AYeakened.  a.  Causes  outside  of  the  pericardium.  1.  Gen- 
eral exhaustion.  2.  Thick  chest-walls,  large  mammary  gland.  3. 
Emphvsema  of  the  lungs  overlapping  the  heart,  b.  Affections  of  the 
pericardium,  as  fluid  or  air  in  the  pericardial  sac.  c.  Conditions  of 
the  heart.     Atrophy  ;  myocarditis  ;  some  cases  of  dilatation. 

In  short,  loudness  of  all  the  sounds  occurs  from  (a)  conditions  out- 
side of  the  heart ;  heart  nearer  chest-wall,  consolidation  of  lungs,  cavi- 
ties ;  (b)  conditions  of  the  heart  itself ;  hypertrophy ;  overaction. 
Weakness  of  the  sound  occurs  from  :  (a)  Conditions  outside  of  the 
heart  :  thick  chest- walls,  emphysema,  general  exhaustion  ;  (6)  affec- 
tions of  the  pericardium  :  effusions  ;  (c)  affections  of  the  heart  :  atro- 
phy ;  dilatation  ;  myocarditis. 

Modifications  of  Individual  Sounds.  The  above  applies  to  all 
the  sounds.  Increase  or  diminution  of  the  systolic  or  of  the  diastolic 
sounds,  or  of  any  one  of  the  four  sounds,  may  be  present. 

Increase  in  Loudness  of  the  Systolic  Sound.  Increased  loud- 
ness of  the  first  sound  is  noted  when  the  muscle  is  hypertrophied,  and 
the  tension  on  the  valves  thereby  increased.  In  hypertrophy  of  the 
left  ventricle  the  increase  is  most  marked.  The  sound  is  duller  and 
has  a  prolongation  which  is  very  characteristic.  In  hypertrophy  of 
the  right  ventricle  the  sound  is  dull  and  prolonged  over  the  sternum, 
but  not  to  the  same  degree  as  when  the  left  is  hypertrophied. 

Increase  in  Loudness  of  the  Diastolic  Sound.  Either  of  the 
second  or  diastolic  sounds  may  be  increased  in  loudness  or  accentuated. 

Fig.   165. 

A 


Normal  first  Accentuated 

and  second  sounds.       first  sound. 


1.  Tin1  Aort'u-  Diastolic  Sound.  Anything  which  causes  increased 
tension  in  the  aortic  circulation,  and  hence  increased  contractile  force 
of  the  aorta,  will  increase  the  intensity  or  accentuation  of  the  second 
sound.     In  hypertrophy  of  the  heart  the  aortic  sound  is  accentuated 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     625 

because  there  is  corresponding  increased  contraction  of  the  aorta,  fol- 
lowing the  forcible  expulsion  of  the  blood  from  the  ventricle.  Increase 
in  arterial  tension  is  also  due  to  increased  contraction  of  the  aorta  when 
there  is  peripheral  resistance  to  the  outflow  of  blood.  It  is  associated 
with  the  following  conditions  which  cause  accentuation  of  the  second 
sound  :  Atheroma  of  the  aorta,  or  of  the  arteries  in  general ;  aneurism 
of  the  aorta  ;  disease  of  the  kidneys,  and  particularly  in  that  form  in 
which  there  are  also  general  arterial  changes — namely,  chronic  inter- 
stitial nephritis.  It  is  true  that  the  accentuation  may  be  partly  due 
to  the  hypertrophy  of  the  heart  which  coexists. 

Accentuation  of  the  aortic  second  sound  occurs  independently  of  per- 
manent change  in  the  arteries.  If  for  any  reason  there  is  spasm  of  the 
peripheral  capillaries,  as  from  a  chill,  from  epilepsy,  from  nervousness 
due  to  hysteria,  tension  in  the  arteries  is  heightened,  and  hence  the 
second  sound  accentuated.  It  is  seen  that  accentuation  of  the  second 
sound  is,  therefore,  a  marked  index  of  the  state  of  the  vascular  system 
in  general ;  it  is  not  an  evidence  of  disease  of  the  heart  alone.  In 
certain  fevers  and  in  states  of  the  blood  in  which  the  vasomotor  nerves 
are  irritated,  causing  peripheral  contraction,  as  in  scarlatina,  accentu- 

FlG.  166. 

A 

n  n   r 


Normal  first  and       Accentuated 
second  sounds.      second  sound. 


ation  of  the  second  sound  is  observed,  often  before  the  development  of 
local  inflammatory  diseases  due  to  the  same  cause,  as  nephritis  in  scar- 
latina. The  occurrence  of  this  complication  may  be  suspected  when 
accentuation  of  the  aortic  second  sound  is  heard. 

2.  The  Pulmonary  Diastolic  Sound.  This  is  due  to  the  same  phys- 
ical condition  which  causes  accentuation  of  the  aortic  second  sound. 
Anything  which  heightens  the  tension  in  the  pulmonary  artery  will 
cause  increased  loudness.  In  health  the  pulmonary  second  is  not  so 
loud  as  the  corresponding  aortic  sound.  If,  therefore,  we  find  in  the 
second  or  third  left  interspace  the  sound  as  loud  as  an  aortic  sound,  or 
louder,  it  can  be  said  that  the  pulmonary  second  sound  is  accentuated. 

It  is  due  :  1.  To  any  condition  which  causes  congestion  within  the 
lungs,  the  right  ventricle  being  at  the  same  time  of  normal  or  increased 
strength.  It  is  heard  in  the  early  stages  of  pneumonia,  and,  if  the 
course  of  the  disease  continues  favorable,  may  remain  accentuated  to 
the  end.  If,  on  the  other  hand,  the  circulation  is  embarrassed,  and 
the  right  heart  is  failing,  it  will  become  fainter,  and  may  be  scarcely 
recognizable.  Such  change  in  the  sound  accompanies  increase  of  respi- 
ratory distress,  and  indicates  that  the  right  heart  is  becoming  ex- 
hausted. It  is,  therefore,  an  ominous  sign  in  acute  pulmonary  disease. 
If  the  case  is  unfavorable,  the  signs  of  right-sided  dilatation  will  sub- 
sequently occur.  2.  It  occurs  in  emphysema  of  the  lungs.  Notwith- 
standing the  covering  of  the  heart  by  the  lung,  the  sound  can  be  heard, 

40 


626  SPECIAL  DIAGNOSIS. 

and  may  be  the  only  one  of  the  four  sounds  which  can  be  distin- 
guished. 3.  In  valvular  disease  of  the  heart  seated  at  the  mitral  orifice 
accentuation  of  the  pulmonary  second  sound  is  heard,  due  to  increased 
tension  in  the  pulmonary  artery.  In  mitral  obstruction  the  blood  is 
retained  in  the  auricle  and  pulmonary  veins,  causing  a  resistance  to 
the  force  of  the  right  ventricle.  Increased  tension  in  the  pulmonary 
artery  is  the  result,  with  exaggerated  strain  upon  the  valves.  In 
mitral  regurgitation,  with  the  systole  the  blood  is  thrown  back  into 
the  auricle,  and  consequently  meets  with  blood  coming  from  the  lungs. 
This  in  time  increases  the  amount  of  blood  and  of  blood-pressure  in 
the  pulmonary  artery.  A  heightened  tension  results.  Skoda  pointed 
out  the  significance  of  this  association.  Sometimes  in  doubtful  cases, 
either  in  the  presence  or  absence  of  a  murmur  at  the  mitral  orifice,  the 
occurrence  of  this  sign  makes  it  more  than  probable  that  there  is  mitral 
valvulitis. 

Diminished  Accentuation  of  Feebleness  of  the  Sounds.  1. 
Feebleness  of  the  Mitral  Sound.  Feebleness  of  the  mitral  sound  ob- 
served at  the  apex  of  the  heart  may  be  an  indication  of  weakness  of 
the  muscle  from  dilatation,  atrophy,  or  myocarditis.  It  must  be  remem- 
bered, however,  that  weakness  of  the  ventricle  is  not  attended  by  en- 
feeblement  of  sound  alone,  but  that  when  the  right  or  left  ventricle  is 
weakened  the  duration  of  the  sound  is  lessened.  The  loudness  remains 
the  same,  or  may  be  increased.    Note,  then,  that  a  short  systolic  sound, 


a 


n 


Normal  first  and       Diminished 
second  sounds.         first  sound. 

loud,  sharp,  flapping,  sometimes  reverberating,  heard  at  the  apex,  indi- 
cates dilatation  or  feebleness.  The  tension  of  the  ventricles  and  valves 
creating  the  sound  is  increased  by  internal  pressure.  The  systolic 
sounds  become  like  the  diastolic,  and  may  be  distinguished  by  the  ear 
with  difficulty ;  but  if  the  time  is  taken  with  the  finger  on  the  apex- 
beat  or  carotid  artery,  if  the  heart's  action  is  slow  the  distinction  can 
readily  be  made. 

Diminished  Accentuation  of  the  Aortic  Sound.  This  is  an  indication 
of  cardiac  weakness,  and  is  apt  to  ensue  in  the  course  of  fevers  when 
exhaustion  takes  place.  It  is  a  sign  of  myocarditis  and  of  degenera- 
tion of  the  muscular  walls  of  the  heart.  Under  these  circumstances 
the  systole  of  the  ventricle  is  also  weakened. 

Feebleness  of  the  aortic  second  sound,  with  hypertrophy  and  hence 
strong  contraction  of  the  ventricle,  occurs  when  the  aortic  leaflets  are 
swollen  or  enlarged  and  thickened.  This  condition  of  the  valves  is  due 
to  atheroma,  and  is  in  all  probability  associated  with  atheroma  of  adja- 
cent vessels,  as  the  coronary  arteries.  It  is,  therefore,  a  sign  of  serious 
importance. 

diminished  Accentuation  of  the  Pulmonary  Sound.  This  is  of  impor- 
tance in  the  course  of  valvular  disease  of  the  heart,  providing  previous 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     627 

accentuation  has  been  observed.  If  the  marked  loudness  gives  way  to 
feebleness,  there  is  strong  probability  that  the  right  heart  is  under- 
going dilatation  with  regurgitation  at  the  tricuspid  orifice.  While 
accentuation  of  the  pulmonary  second  sound  in  valvular  disease  is  of* 
good  omen,  enfeeblement  of  the  sound  is  of  bad  prognostic  omen,  indi- 
cating weakness  of  the  right  ventricle. 

Alterations  in  the  Rhythm.  Foetal  rhythm  of  the  heart : 
Embryocardia — a  term  first  used  by  Huchard  to  designate  a  condition 
in  which  the  pauses  between  the  heart-sounds  are  of  equal  length.  The 
first  and  second  sounds  are  exactly  alike,  resembling  the  beat  of  the 
foetal  heart.  The  sign  is  of  importance  in  prognosis.  In  acute  dis- 
ease and  in  fever  it  indicates  enfeeblement  of  the  heart  and  reduction 
of  arterial  tension.  In  the  later  stages  of  Graves'  disease  it  is  a  fore- 
runner of  death.  It  is  distinguished  from  the  rapid  beat  of  the  heart 
in  tachycardia  by  the  fact  that  in  the  latter  condition  the  normal 
rhythm  is  preserved. 

Cantering  Rhythm  of  the  Heart.  The  ear  recognizes  three  sounds. 
The  usual  sounds  may  or  may  not  be  attended  by  murmur,  and  the 
interpolated  sound  may  be  dull,  or  short  and  sudden.  It  may  occur  at 
various  periods  in  the  cardiac  cycle,  either  just  before  the  systolic  sound, 
just  after  the  diastolic  sound,  or  during  the  diastolic  pause.  The  rhythm 
recalls  the  sound  of  a  horse  cantering.  It  was  termed  by  Bouillaud 
the  bruit  de  galop.  When  the  interpolated  sound  resembles  the  first 
or  second  it  is  similar  to  reduplication  of  the  sounds.  It  has  been 
observed  in  hypertrophy  of  the  heart,  especially  of  the  left  ventricle ; 
dilatation  of  the  heart ;  in  adherent  pericardium  with  dilated  hyper- 
trophy ;  in  myocarditis,  in  the  course  of  fevers ;  and  in  excessive 
ansemia.  It  is  heard  loudest  over  the  right  and  left  ventricles. 
Potain  thinks  it  is  due  to  tension  communicated  to  the  wall  of  the 
ventricle  by  the  entrance  of  blood  into  its  cavity,  and  is  more  marked 
when  the  wall  is  least  extensible,  as  in  hypertrophy  on  the  one  hand 
or  exhaustion  of  the  muscle  ;  in  either  of  the  two  the  walls  vibrate 
more  readily.  The  triple  rhythm  is  of  bad  prognostic  omen  in  chronic 
Blight's  disease. 

Reduplication  of  the  Sounds.  Reduplication,  or  apparent 
doubling  of  the  heart-sounds,  occurs  in  various  forms.  In  health  the 
systolic  sounds  are  created  synchronously  ;  a  fraction  of  a  second,  not 
appreciated  by  the  ear,  separates  the  diastolic  sounds.  In  so-called 
reduplication  one  systolic  sound  may  follow  the  other,  or  the  aortic  and 
pulmonary  diastolic  sounds  may  be  created  at  distinct  intervals.  As 
has  been  stated,  in  galloping  rhythm  the  idea  of  reduplication  is  some- 
times transmitted  to  the  ear.  Reduplication  may  take  place  in  health 
under  the  influence  of  respiratory  movements.  The  systolic  sounds 
may  be  doubled  at  the  end  of  expiration  and  the  commencement  of 
inspiration,  while  the  diastolic  sounds  are  doubled  at  the  end  of  inspi- 
ration and  the  commencement  of  expiration.  In  mitral  disease  redu- 
plication, or  want  of  synchronous  closure  of  the  two  valves,  is  of  frer- 
quent  occurrence.  The  heart-sounds  are  doubled  and  heard  over  the 
base  of  the  heart.  Reduplication  of  the  systolic  sounds  occurs  in 
chronic  Bright' s  disease. 


628  SPECIAL  DIAGNOSIS. 

Reduplication,  or  Doubling  of  the  Systolic  Sounds,  is  heard  over  the 
apex  or  the  right  ventricle.  Several  explanations  have  been  given 
for  the  cause  of  the  reduplication.  At  first  it  was  thought  to  be  due 
to  want  of  synchronism  in  the  action  of  the  ventricles — that  one  ven- 
tricle contracted  before  the  other,  due  to  the  fact,  of  course,  that  the 
presence  of  blood  stimulates  one  but  not  the  other.  By  Hayden  it 
was  thought  that  reduplication  of  the  first  sound  was  due  to  the  two 
major  elements  of  the  sound  acting  asynchronously,  the  muscular  sound 


n 


Fig.  168. 


n 


a.  b 

Normal  first  and      Reduplicated 

second  sounds.         first  sound. 

taking  place  before  the  sound  produced  by  the  tension  of  the  valves. 
Dr.  George  Johnson  took  the  view  that  the  reduplication  was  due  to 
the  contraction  of  the  auricle  and  ventricle  ;  that  the  sound  produced 
by  the  former  was  heard  on  account  of  hypertrophy  of  the  auricle,  and 
heard  first  because  of  the  natural  order  of  precedence.  Thus  far  the 
reasons  for  each  view  have  not  been  fully  established. 

Sansom  believes  that  reduplication  of  the  first  sound  is  due  to  the 
shock  communicated  to  the  contents  of  the  ventricle  just  before  systole 
— that  is,  during  the  auricular-systolic  period — in  other  words,  it  is 
due  to  the  indirect  effect  of  the  auricular  systole.  The  contraction  of 
the  auricle  makes  tense  the  auriculo-ventricular  valve  of  the  left  side. 
If  it  occurs  late  in  the  diastole,  or  just  before  the  systole,  reduplication 
of  the  first  sound  is  caused  ;  if  early  in  the  diastole,  reduplication  of 
the  second  sound  is  created. 

Reduplication  of  the  Diastolic  Sounds.  While  held  by  some  authori- 
ties to  occur  in  a  large  proportion  of  healthy  individuals  at  the  end  of 
inspiration  and  the  commencement  of  expiration,  other  observers, 
equally  careful,  think  that  it  is  extremely  rare.  It  is  of  frequent 
occurrence  in  the  patients  of  the  Philadelphia  Hospital.  This  is  no 
doubt  due  to  the  fact  that  so  many  of  the  inmates  are  the  subjects 
of  all  forms  of  lung  disease,  or  disease  of  the  vascular  system,  with 
muscular  degeneration  of  the  heart,  that  the  equability  of  the  pul- 
monic circulation  is  disturbed.  There  is  no  doubt  that  it  can  be 
modified  or  induced  by  inspiration.  It  is  usually  heard  at  the  end  of 
inspiration  and  commencement  of  expiration.  Actual  reduplication  of 
the  second  sound  occurs  when  the  normal  asynchronism  of  the  closure 
of  the  aortic  and  pulmonary  valves  is  exaggerated.  It  has  been  found 
that  the  valve  of  the  pulmonary  artery  closes  a  fraction  of  a  second 
after  the  aortic  valve.  The  ear  usually  fails  to  appreciate  the  differ- 
ence unless  there  are  differences  of  blood-pressure  ;  when  doubled,  and 
therefore  appreciated,  it  is  indicative  of  a  difference  in  blood-pressure 
between  the  two  sides  of  the  circulation.  Increased  resistance  in 
either  will  lead  to  increased  tension,  quickened  recoil,  and  hence  quick- 
ened closure  of  the  valve.     The  conditions  that  are  associated  with  the 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     629 

doubling  of  the  second  sound  are  (1)  and  most  frequently,  mitral  sten- 
osis ;  (2)  obstruction  of  the  circulation  in  the  lung — tuberculosis,  em- 
physema, and  bronchopneumonia  ;  (3)  dilatation  of  the  right  ventricle  ; 
(4)  myocarditis.  The  sound  is  heard  at  the  second  and  third  costal 
cartilages  along  the  left  edge  of  the  sternum.  It  is  frequently  heard 
at  the  fourth  and  fifth  cartilages  on  the  left  side.  In  cases  of  mitral 
stenosis  it  is  heard  near  the  apex. 

Fig.  169. 

A 


a.  b. 

Normal  first  and  Reduplicated  and 

second  sounds.        accentuated  second  sound. 
Illustrating  diagrammatically  modifications  of  the  heart-sounds.    (Gibson  and  Russell.) 

Simulated  doubling,  or  false  reduplication,  is  a  sound  produced  at 
the  mitral  orifice.  It  is  difficult  to  tell  it  from  true  doubling  or  redu- 
plication. It  is  most  distinct  at  the  base  of  the  heart  along  the  left 
edge  of  the  sternum.  Occasionally  it  is  more  distinct  near  the  apex 
than  elsewhere.  It  occurs  with  the  conditions  found  in  true  doubling 
and  in  mitral  obstruction.  Cause.  Sansom,  Cheadle,  and  others  dis- 
tinctly point  out  that  this  double  second  sound  is  of  frequent  occur- 
rence, and  that  it  is  heard  most  frequently  at  the  apex.  Sansom 
thinks  that  the  cause  for  simulated  doubling  of  the  second  sound  is 
the  same  as  for  doubling  of  the  first.  There  is,  first,  the  normal  second 
sound  ;  second,  a  tension  of  the  mitral  curtain  producing  the  second 
simulated  sound.  This  tension  is  due  to  the  shock  of  the  blood  coming 
from  the  auricle  to  the  ventricle. 

III.  Abnormal  Sounds  or  Murmurs.  Abnormal  sounds  may  be 
heard  over  the  heart  in  addition  to  or  replacing  the  normal  sounds. 
These  sounds  are  produced  in  the  pericardium,  in  the  heart,  or  in  the 
bloodvessels.  They  are  divided  into  friction-sounds  and  murmurs. 
They  are  recognized  because  they  are  a  departure  from  the  normal 
sounds  or  because  they  are  superadded  sounds. 

Abnormal  Sounds  in  the  Pericardium.  They  are  known  as 
friction-sounds  and  splashing  or  bubbling  sounds.  The  former  occur  in 
the  first  stage  of  pericarditis,  and  are  due  to  the  rubbing  together  of 
the  inflamed  surfaces,  either  the  congested,  vascular  pericardium,  or 
the  membrane  bathed  in  exudation,  or  covered  by  lymph.  The  fric- 
tion-sound is  recognized  by  (1)  its  character,  (2)  time,  (3)  position,  (4) 
transmission,  (5)  movability,  (6)  modification  by  position  of  patient, 
pressure,  course  of  disease,  etc.  1.  The  pericardial  friction  is  usually 
of  a  to-and-fro  character,  and  can  be  recognized  as  distinct  from  the 
heart-sounds.  It  resembles  the  rubbing  or  scraping  together  of  two 
roughened  surfaces.  2.  It  is  not  necessarily  synchronous  with  each 
sound.  It  is  a  to-and-fro  sound,  systolic  and  diastolic  in  time.  It 
may,  however,  be  only  systolic  or  only  diastolic.  3.  It  is  heard  over 
the  body  of  the  heart,  usually  in  the  third  and  fourth  interspaces,  or 
even  over  the  right  ventricle.     4.  It  is  not  transmitted  away  from  the 


630  SPECIAL  DIAGNOSIS. 

heart.  Its  location  may  shift  from  day  to  day  in  the  precordial  area. 
5.  It  may  be  modified  by  pressure  or  by  respiratory  movement,  or  be 
influenced  by  the  position  of  the  patient.  It  may  disappear  entirely 
in  the  upright  posture.  An  impression  of  nearness  to  the  ear  is  given 
by  the  sound  observed  in  the  first  stage  of  pericarditis.  It  may  be  in- 
creased or  lessened  in  loudness  by  a  deep  inspiration.  It  disappears 
during  the  period  of  effusion,  to  return  after  that  is  absorbed. 

Diagnosis.  It  must  be  distinguished  from  the  pleural  friction,  which 
disappears  if  the  patient  is  asked  to  hold  his  breath.  The  pericardial 
friction  is  of  cardiac  rhythm,  the  pleural  friction  of  respiratory  rhythm. 
It  must  also  be  distinguished  from  the  so-called  exocardial  _  friction- 
sounds.  The  pleura  adjacent  to  the  pericardium  may  be  inflamed. 
With  each  beat  of  the  heart  the  rough  surfaces  of  the  pleura  are  agi- 
tated and  generate  a  friction.  It  is  seated  along  the  edges  of  the  right 
auricle  or  left  ventricle.  It  is  systolic  in  rhythm,  but  has  the  special 
characteristic  that  it  is  modified  by  respiration.  It  may  be  arrested  if 
the  patient  holds  his  breath.  It  is  increased  by  inspiration,  or  dimin- 
ished in  expiration  when  the  lungs  recede  from  the  heart  in  expiration. 
The  pericardial  friction  must  be  distinguished  from  the  crepitations 
and  rales  of  cardiac  rhythm  produced  by  the  impact  of  the  heart 
against  the  lung.  They  disappear  when  the  breath  is  held.  The  dis- 
tinctions between  pericardial  frictions  and  cardiac  murmurs  will  be 
considered  later. 

Splashing  sounds  are  heard  when  there  are  air  and  fluid  in  the  peri- 
cardium. They  may  be  bubbling  or  gurgling  or  resemble  the  sound 
of  a  water-wheel.     They  continue  when  the  breath  is  held. 

■  Abnormal  Sounds  in  the  Heart  and  Vessels.  Murmurs. 
If  the  student  listens  with  the  stethoscope  over  a  large  superficial 
vessel,  and  does  not  employ  pressure,  he  will  not  detect  any  sound. 
If,  however,  pressure  is  employed,  a  sound  or  murmur  is  produced. 
The  passage  of  the  blood  through  the  vessel  produces  no  sound  because 
the  vessel  or  tube  is  of  equal  calibre.  The  pressure  of  the  stethoscope 
alters  the  calibre  and  compels  the  fluid  to  pass  through  a  narrow  orifice 
into  a  wider  space.  In  this  manner  a  fluid  vein  is  produced.  The 
vibration  of  the  molecules  of  the  agitated  fluid  vein  produces  a  sound 
or  murmur.  The  loudness  of  the  sound  depends  upon  the  swiftness 
of  the  flow.  The  sound  in  this  instance  is  carried  in  the  direction  of 
the  blood-current,  hence  the  murmur  is  known  as  an  onward  murmur. 

The  reverse  may  take  place.  The  fluid  may  flow  backward  from  a 
wider  into  a  narrower  space  without  the  production  of  sound  ;  if,  how- 
ever, the  fluid  breaks  on  bevelled  edges,  as  the  leaflets  of  heart-valves 
projecting  into  the  current,  the  fluid  is  again  thrown  into  vibration  and 
produces  noise.  If  there  is  considerable  constriction  by  the  bevelled 
edge,  the  sound  is  carried  farthest  against  the  natural  flow  of  the  fluid 
— hence  the  term  backward  murmur.  Some  authors  hold  that  mur- 
murs are  also  due  to  lateral  vibrations  of  the  walls  of  the  heart  or  of 
the  vessels.  Some  murmurs  may  resemble  tones,  and  are  called  musi- 
cal murmurs.  Such  murmurs  are  due  either  to  the  vibrations  of  the 
solids  set  up  by  the  vibrating  fluid  vein,  or  to  the  vibrations  of  the 
fluid  vein  alone. 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     631 

Murmurs  are  divided  into  two  classes,  in  accordance  with  their  seat 
of  development.  Murmurs  originating  in  the  heart  are  known  as  car- 
diac murmurs.  Murmurs  originating  in  the  bloodvessels  are  vascular 
murmurs.  (See  The  Arteries.)  Cardiac  and  vascular  murmurs  are 
divided  into  (1)  organic  murmurs,  if  due  to  physical  changes  of  the 
heart  or  vessels  ;  (2)  inorganic,  functional,  or  hcemic,  if  due  to  changes 
in  the  quality  of  the  blood.  (See  Functional  Murmurs.)  Cardiac 
murmurs  are  always  generated  at  the  orifices  from  disease  or  from 
incompetency  of  the  valves,  or  from  patulous  non-valve  opening.  The 
orifices  are  valvular  and  non-valvular. 

Murmurs  at.  Valvular  Orifices.  The  valvular  orifices  and 
their  anatomical  relations  have  been  described.  Murmurs  are  produced 
at  these  orifices  when  they  are  open  or  when  normally  they  should  be 
closed.  If  the  murmur  is  produced  when  the  orifice  is  open  it  is 
because  there  is  narrowing  of  the  orifice  or  dilatation  of  the  cavity 
(relative  narrowing).  The  murmur,  then,  is  always  produced  ivith  the 
natural  current  of  blood,  and  hence  is  known  as  an  onward  or  obstructive 
murmur.  It  always  or  nearly  always  implies  organic  disease  at  the 
valve-orifice,  hsemic  murmurs  excluded.  If  the  murmur  is  produced 
when  the  orifice  should  be  closed,  and  hence  when  the  valve  leaks,  it  is 
because  the  valves  are  diseased  and  cannot  shut  the  orifice,  or  because 
they  are  too  small — incompetent — to  shut  it.  Such  murmurs  are  pro- 
duced against  the  natural  current  of  blood,  and  are  known  as  backward 
or  regurgitant  murmurs. 

Murmurs  at  Non-valvular  Orifices.  The  orifices  of  the  vena 
cavse  and  of  the  pulmonary  veins,  and  of  the  perforations  of  the  septa 
in  congenital  heart  disease,  are  non-valvular.  They  are  at  times  the 
seat  of  murmurs — as  in  open  foramen  ovale  or  perforated  ventricular 
septum. 

Diagnosis  of  Murmurs.  The  student  has  learned  that  an  abnor- 
mal sound  or  a  murmur  is  present.  It  is  necessary  then  to  determine, 
first,  at  which  orifice  the  murmur  is  produced  (the  seat  of  the  murmur) 
and,  second,  the  kind  of  murmur — obstructive  or  regurgitant.  Mur- 
murs are  therefore  studied  as  heart-sounds  are  studied,  as  to  their 
position  of  maximum  intensity,  their  time,  and  the  direction  of  their 
transmission.  The  position  of  the  murmur  indicates  which  valve- 
orifice  is  affected,  the  time  and  the  direction  of  transmission,  and  the 
kind  of  murmur. 

The  Position  of  Maximum  Intensity  of  the  Murmur.  The 
Orifice  Affected.  We  are  enabled  accurately  to  determine  the  orifice 
at  which  the  murmur  is  generated  by  noting  the  position  of  maximum 
intensity  of  the  murmur.  This  corresponds  to  the  area  at  which  the 
normal  sound  of  the  respective  valve  is  heard  loudest.  It  may  be  re- 
membered that  the  cardiac  orifices  are  closely  situated,  and  that,  there- 
fore, the  murmurs  must  be  generated  within  a  small  area,  so  small  that 
it  would  be  impossible  to  ascertain  at  which  valve-orifice  the  murmur 
is  created,  were  it  not  for  the  fact  that  under  the  laws  of  conduction  of 
sound  the  murmurs  are  conducted  away  from  their  point  of  origin  to 
certain  definite  stations,  where  in  health  the  respective  valve-sound  is 
also  heard  loudest. 


632 


SPECIAL  DIAGNOSIS. 


1.  Murmurs  at  the  Apex — the  Mitral  Area.  A  murmur  heard 
loudest,  or  with  the  greatest  intensity,  at  the  apex  is  known  as  a  mitral 
murmur.  It  is  created  at  the  mitral  orifice,  but  is  conducted  to  the 
apex  by  the  left  ventricle,  which  is  nearest  the  chest-wall  at  this  point. 
(See  1,  Fig.  164.) 

2.  Murmurs  at  the  Xijjhoid  Cartilage — the  Tricuspid  Area.  The 
murmur  is  heard  loudest  at  the  xiphoid  cartilage  or  the  head  of  the 
fourth  or  fifth  rib.  It  is  created  at  the  tricuspid  orifice,  and  is  heard 
most  distinctly  over  the  lower  portion  of  the  sternum,  and  along  the 
left  edge,  because  the  right  ventricle  is  in  apposition  with  the  chest- 
wall  at  this  spot.     (See  2,  Fig.  164.) 

3.  Murmurs  at  the  Second  Costal  Cartilage  or  Second  Interspace  on 
the  Right — the  Aortic  Area.  When  a  murmur  is  heard  with  great- 
est intensity  at  this  point  it  is  usually  generated  at  the  aortic  orifice, 
and  is  conducted  to  this  region  by  the  aorta,  which  comes  nearest  to 
the  surface  of  the  chest  at  this  point.     (See  3,  Fig.  164.) 

4.  Murmurs  in  the  Second  Left  Interspace — the  Pulmonic  Area.  A 
murmur  heard  loudest  at  the  second  interspace  along  the  left  edge  of 
the  sternum  is  generated  at  the  pulmonary  orifice  ;  it  is  heard  loudest 
in  this  area  because  the  pulmonary  artery  is  nearest  the  chest  at  this 
point.     (See  4,  Fig.  164.) 

The  Rhythm  or  Time  of  the  Murmur.  The  Kind  of  Murmur. 
Having  determined  the  point  of  maximum  intensity  of  the  murmur, 
hence  the  valve  at  which  it  has  its  origin,  we  next  wish  to  determine 
the  kind  of  murmur.  A  murmur  which  is  produced  at  orifices  when 
they  should  be  closed  is  known  as  the  murmur  of  regurgitation,  as  the 
valve  permits  the  blood  to  flow  backward.     A  murmur  that  occurs 


Fig.  170. 


Maximum  intensity  of  murmur  of  mitra  1  regurgitation  ;  systolic ;  transmitted  to  the  left. 


when  the  blood  should  in  health  be  passing  through  an  orifice  is  known 
as  a  murmur  of  obstruction,  as  the  flow  of  blood  is  obstructed.  We 
have  to  determine  whether  the  murmur  at  an  orifice  is  due  to  regurgi- 
tation  or  to  obstruction.    This  is  ascertained  by  the  time  of  the  murmur. 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     633 

The  time  of  the  murmur  is  determined  by  the  heart-sounds,  by  the 
impulse,  and  by  the  pulse. 

Murmurs  with  the  Systole. 

1.  In  the  Mitral  Area.  In  health,  during  this  time,  the  auriculo- 
ventricular  valve  is  closed.  The  murmur  indicates  there  is  such  dis- 
ease as  to  permit  of  a  backward  flow  of  blood,  or  of  regurgitation,  into 
the  auricle.  It  is  the  murmur  of  mitral  regurgitation.  It  may  be  due 
to  disease  of  the  valves  or  to  incompetency.     (See  Fig.  170.) 


Maximum  intensity  of  murmur  of  tricuspid  regurgitation  ;  systolic. 

2.  In  the  Tricuspid  Area.  As  on  the  left  side,  the  murmur  in  this 
area  is  due  to  valvular  disease  or  valvular  incompetency,  which  per- 
mits of  regurgitation,  tricuspid  regurgitation.     (See  Fig.  171.) 

Fig.  172. 


Position  of  maximum  intensity  and  directions  of  transmission  of  murmur  of  aortic  obstruction. 


3.  In  the  Aortic  Area.  During  this  time  the  blood  is  flowing  from 
the  ventricle  into  the  aorta.  If  there  is  disease  which  causes  obstruc- 
tion at  the  orifice  the  murmur  of  aortic  obstruction  is  produced.     The 


634  SPECIAL  DIAGNOSIS. 

murmur  may  be  due  to  ansemia  ;  to  disease  of  the  aorta,  or  to  its  mal- 
position.    (See  Fig.  172.) 

4.  In  the  Pulmonary  Area.  The  pulmonary  orifice  is  affected  in 
the  same  way  as  the  aortic  orifice  under  the  same  circumstances.  The 
murmur  is  due  to  pulmonary  obstruction.  It  is  exceedingly  rare.  It 
is  more  frequently  hsemic.     (See  Fig.  175.) 

Murmurs  with  the  Diastole. 

1.  In  the  Mitral  Area.  The  blood  is  flowing  from  the  left  auricle 
to  the  left  ventricle.  Disease  of  the  valves  obstructs  the  flow.  The 
murmur  occurs  in  the  beginning,  in  the  middle,  or  at  the  end  of  the 
long  silence.  Mid-diastolic  and  late  diastolic,  or  because  it  occurs 
before  the  systole,  presystolic,  are  the  terms  applied  to  this  murmur. 
It  is  the  murmur  of  mitral  obstruction.     (See  Fig.  173.) 

Fig.  173. 


Maximum  intensity  of  murmur  of  mitral  obstruction  ;  presystolic,  localized  or  transmitted  as 

area  shows. 
1.  Normal  impulse.    O.  Area  of  reduplication  of  second  sound. 

2.  In  the  Tricuspid  Area.  It  occurs  for  the  same  reason  and  at  the 
same  time  as  the  diastolic  murmurs  generated  at  the  mitral  orifice. 
It  is  rare,  although  more  common  than  usually  supposed,  to  find  tri- 
cuspid obstruction. 

3.  In  the  Aortic  Area.  The  aortic  valve  closes  in  the  diastole.  A 
murmur  indicates  it  is  so  diseased  that  it  cannot  prevent  blood  flowing 
backward  or  regurgitating  into  the  ventricle.  It  is  the  murmur  of 
aortic  regurgitation.  A  murmur  of  the  same  time  and  in  the  same 
situation  may  be  due  to  dilatation  or  aneurism  of  the  aorta.  (See  Fig. 
174.) 

4.  In  the  Pulmonary  Area.  A  diastolic  murmur  in  this  area  is  due 
to  regurgitation  at  the  pulmonary  orifice.     (See  Fig.  175.) 

Murmurs  are  divided  as  to  time  into  systolic  and  diastolic  murmurs. 
The  above  shows  that  we  may  have  practically  only  three  systolic  and 
two  diastolic  murmurs.  The  systolic  murmurs  are  aortic  obstruction 
and  mitral  and  tricuspid  regurgitation.  The  diastolic  murmurs  are 
aortic  regurgitation  and  mitral  obstruction. 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     635 

The  Direction  of  Transmission.  It  depends  upon  the  situation 
of  the  murmur  and  the  time  at  which  it  is  produced.  Some  murmurs 
are  not  transmitted.  The  transmission  is  usually  in  the  direction  of 
the  currents  which  produce  them. 

Fig.  174. 


Positions  of  maximum  intensity  and  directions  of  transmission  of  murmur  of  aortic  regurgitation. 

Murmurs  in  the  Mitral  Area.  To  the  axilla.  A  murmur  which  is 
produced  at  the  apex  with  the  systole,  caused  by  regurgitation  at  the 
mitral  orifice,  is  transmitted  into  the  axilla,  and  may  be  heard  at  the 
angle  of  the  scapula.  The  murmur  which  is  produced  in  the  same 
area  before  the  systole — obstruction — is  usually  not  transmitted.  It  is 
heard  at  the  apex,  or  a  little  inside  of  the  apexj  or  may  rarely  have  its 
point  of  maximum  intensity  in  the  third  interspace.  Sometimes  it  is 
transmitted  to  the  axilla  and  to  the  angle  of  the  scapula.  (See  Figs. 
170  and  173.) 

Murmurs  in  the  Tricuspid  Area.  The  murmur  of  tricuspid  regurgi- 
tation is  not  transmitted.  It  is  heard  over  a  relatively  large  area,  de- 
pending upon  the  intensity  of  the  sounds. 

Murmurs  in  the  Aortic  Area.  Upward  and  Along  the  Vessels.  The 
murmur,  systolic  in  time,  heard  at  the  second  costal  cartilage  on  the 
right,  due  to  aortic  obstruction,  is  transmitted  in  the  direction  of  the 
blood-current.  The  sound  is  conducted  by  the  vessels  and  by  the 
fluid  ;  it  is,  therefore,  heard  along  the  course  of  the  aorta  and  in  the 
carotid  arteries.  Downivard  to  the  Apex.  The  murmur  of  aortic  re- 
gurgitation, heard  in  the  same  area,  is  transmitted  downward  along  the 
course  of  the  sternum.  It  may  be  transmitted  to  the  apex,  or  may 
be  heard  along  the  sternum  only.  The  left  ventricle  conducts  this 
murmur.     (See  Figs.  172  and  174.) 

Character  of  the  Murmurs.  Murmurs  are  further  distinguished 
by  their  character  and  the  degree  of  loudness.  By  the  character  of  the 
murmurs  we  are  aided  (1)  in  distinguishing  them  from  heart-sounds  ; 

(2)  in  estimating  the  nature  of  the  lesion  that  produces  the  murmur  ; 

(3)  in  judging,  in  the  case  of  murmur  of  mitral  obstruction,  of  the 
presence  or  absence  of  that  disease. 


636 


SPECIAL  DIAGNOSIS. 


Distinction  feom  Normal  Sounds.  Normal  sounds  are  sounds 
of  tension  ;  murmurs  are  sounds  of  rhythmical  vibration.  The  normal 
sounds  of  the  heart  have  been  described  by  the  syllable  "  ubb,"  "  dupp," 
"  od,"  and  abnormal   sounds  of  endocardial  origin  by  "  uf"   "  uv" 


Maximum  intensity  of  pulmonary  systolic  murmur. 
O .  Area  of  murmur  of  anaemia. 


us"  "  ush,"  or  by  full  vowel  sounds  as  "  oo, 


»  u  „,  }}  a 


ah,"  and  "aw, 


by  musical  tones,  or  by  interrupted  tones,  or  by  general  sounds,  as 
"  urr  "  or  "  orr." 

The  Nature  of  the  Lesion.  The  murmurs  may  be  rough  or  rasping, 
musical  or  whistling  in  character.  They  may  be  high  or  low  in  pitch. 
Murmurs  that  are  rough  and  high  in  pitch  are  usually  due  to  disease 
of  the  valves,  causing  thickening  or  stiffening  of  the  leaflets,  or  to  the 
projection  of  an  atheromatous  plate  into  the  lumen  of  the  orifice.  Such 
conditions  occur  in  chronic  endarteritis  and  chronic  endocarditis  or 
valvulitis.  On  the  other  hand,  murmurs  that  are  soft  and  low  in  pitch 
are  usually  due  to  a  physical  condition  which  causes  swelling  of  the 
valve  or  occlusion  by  soft  exudations ;  they  are  heard  in  endocarditis 
of  rheumatic  origin,  or  the  malignant  form  of  endocarditis.  The  only 
murmur  which  has  special  characteristics  is  the  murmur  of  mitral 
obstruction.  It  is  a  prolonged  murmur  of  a  churning  or  grinding  char- 
acter, sometimes  rippling,  and  as  if  fluid  were  being  forced  through  a 
narrow  channel.  It  is  usually  presystolic,  but  may  occur  in  the  middle 
of  the  diastole. 

Loudness.  The  loudness  of  the  murmur  is  not  of  special  signifi- 
cance, although,  in  general,  it  may  be  said  that  it  indicates  good  com- 
pensation, and  that  the  heart  muscle  is  sufficiently  strong  to  meet  the 
demands  of  the  circulation.  Murmurs  are  louder  in  the  recumbent 
than  in  the  erect  posture  in  some  instances,  especially  mitral  and  tricus- 
pid murmurs.  Murmurs  are  often  more  distinct  after  exertion.  Loud 
murmurs  may  become  weak,  and  this  change  in  character  of  the  sound 
is  of  serious  omen.  They  may  disappear  in  the  course  of  fevers  and 
in  the  dying  state. 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     637 

Disappearance  of  Murmur.  The  student  will  often  find  that 
after  a  patient  has  been  under  treatment  for  a  short  time  the  murmurs 
disappear.  This  is  probably  due  to  the  fact  that  there  is  complete 
compensation.  In  the  terminal  stages  of  cardiac  disease  they  disap- 
pear because  of  weakness  of  the  heart  muscle.  Rarely  they  disappear 
because  the  roughened  valve  causing  them  has  been  repaired.  (See 
"  Disappearance  of  Murmurs/'  by  the  author.  British  Medical  Journal, 
1897.)  In  other  cases  it  may  be  necessary  to  bring  out  a  faint  mur- 
mur or  increase  its  intensity  by  having  the  patient  move  about ;  this 
renders  it  more  distinct  by  inducing  more  rapid  action  of  the  heart. 

The  Significance  of  Murmurs.  Murmurs  heard  at  the  various 
orifices  indicate  either  (1)  disease  of  the  valves  •  (2)  incompetency  of 
the  valves  ;  (3)  disease  of  the  blood  ;  or  (4)  disease  of  the  vessels  in 
intimate  relation  with  the  heart.  The  systolic  murmur  at  the  second 
costal  cartilage  on  the  right  may  be  heard  when  there  is  disease  at  the 
aortic  orifice,  causing  obstruction ;  in  atheroma  of  the  aorta  ;  in  cases 
of  aneurism  just  above  the  valves ;  in  anaemia,  and  chlorosis,  and  in 
some  vasomotor  neuroses,  as  Graves'  disease.  Before  concluding  that 
the  murmur  is  due  to  disease  of  the  valves  we  must  be  able  to  exclude 
the  other  conditions.  Atheroma  of  the  aorta,  is  most  difficult  to  distin- 
guish from  obstruction,  because  the  character  of  the  murmur  is  the 
same  and  the  associated  conditions  are  similar.  In  both  there  may  be 
a  previous  history  of  gout,  rheumatism,  syphilis,  or  alcoholism.  The 
latter  are  associated  with  atheroma  in  other  arteries  of  the  body,  and 
with  degenerative  changes  that  accompany  atheroma.  In  young  sub- 
jects, in  whom  there  has  been  a  direct  history  of  rheumatism,  or  when 
the  process  has  followed  septicaemia,  the  probabilities  are,  in  nearly 
all  the  cases,  that  the  murmur  is  due  to  aortic  obstruction.  To  dis- 
tinguish the  murmur  of  anaemia,  chlorosis,  or  Graves'  diseases  is  often 
difficult.  The  associate  symptoms  in  each  case  are  different,  however, 
and  with  the  changes  in  the  blood  indicate  the  nature  of  the  murmur. 

In  other  valve  areas  the  chief  task  is  to  decide  whether  the  murmur 
is  organic,  due  to  valvulitis,  or  whether  it  is  functional,  due  to  incompe- 
tency or  to  anaemia. 

Murmurs  due  to  Incompetency.  The  valves  are  sometimes 
unable  to  close  properly.  The  cavity  of  the  ventricles  may  increase 
in  size,  so  that  the  valves  do  not  coaptate  to  close  the  widened  orifice. 
The  tricuspid  and  mitral  valve  leaflets  often  become  thus  incompetent. 
Mitral  and  tricuspid  regurgitation  ensue.  The  murmurs  are  soft  and 
low  in  pitch  and  not  widely  transmitted  ;  the  heart  is  dilated. 

Murmurs  of  Anjemia.  The  murmurs  of  anaemia  have  some  char- 
acteristics which  aid  in  distinguishing  them  from  true  organic  mur- 
murs. The  most  important  of  these  are  :  (1)  The  situation  of  the  mur- 
mur ;  (2)  its  character ;  (3)  the  direction  in  which  it  is  transmitted ;  (4) 
the  time  ;  (5)  the  associate  signs  ;  (6)  the  secondary  heart-muscle  changes. 
1.  The  murmurs  of  anaemia  may  be  heard  at  any  orifice,  but  are  usually 
heard  at  the  second  costal  cartilage,  or  the  third  interspace,  on  the  left 
side.  They  are  generated  at  the  pulmonary  orifice,  or  in  the  cone  of 
the  right  ventricle.  The  murmur  at  the  pulmonary  orifice  may  be 
heard  as  high  as  the  second  interspace,  but  otherwise  is  not  transmitted. 


638 


SPECIAL  DIAGNOSIS. 


Murmurs  of  anaemia  are  also  heard  at  the  apex,  at  the  aortic  cartilage? 
and  over  the  tricuspid  area.  They  are  comparatively  infrequent  in 
these  situations,  but  partake  of  the  same  nature  as  the  murmur  heard 
at  the  pulmonary  orifice.  2.  They  are  soft  in  character  and  low  in 
pitch.  They  are  louder  in  the  recumbent  than  in  the  upright  posi- 
tion. Their  loudness  is  increased  by  violent  cardiac  action.  They 
are  loudest  just  at  the  end  of  expiration  or  beginning  of  inspiration. 
3.  They  are  not  transmitted  away  from  the  heart.  4.  They  are  systolic 
in  time.  5.  They  are  associated  with  murmurs  in  other  parts  of  the 
vascular  system,  as  the  murmur  in  the  jugular  veins.  Its  characteris- 
tics and  mode  of  recognition  will  be  described  elsewhere.  6.  Mural 
changes,  as  general  dilatation,  fatty  degeneration,  or  hypertrophy  may 
be  present ;  but  single  chambers  do  not  undergo  change.  The  murmur 
of  anaemia  may  usually  be  considered  to  be  temporary. 


Fig.  176. 


Maximum  intensity  of  murmurs  of  aneemia,  systolic.    iSansom.) 

1    Pulmonary  artery,  59  per  cent.    2.  Apes,  7  per  cent.    3.  Right  v.  and  conus,  11  per  cent. 

4.  Aortic  area,  11  per  cent.    1  and  2.  Pulmonary  and  apex  coexisting,  9  per  cent. 


^Functional  Murmurs  not  Anaemic.  Drummond  divides  func- 
tional murmurs  into  three  classes  :  cardio-heemic  or  anaemic  ;  cardio- 
muscular  or  neuro-typtic,  and  cardio-respiratory.  The  first  has  been 
considered  above.  The  cardio-muscular  murmur  attends  excited  action 
of  the  heart.  It  is  heard  loudest  at  the  fourth  left  interspace  close  to 
the  sternum  ;  loudest  in  the  upright  posture  ;  loudest  at  the  end  of 
expiration,  It  disappears  at  the  end  of  inspiration,  or  when  the  patient 
lies  on  the  side.  Of  course,  it  is  increased  by  exertion  and  excitement. 
It  is  rough  or  whizzing  in  character.  The  cardio-respiratory  murmur 
is  fairly  common.  It  is  most  marked  in  inspiration,  but  may  be  heard 
in  both  acts.  It  is  systolic  in  time,  and  is  heard  loudest  at  the  apex, 
but  I  have  often  heard  it  along  the  left  border  of  the  heart,  as  high  as 
the  second  rib  and  in  the  axilla,  and  at  the  angle  of  the  scapula.  It  is 
short  and  whiffing,  and  the  sound  gives  one  the  impression  that  the 
heart  is  striking  the  lung. 

Influence  of  Pressure.     Pressure  exerted,  Sewall  says,  while  using 
the  flexible  stethoscope  over  the  second  costal  interspace  annuls  in  part, 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     639 

or  wholly,  the  second  sound  of  the  heart ;  but  if  the  ascending  aorta 
be  dilated  or  the  site  of  an  aneurism,  the  second  sound  persists  strongly 
notwithstanding  firm  pressure. 
Further,  firm  pressure  removes  — 

(A)  1.  Hsemic  murmurs  over  the  base  of  the  heart  (save  Jenner's 
pulmonary  murmurs). 

2.  An  aortic  obstructive  murmur  of  the  apex. 

3.  When  mitral  and  aortic    regurgitant  murmurs  coexist,  the 

aortic  murmur  is  diminished  in  the  greater  degree. 

4.  Aortic  regurgitant  murmurs  over  the  second  right  intercostal 

space. 

While  it  does  not  markedly  affect — 

(JB)  1 .  Mitral  regurgitant  murmurs  heard  over  the  apex  ;  or 

2.  Mitral  obstructive  murmurs  over  the  same  spot. 

3.  Tricuspid  regurgitant  murmurs  over  the  area  of  greatest  in- 

tensity. 

4.  Aortic  regurgitant  murmurs  over  the  apex  (see  (A),  No.  3). 

Secondary  Effect  of  Valve-lesions  on  the  Heart  and  Pulse. 

The  secondary  effect  of  valve-lesions  on  the  heart  and  pulse  aid  in  the 
diagnosis.  While  we  are  enabled  by  the  time  of  the  murmur,  the  posi- 
tion, and  the  direction  of  transmission  to  affirm  the  nature  of  the  dis- 
ease at  the  respective  valve-orifices,  other  physical  signs  further  aid 
us  in  determining  more  precisely  the  lesion  and  its  seat.  They  are 
derived  from  the  heart  and  the  pulse.  They  depend  upon  the  second- 
ary effect  of  the  lesion  upon  the  heart  and  upon  the  circulation.  In 
aortic  obstruction,  on  account  of  obstruction  to  the  flow  of  blood,  the 
left  ventricle  hypertrophies ;  moreover,  the  blood  stream  is  lessened  in 
volume,  and  hence  the  pulse  is  small  and  of  high  tension.  The  physi- 
cal signs  of  hypertrophy  and  small  pulse  are  corroborative  evidence  of 
this  lesion  at  the  left  orifice.  In  aortic  regurgitation  the  blood  flows 
back  into  the  ventricle.  On  this  account,  therefore,  some  dilatation 
takes  place,  a  dilatation  which,  if  compensation  is  perfect,  is  overcome 
by  hypertrophy.  The  signs,  however,  of  enlarged  left  heart  are  pres- 
ent, as  shown  by  inspection,  palpation,  and  percussion.  But  the  pulse 
of  aortic  regurgitation  is  of  the  greatest  diagnostic  significance.  With 
the  finger  on  the  radial,  the  impression  is  at  once  received  of  recedence 
of  the  pulse- wave  as  soon  as  it  strikes  the  finger.  This  is  more  marked 
if  the  hand  is  elevated.  It  is  the  water-hammer,  or  Corrigan's,  pulse. 
In  mitral  regurgitation  the  left  auricle  does  not  change,  but  the  stress 
is  thrown  upon  the  right  side  of  the  heart,  and  we  have  the  signs  of 
right-sided  hypertrophy  and  dilatation ;  but  more  marked  than  this  is 
the  evidence  of  high  tension  of  the  pulmonary  artery,  shown  by  accen- 
tuation of  the  second  sound.  (See  p.  625.)  In  mitral  regurgitation, 
the  blood  flows  back  into  the  auricle,  and  when  the  right  heart  weak- 
ens engorges  the  venous  system.  The  arterial  system  is  in  consequence 
devoid  of  blood,  and  hence  the  arteries  are  empty.  The  pulse  is  small 
and  feeble.  The  depleted  coronary  arteries  do  not  nourish  the  ven- 
tricles, hence  dilatation  or  failure  in  nutrition  soon  ensues,  and  the 


640  SPECIAL  DIAGNOSIS. 

heart  is  further  weakened.  In  addition  to  being  small  and  feeble,  the 
pulse,  on  account  of  inefficient  and  hurried  contractions  of  the  ventricle, 
is  irregular  and  intermittent. 

In  mitral  obstruction,  in  addition  to  the  characteristic  murmur,  the 
thrill  is  of  great  significance.  Moreover,  the  left  auricle  hypertrophies, 
and  shortly  afterward  the  right  heart.  It  is  accompanied  by  an  ac- 
centuated pulmonary  second  sound,  and  frequently  by  doubling  of  that 
sound.     The  pulse  is  small  and  feeble. 

Multiple  Cardiac  Murmurs.  More  than  one  murmur  may  be 
heard  over  the  heart.  The  number  depends  upon  the  number  of 
valves  that  are  the  seat  of  disease  and  the  lesions  at  the  orifices.  We 
may  have  valvulitis  of  the  aortic,  mitral,  and  tricuspid  valves  conjoined. 
More  commonly  one  valve  is  diseased,  giving  rise  to  a  murmur,  while 
another  valve  is  incompetent,  on  account  of  dilatation,  and  a  murmur 
thus  generated  at  its  orifice  It  is  common  to  see  aortic  obstruction 
from  valvulitis  and  mitral  regurgitation  from  incompetency  ;  mitral 
obstruction  or  regurgitation  from  valvulitis,  and  tricuspid  regurgita- 
tion from  incompetency.  I  have  seen  double  aortic  disease  (combined 
obstruction  and  regurgitation),  double  mitral  disease,  and  tricuspid 
regurgitation.  The  diagnosis  of  the  various  murmurs  will  be  dis- 
cussed in  the  chapter  on  Valvulitis. 

The  Arteries.  The  stethoscope  should  always  be  used  in  examining 
the  arteries.  The  double  stethoscope  is  preferable,  as  strong  pressure 
must  be  avoided  upon  the  vessels.  When  the  single  stethoscope  is  used 
some  diagnostic  value  attaches  to  the  character  of  the  shock  that  is  trans- 
mitted to  the  head.  The  arteries  open  to  auscultation  are  the  carotids 
when  the  neck  is  slightly  extended  ;  the  subclavian  ;  the  innominate 
above  the  sterno-clavicular  articulation  ;  the  brachial  artery  in  the 
bend  of  the  elbow,  with  the  arm  slightly  extended  ;  and  the  crural 
artery  just  below  Poupart's  ligament.  The  normal  systolic  and  dias- 
tolic heart-sounds  are  often  heard  in  the  carotid  and  subclavian  arte- 
ries. The  systolic  sounds  may  be  heard  over  the  abdominal  aorta, 
due  to  tension  of  the  vessels.  The  diastolic  sound  is  rarely  heard  in 
this  situation.     In  the  other  vessels  no  sounds  are  heard. 

Induced  or  pressure-murmur.  By  pressure  with  the  stethoscope  over 
one  of  the  vessels  its  calibre  is  modified  and  a  murmur  created.  This 
murmur  corresponds  in  time  with  the  pulse,  hence  it  is  systolic,  and 
increases  or  diminishes  in  intensity,  depending  upon  the  amount  of 
pressure  placed  upon  it.  Just  here  may  be  mentioned  the  systolic 
humming  which  is  heard  in  children  between  the  third  month  and  the 
sixth  year  over  the  fontanelles  and  sometimes  over  the  rest  of  the 
head.  '  (See  The  Head.) 

Abnormal  Sounds.  Abnormal  sounds  or  murmurs  are  due  to 
alterations  of  the  blood,  disease  outside  of  the  vessels  causing  pressure, 
and  disease  of  the  vessels.  Murmurs  from  disease  of  the  vessels,  as 
the  aorta,  are  discussed  under  the  head  of  arterio-sclerosis  or  aneurism. 

Conduction  Murmurs.  Murmurs  may  be  propagated  into  the 
arteries.  A  systolic  murmur  created  at  the  aortic  orifice  may  be  heard 
in  the  vessels  of  the  neck  and  along  the  aorta.  On  the  other  hand, 
in  aortic  regurgitation,  the  diastolic  sound  normal  in  the  carotid  and 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     641 

subclavian  disappears,  and  the  diastolic  murmur  is  not  heard.  Double 
Sounds  of  the  Vessels.  Double  sounds  are  sometimes  heard  in  the 
crural  artery  under  the  following  circumstances  :  (1)  In  aortic  insuffi- 
ciency ;  (2)  in  mitral  stenosis ;  (3)  in  lead-poisoning ;  (4)  in  pregnancy. 
Duroziez's  double  murmur,  heard  when  greater  pressure  is  used  by  the 
stethoscope,  occurs  in  aortic  regurgitation  when  there  is  good  compen- 
sation. Many  authorities  refer  to  this  as  a  valuable  diagnostic  sign 
in  this  affection.  The  double  sound  in  all  instances  occurs  with  large 
and  quick  pulse.  It  is  probably  caused  by  sudden  collapse  of  the 
artery,  and  the  reflux  blood-current  which  is  possibly  an  aortic  regur- 
gitation. 

Murmurs  due  to  Alteratioxs  of  the  Blood.  They  are  gen- 
erated in  anaemia  and  chlorosis.  They  are  called  functional  murmurs, 
to  distinguish  them  from  murmurs  due  to  disease  of  the  vessels.  They 
are  systolic  in  time.  They  are  soft  and  low  in  pitch,  often  of  a  musical 
character.  The  degree  of  loudness  may  vary  with  the  position  of  the 
patient.  They  are  increased  by  excitement.  The  intensity  of  the  mur- 
mur increases  in  the  course  of  fevers. 

Murmurs  in  Relaxed  Vessels.  Murmurs  in  the  vessels,  appar- 
ently of  functional  origin,  are  sometimes  heard.  The  vessels  are 
dilated  from  actual  disease.  The  increased  calibre  favors  the  develop- 
ment of  a  murmur  by  the  creation  of  a  fluid  vein.  Dilatation  of  the 
innominate  artery  sometimes  takes  place,  giving  rise  to  a  murmur,  which 
in  loudness  and  character  simulates  the  murmur  of  aneurism.  A 
functional  murmur  is  sometimes  heard  in  the  vessels,  independently  of 
disease,  in  cases  of  aortic  regurgitation.  The  murmur  is  systolic  in 
time. 

Pressure-murmurs.  Pressure  of  the  stethoscope,  or  that  caused 
by  diseases  outside  of  the  bloodvessels.  When  heard  over  the  subclavian 
artery,  the  pressure-murmur  may  be  due  to  adhesions  or  consolidation 
at  the  apex  of  the  lung.  It  is  more  frequently  heard  at  the  left,  and 
may  only  be  present  during  full  expansion  of  the  lung.  It  is  due  to 
temporary  pulling  or  bending  of  the  artery  during  deep  breathing. 
When  it  occurs  on  both  sides  it  is  not  of  much  significance.  Murmurs 
in  the  axillary  artery,  or  in  any  arteries  surrounded  by  enlarged  lym- 
phatic glands,  are  created  by  their  pressure.  Murmurs  in  the  thyroid 
gland  have  been  referred  to.     (See  Goitre.) 

Murmurs  due  to  Disease  of  the  Arteries.  In  the  aorta  the 
murmurs  are  due  to  aneurism  or  atheroma,  or  both.  They  may  be 
systolic  or  diastolic.  In  the  smaller  vessels  both  conditions  may  be 
present,  although  atheroma  is  the  usual  one.  The  murmur  is  systolic 
in  time,  rough  in  character,  strong  or  weak.  It  is  associated  with 
other  signs  of  atheroma. 

The  Veins.  In  health  no  sounds  are  heard.  Two  conditions 
contribute  to  the  creation  of  a  murmur  in  the  veins  :  (1)  Change  in  the 
character  of  the  blood  ;  (2)  dilatation  with  the  occurrence  of  positive 
venous  pulse. 

The  Venous  Hum.  In  aneemia  and  chlorosis,  and  sometimes  in 
healthy  patients,  a  hum  or  murmur,  or  buzzing  sound  is  heard  over 
the  jugular  veins.     It  is  louder  on  the  right  side  than  on  the  left.     It  is 

41 


642  SPECIAL  DIAGNOSIS. 

soft  and  low  in  pitch,  and  may  be  musical ;  it  has  been  described  as 
humming  or  whizzing.  It  is  continuous.  For  its  detection  a  double 
stethoscope  should  be  used,  as  pressure  increases  it,  and  the  patient 
should  not  turn  the  head  to  one  side,  as  it  is  increased  when  this  posi- 
tion is  taken.  The  murmur  is  modified  by  the  respiration  and  by  the 
cardiac  action.  It  is  louder  in  deep  inspiration  when  the  blood  is 
going  more  rapidly  to  the  thorax.  It  is  also  louder  in  the  upright 
position.  It  is  frequently  louder  during  the  diastole.  The  increased 
loudness  at  these  periods  occurs  because,  from  the  sucking  action 
daring  inspiration  and  during  the  diastole,  the  blood  is  more  rapidly 
drawn  toward  the  heart.  The  murmur  is  caused  by  the  flow  of  blood 
from  the  narrow  jugular  into  its  wider  bulb,  producing  a  fluid  vein. 
Later  authorities  believe  it  to  be  due  to  lateral  vibration  of  the  Avails 
of  the  veins.  Similar  murmurs  are  heard  in  other  veins,  as  in  those 
of  the  extremities  when  the  anaemia  is  profound.  They  are  stronger 
during  the  diastole  of  the  heart.  The  venous  hum  is  sometimes  heard 
at  the  lower  border  of  the  liver,  to  the  right  of  the  median  line,  in 
cirrhosis  of  the  liver.  It  is  created  in  the  enlarged  collateral  veins. 
It  may  be  modified  by  pressure  of  the  stethoscope.  It  may  be  heard 
in  this  situation  in  emaciated  and  cachectic  subjects  not  the  subject  of 
cirrhosis.  The  venous  hum  may  be  heard  in  the  innominate  veins 
(first  and  second  interspaces  and  right  costo-clavicular  articulation),  in 
the  subclavian  and  axillary  veins. 

Pericarditis. 

Inflammation  of  the  Pericardium.  The  inflammation  may  be 
acute  or  chronic.  It  is  also  divided  according  to  the  nature  of  the  in- 
flammation into  simple  fibrinous  inflammation  and  inflammation  with 
effusion.  The  effusion  may  be  serous,  bloody,  or  purulent,  depending 
upon  the  nature  of  the  inflammation.  Pericarditis,  either  acute  or 
chronic,  is  also  divided  into  primary  or  secondary  pericarditis.  The 
primary  form  is  of  extremely  rare  occurrence.  Indeed,  it  may  well 
be  doubted  whether,  in  common  with  the  inflammations  of  serous 
membranes  in  general,  pericarditis  is  ever  primary,  or  so-called  idio- 
pathic, in  origin. 

Causes.  1.  Extension  from  Neighboring  Structures.  Extension  of 
the  inflammation  from  infected  tissues  in  the  vicinity  is  a  common 
cause  of  pericarditis.  It  may  follow  a  pleurisy  and  partake  of  the 
nature  of  the  primary  pleural  inflammation.  It  often  attends  em- 
pyema, either  from  extension  of  the  infection  to  the  pericardium  or 
from  rupture  into  the  pericardial  sac.  It  may  follow  all  forms  of  in- 
flammation of  the  mediastinum.  Disease  of  the  ribs  adjacent  to  the 
pericardium  may  set  up  pericarditis,  acute  and  chronic.  It  attends 
on  the  course  of  aortic  aneurism,  at  times,  but  more  frequently  in- 
fectious endocarditis  and  myocarditis.  Inflammations  below  the 
diaphragm  frequently  give  rise  to  pericarditis.  Peritonitis,  when 
general  or  local ;  sub-diaphragmatic  abscess ;  suppurative  gastritis, 
with  perforation  of  the  stomach  ;  abscess  of  the  liver  ;    suppurating 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     643 

hydatid,  and  other  forms  of  suppuration  below  the  diaphragm,  belong 
to  the  latter. 

2.  General  Infections.  The  general  diseases  causing  inflammation  of 
the  pericardium  are  those  which  affect  serous  membranes.  They  are  : 
Infectious  diseases,  particularly  scarlet  fever,  measles,  erysipelas,  and 
typhoid  fever.  All  forms  of  septicaemia  may  be  attended  by  inflamma- 
tion of  the  pericardium.  Tuberculosis  is  a  frequent  cause  of  pericar- 
ditis. Inflammation  of  this  membrane  frequently  arises  in  the  course 
of  rheumatism.  It  may  occur  in  the  course  of  the  disease,  or  attend 
some  of  the  affections  which  are  themselves  manifestations  of  rheuma- 
tism, such  as  acute  tonsillitis.  In  the  course  of  certain  dyscrasise  the 
pericardium  is  frequently  the  seat  of  inflammation  because  more  vulner- 
able. This  is  particularly  the  case  in  scurvy.  It  occurs  also  in  Bright's 
disease,  and  may  be  the  first  manifestation  to  the  patient  of  this  disease, 
particularly  in  the  chronic  form  of  nephritis.  It  occurs  in  the  course 
of  gout. 

The  various  forms  of  pericarditis  may  occur  at  any  age.  although 
that  which  attends  scarlatina  and  rheumatism  occurs  in  early  life,  while 
late  in  life  it  is  an  attendant  upon  chronic  Bright's  disease  and  gout. 

Acute  Fibrinous  or  Plastic  Pericarditis. 

This  is  probably  the  most  common  form  that  is  seen.  It  is  the 
variety  that  attends  Bright's  disease,  rheumatism,  and  tuberculosis. 
It  may  be  wanting  entirely  in  symptoms.  An  examination  of  the 
heart  in  the  routine  of  duty  may  reveal  its  presence  by  physical  signs. 
In  the  course  of  one  of  the  primary  causal  diseases,  if  the  tempera- 
ture rises  a  little  higher  than  it  should,  or  convalescence  is  delayed, 
pericarditis  should  be  suspected.  Again,  if  the  pulse  is  more  rapid 
and  quicker  than  customary  at  the  period  of  disease  the  examina- 
tion is  made,  or  out  of  proportion  to  the  temperature,  the  disease 
should  be  suspected.  There  may  be  altered  rhythm  or  tumultuous 
action.  In  other  instances  the  patient  may  complain  of  pain  in  the 
region  of  the  heart.  It  is  usually  localized  in  the  fourth  or  fifth  inter- 
space. It  is  not  very  severe  and  not  influenced  by  pressure.  Some- 
times the  pain  is  complained  of  at  the  xiphoid  cartilage.  In  rare 
instances  it  may  resemble  angina.  The  pain  and  the  occurrence  of 
fever  further  call  attention  to  the  heart. 

Physical  Signs.  Inspection.  Nothing  unusual  is  observed,  although 
the  heart  may  be  seen  to  beat  more  violently  against  the  chest-wall. 
The  impulse  is  diffused. 

Palpation.  A  friction-fremitus  may  be  detected,  due  to  the  rub- 
bing together  of  the  roughened  pericardial  surfaces.  It  is  not  always 
present.  It  may  be  felt  when  the  whole  hand  is  laid  over  the  praecor- 
dia,  or  by  palpation  with  the  tips  of  the  fingers.  It  is  most  marked 
over  the  right  ventricle,  particularly  in  the  fourth  interspace,  and  is 
increased  when  the  patient  leans  forward. 

Auscultation.  A  friction-sound  is  usually  present.  It  may  be  present 
while  the  fremitus  is  absent ;  but,  on  the  other  hand,  if  the  fremitus 


644  SPECIAL  DIAGNOSIS. 

is  present,  we  can  always  hear  the  friction.  It  is  heard  over  the  region 
where  the  fremitus  is  felt. 

Point  of  Maximum  Intensity.  It  may  be  heard  along  the  course  of 
the  sternum  It  is  usually  heard  in  the  third  or  fourth  interspace, 
but  may  be  heard  as  high  as  the  second,  adjacent  to  the  sternum  in 
either  interspace.  Sometimes  it  is  heard  at  the  second  costal  cartilage 
on  the  right,  rarely  at  the  apex.  The  point  of  maximum  intensity 
may  vary  with  the  position  of  the  patient. 

Time.  It  is  both  systolic  and  diastolic.  In  some  cases  it  may  be 
only  systolic  in  time,  or  it  may  be  of  a  galloping  nature,  representing 
three  sounds  during  the  cardiac  cycle.  Again,  the  to-and-fro  sound  is 
not  synchronous  with  the  systolic  and  diastolic  sound,  although  it 
occurs  but  once  in  the  cardiac  cycle.  It  may  begin  after  systole,  and 
be  completed  before  the  end  of  the  diastole.  The  impression  that  it 
is  a  superadded  sound  is  most  positive. 

Direction  of  Transmission.     It  is  localized,  and  not  transmitted. 

Character.  It  is  a  to-and-fro  rubbing,  scratching,  or  grating  sound  ; 
it  gives  the  impression  of  being  near  the  ear.  It  may  be  modified  by 
the  pressure  of  the  stethoscope  and  by  the  position  of  the  patient.  It 
may  be  heard  in  the  erect  and  disappear  in  the  recumbent  posture. 

Diagnosis.  Acute  pericarditis  without  effusion  is  not  recognized 
generally,  because  it  is  not  sought  for.  In  the  larger  number  of 
cases,  as  previously  intimated,  there  have  been  no  indications  of  dis- 
ease of  the  pericardium  during  life.  If  sought  for,  however,  the  diag- 
nosis is  usually  easy.  The  pericardial  friction  may  be  mistaken  for 
an  organic  heart-murmur  or  for  -pleural  or  pleuro-pericardial  friction. 
It  is  often  difficult  to  distinguish  the  to-and-fro  friction  from  the  mur- 
murs of  double  aortic  disease.  If  attention  is  paid  to  the  general  and 
local  phenomena,  the  mistake  is  not  likely  to  be  made.  The  location 
of  the  murmurs  in  organic  heart  disease,  the  direction  of  the  transmis- 
sion, the  character  of  the  murmur,  the  peculiar  character  of  the  pulse, 
and  the  secondary  effects  upon  the  muscles  of  the  heart,  point  to  the 
diagnosis  of  valvular  lesion.  The  pleuro-pericardial  friction  which 
simulates  pericardial  friction  usually  occurs  in  the  course  of  phthisis 
or  pleuropneumonia.  It  is  modified  by  respiratory  movement :  (1)  It 
may  disappear,  or  at  least  diminish,  if  the  breath  is  held  ;  (2)  a  full  expi- 
ration may  cause  its  disappearance.  While  it  is  of  cardiac  rhythm  it 
is  modified  by  the  respiratory  rhythm,  so  that  on  inspiration  it  is 
usually  more  marked.  The  pleuro-pericardial  friction  is  not  so 
strikingly-  modified  by  position.  Pleural  Friction.  Tins  is  of  respira- 
tory rhythm  and  ceases  with  cessation  of  breathing.  The  pericardial 
friction  persists  even  if  the  breath  is  held. 

Pericarditis  with  Effusion. 

I  knov  of  no  affection  which  is  more  frequently  overlooked  during 
life  than  pericardial  effusion  This  is  because  it  develops  without 
symptoms.  In  plastic  pericarditis  we  have  referred  to  the  occurrence 
of  pain.     This  may  occur  before  the  effusion  in  the  latter  form,  but  is 


PLATE   XXVIII. 


Pericarditis  With  Effusion. 

FIO.   2. 


Syst.  retr. 


Adherent  Pericardium.     Chronic   Left-Sided  Pleurisy. 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     645 

usually  moderate.  As  with  dry  pericarditis,  however,  it  may,  in  rare 
instances,  be  very  severe,  anginous  in  character,  and  be  increased  by 
pressure  over  the  heart  or  on  the  pit  of  the  stomach. 

The  symptoms  are  usually  due  to  the  special  character  of  the  inflam- 
mation and  the  presence  of  fluid  in  the  pericardium. 

1.  General  Symptoms.  In  non-suppurative  cases  the  symptoms 
are  usually  cerebral.  Delirium  may  be  moderate  or  maniacal.  It 
must  not  be  confounded  with  the  delirium  which  occurs  in  the  course 
of  acute  rheumatism  with  hyperpyrexia.  In  addition,  choreiform 
movements  have  been  described.  They  may,  however,  be  of  rheu- 
matic origin.  Other  cerebral  symptoms,  as  hemiplegia  and  convulsive 
attacks,  occur  in  the  course  of  pericarditis,  probably  due  to  an  associ- 
ated endocarditis,  causing  embolism.  In  some  cases  albuminuria  is 
found. 

The  general  symptoms  of  pericardial  effusion  depend  upon  the 
nature  of  the  primary  disease  and  the  character  of  the  fluid.  In 
tuberculous  pericarditis,  emaciation,  irregular  fever,  sweats  and  prostra- 
tion ensue.  In  purulent  pericarditis  there  may  be  recurring  chills  with 
a  temperature-range  decidedly  intermitting,  along  with  other  phenom- 
ena of  purulent  accumulation.  In  a  case  recently  seen  (1895)  the 
patient  was  extremely  debilitated  and  prostrated  on  account  of  pneumo- 
nia following  influenza.  He  was  extremely  anaemic,  and  the  blood- 
count  showed  diminution  of  red  cells  to  one-half  without  other  change. 
Every  fourth  day  after  a  chill  the  temperature  would  rise  to  103°  or 
104°.  A  friction-sound  was  detected  after  the  second  chill.  It  disap- 
peared, but  the  physical  signs  of  effusion  were  not  positive.  From 
the  first  the  heart's  action  was  so  weak  that  the  sounds  were  scarcely 
discernible.  At  the  autopsy  four  or  five  ounces  of  pus  were  found  in 
the  pericardial  sac.  The  purulent  accumulation  was  the  only  lesion 
to  account  for  the  symptoms,  and,  we  would  say  now,  was  no  doubt 
a  pneumococcus  infection. 

2.  Local  Symptoms  The  local  symptoms  are  due  to  the  accumu- 
lation of  fluid  within  the  pericardium.  Dyspnoea  is  the  most  common. 
The  degree  depends  upon  the  amount  of  effusion.  If  the  latter  is 
large,  there  may  be  extreme  orthopnoea  ;  if  the  effusion  is  present  for 
a  considerable  time,  it  may  give  rise  to  no  symptoms.  Dysphagia. 
In  large  effusions  this  may  occur,  on  account  of  pressure  upon  the 
oesophagus.  Altered  Cardiac  Rhythm.  The  effect  of  the  effusion  upon 
the  heart  is  to  interfere  with  its  action.  Although  usually  regular, 
on  the  slightest  exertion  or  the  least  excitement  it  palpates  violently  or 
becomes  irregular.  The  heart's  action  is  increased  in  frequency  ;  when 
the  effusion  is  very  large  it  may  be  not  only  irregular,  but  also  inter- 
mittent. Aphonia  may  occur  from  pressure  upon  the  recurrent  laryn- 
geal nerve.  Cough  of  an  irritative  character  is  sometimes  noted.  The 
pulsus  paradoxus  may  be  present. 

3.  Physical  Signs.  (Plate  XXVIII.,  Fig.  1.)  Inspection. 
There  is  bulging  of  the  prsecordia,  particularly  in  children.  The  ribs 
and  interspaces  are  prominent.  In  adults  the  interspaces  are  even  with 
or  distended  beyond  the  surface  of  the  ribs,  and  are  sometimes  widened. 


646  SPECIAL  DIAGNOSIS. 

The  enlargement  may  extend  to  the  anterolateral  region  of  the  left 
chest.  The  large  effusion  interferes  with  expansion  of  the  lung  on  the 
left  side,  and  hence  movement  is  diminished.  The  epigastrium  may 
be  prominent,  on  account  of  displacement  downward  of  the  diaphragm 
and  liver.  The  apex-beat  is  absent  or  faintly  seen,  displaced  upward 
and  to  the  left.  It  does  not  extend  as  near  the  left  border  of  d illness 
as  in  dilatation.  It  may  be  seen  in  the  fourth  interspace,  or  a  faint 
impulse  may  be  observed  in  the  second  and  third  interspaces  beyond 
the  mid-clavicular  line. 

Palpation.  The  impulse  is  feeble  and  diminishes  in  force  as  the 
effusion  increases.  The  position  of  the  apex  as  determined  by  inspec- 
tion is  confirmed.  Ewart  points  out  that  the  first  rib  is  palpable  at 
its  sternal  attachment  in  pericardial  effusion.  The  pericardial  fric- 
tion which  may  have  been  present  at  first  disappears  with  the  effusion. 
Fluctuation  may  be  detected  in  large  effusions.  The  liver  in  large 
effusions  is  depressed  and  readily  palpable. 

Percussion.  The  area  of  precordial  dulness  is  increased.  There 
is  increase  of  the  lateral  boundaries  and  great  increase  of  absolute  dul- 
ness. The  increase  of  area  is  usually  in  all  directions,  although  in- 
crease of  the  dulness  upward  and  to  the  left  only  is  very  common.  It 
may  extend  as  high  as  the  second  rib.  As  pointed  out  by  Rotch, 
dulness  in  the  fifth  right  interspace  in  the  angle  formed  by  the  right 
border  of  the  heart  and  the  right  lobe  of  the  liver  is  common  in  effu- 
sion. It  may  be  an  early  sign  of  effusion.  Ebstein  calls  this  region 
the  cardio-hepatic  triangle,  and  points  out  that  the  dulness  is  absolute 
in  effusion,  although  impaired  in  normal  states  because  of  proximity  to 
the  liver. 

Pulmonary  resonance  is  modified  posteriorly  in  large  effusions.  The 
dulness  in  large  effusion  includes  the  axillary  region,  so  that  it  may 
simulate  a  pleural  effusion.  The  dulness,  however,  does  not  extend 
below  the  eighth  rib  in  this  region,  whereas,  in  pleural  effusion,  dul- 
ness always  extends  to  the  bottom  of  the  pleural  sac.  In  a  large  peri- 
cardial effusion  the  semilunar  space  of  Traube  is  obliterated. 

Auscultation.  The  sounds  are  feeble  and  distant.  They  may  be 
scarcely  heard  at  all  over  the  precordial  region.  The  sounds  at  the 
base  of  the  heart  are  diminished  in  intensity.  If  a  friction-sound  was 
heard  at  the  beginning,  it  disappears  entirely  as  the  effusion  is  poured 
out.  In  moderate  effusions  the  friction  may  be  heard  when  the  erect 
posture  is  assumed. 

It  must  not  be  forgotten  that  the  physical  signs,  and  especially  the 
change  in  impulse  and  the  area  of  precordial  dulness,  are  modified  by 
the  position  of  the  effusion.  Accumulations  occur  behind  the  heart  or 
above  it,  and  in  these  situations  interfere  least  with  the  displacement 
or  the  enfeeblement  of  the  apex-beat.  The  area  of  dulness,  however, 
is  increased  upward. 

In  cases  of  large  effusion  the  compression  of  the  lung  may  cause 
bronchial  breathing  to  be  heard  posteriorly  or  in  the  axillary  region. 
In  a  case  under  my  care  the  diagnosis  of  pericardial  effusion  was 
readily  made,  but  the  enormous  effusion  so  markedly  simulated  an 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     647 

effusion  into  the  pleural  cavity  that  both  serous  cavities  were  believed 
to  contain  fluid.  Aspiration  was  performed  in  the  sixth  interspace  in 
the  anterior  axillary  line.  The  fluid  was  removed  from  the  peri- 
cardium, as  was  afterward  determined.  During  life  pressure-signs — 
laryngeal  stridor,  difficulty  of  deglutition,  and  extreme  dyspnoea — were 
present.  Early  vomiting,  epigastric  pain  and  tenderness,  slight  de- 
lirium, albuminuria,  and  an  excessively  weak,  rapid  pulse  occurred  in 
the  course  of  the  disease.  The  patient  was  a  male,  twenty  years  of 
age.  The  effusion  was  due  to  tuberculous  pericarditis,  secondary  to 
tuberculosis  of  the  bronchial  glands.  The  physical  signs  were  prom- 
inence of  the  praecordia ;  bulging  of  the  interspaces  on  the  left  side  ; 
diminished  expansion  of  the  left  side — anteriorly,  laterally,  and  poste- 
riorly ;  increased  expansion  at  the  extreme  apex  of  the  lung.  The 
vocal  fremitus  was  absent  below  the  second  interspace  in  front,  below 
the  third  in  the  axilla,  and  diminished  below  the  spine  of  the  scapula 
behind.  There  was  dulness  from  the  second  left  rib  in  front  to 
the  margin  of  the  thorax ;  from  the  fourth  to  the  eighth  rib  in  the 
axilla  ;  below  the  eighth  rib,  tympany.  The  dulness  extended  be- 
yond the  margin  of  the  sternum  on  the  right  side,  almost  to  the 
right  nipple-line,  in  the  fourth  and  fifth  interspaces.  Posteriorly,  dul- 
ness from  the  middle  of  the  scapula  to  the  base  of  the  thorax,  except 
along  the  vertebrae,  where,  from  the  seventh  to  the  ninth  rib,  there 
was  tympany.  The  physical  signs  of  pericardial  effusion  on  auscul- 
tation were  marked.  In  the  axilla  the  breath-sounds  were  absent. 
There  were  bronchial  breathing  and  bronchophony  behind  from  the 
spine  of  the  scapula  to  the  base  along  the  vertebrae.  They  were  most 
marked  opposite  the  angle  of  the  scapula,  where  the  above-noted  tym- 
pany was  observed.  In  the  mid-scapular  line  the  breath-sounds  dimin- 
ished from  above  downward,  and  Avere  absent  at  the  base.  It  is  seen 
that  the  physical  signs  of  pleural  effusion  were  present  posteriorly  and 
laterally,  due  to  the  enormous  effusion.  At  the  autopsy  the  pericar- 
dium was  found  to  contain  sixty-four  ounces  of  fluid. 

Pleural  effusions  may  be  excluded  in  similar  cases  by  the  absence 
of  dulness  in  the  axillary  region  below  the  eighth  rib  ;  by  increase  in 
dulness  beyond  the  right  edge  of  the  sternum  ;  and,  at  the  same  time, 
by  the  absence  of  signs  indicating  dislocation  of  the  heart  to  the  right. 

Diagnosis.  Pericardial  effusion  must  be  distinguished  from  dilata- 
tion of  the  heart.  Although  feeble  and  diffuse,  the  expansile  shock  of 
the  impulse  is  more  distinct  than  in  dilatation.  This  distinction  is  not 
generally  difficult  if  the  patient  has  been  under  observation  during  the 
development  of  the  disease.  The  impulse  is  not  always  absent  in  dila- 
tation. Fluctuation  may  be  detected.  The  area  of  dulness  in  dilata- 
tion does  not  extend  upward  except  in  cases  in  which  the  right  auricle  is 
enlarged.  The  dulness  does  not  extend  downward  in  dilatation  with- 
out a  similar  displacement  of  the  apex  impulse.  The  shape  of  the 
dulness  differs.  In  dilatation  the  dulness  is  square  in  shape ;  in 
effusion  it  is  triangular  or  pear-shaped,  with  the  base  downward.  In 
dilatation  the  sounds  are  accentuated,  and  are  of  a  valvular  character ; 
in  effusion  they  are  muffled.     Dilatation  does  not  cause  the  pressure- 


648  SPECIAL  DIAGNOSIS. 

symptoms  that  occur  in  effusion.  In  pericardial  effusion  Bamberger's 
sign  is  of  importance.  When  the  patient  is  sitting  upright  an  area  of 
dulness  about  the  size  of  a  silver  dollar  can  be  marked  out  at  the 
angle  of  the  scapula.  Over  it,  dulness,  increased  fremitus,  and  bron- 
chial breathing  are  made  out.  If  the  patient  leans  forward,  the  dulness 
and  the  other  signs  of  consolidation  disappear,  to  return  when  he  sits 
upright.  In  children  pseudo-pleuritic  signs  are  often  present  poste- 
riorly— dulness,  pleuritic  friction,  broncho-oegophony — but  will  disap- 
pear if  the  patient  is  put  in  the  knee-chest  posture.  It  is  of  diag- 
nostic significance  to  have  change  of  the  rhythm  and  the  character  of 
the  sound  from  day  to  day,  or  of  its  degree  of  loudness  on  movement 
of  the  patient. 

In  pericarditis  with  effusion,  after  its  absorption,  the  friction-sound 
may  return.  Often  it  may  disappear  entirely  and  all  signs  of  pericar- 
dial inflammation  subside.  In  plastic  pericarditis  and  pericarditis  with 
effusion  adhesion  of  the  two  layers  of  the  pericardium  may  take  place. 

Effusions  into  the.  pericardial  sac  of  serum,  of  blood,  or  of  air,  may 
take  place  without  previous  inflammation. 

Hydro-pericardium.  This  may  occur  in  the  course  of  general 
dropsy  from  kidney  or  heart  disease.  It  may  not  prove  fatal  of  itself, 
but  when  associated  with  effusion  in  the  pleural  sac  it  contributes  to 
the  orthopnoea,  which  may  cause  death.  Rarely  after  scarlet  fever, 
effusion  into  the  pericardial  sac  may  be  the  only  dropsical  symptom. 
The  physical  signs  are  those  of  effusion.  It  is  not  attended  by  fever. 
It  is  frequently  overlooked,  because  investigation  beyond  the  pleura 
is  not  made  after  an  effusion  into  that  cavity  has  been  found. 

Haemo-pericardium.  This  occurs  on  account  of  rupture  of  an 
aneurism  of  the  first  part  of  the  aorta,  of  the  heart  itself,  or  of  the 
coronary  arteries.  Wounds  of  the  pericardium  and  heart  cause  hsemo- 
pericardimn.  The  extension  of  the  ulceration  of  malignant  endocar- 
ditis to  the  surface  may  cause  gradual  effusion  of  blood.  (See  Keat- 
ing, Transactions  of  the  Philadelphia  Pathological  Society.)  The  physical 
signs  are  those  of  effusion.  Death  usually  takes  place  before  there  has 
been  time  to  make  a  sufficiently  accurate  examination  to  determine  its 
presence.  Rapid  heart-failure  due  to  compression  is  the  cause  of  death. 
In  the  case  referred  to  above,  and  in  cases  of  rupture  of  the  heart,  the 
patient  may  live  for  many  hours  with  dyspnoea  and  progressive  weak- 
ening of  the  heart.  In  tuberculosis  and  cancer  the  effusion  is  fre- 
quently blood-stained. 

Pneumo-pericardium.  This  occurs  very  rarely,  and  is  due  to  per- 
foration from  without  by  a  stab-wound,  or  perforation  from  the  lung, 
oesophagus,  or  stomach.  A  purulent  exudation  may  undergo  decom- 
position, causing  an  accumulation  of  gas.  If  it  arises  from  perforation, 
acute  pericarditis  is  set  up.  The  accumulation  of  gas  causes  tympany 
over  the  movable  area  of  percussion-dulness.  The  most  striking  sign 
is  noted  on  auscultation.  Churning,  splashing,  or  metallic  sounds  are 
heard,  drowning  the  feeble  heart-sounds.    Death  usually  occurs  quickly. 

Adherent  Pericardium.  (Plate  XXVIIL,  Fig.  2.)  Chronic  adhe- 
sive pericarditis  may  follow  the  acute  form  or,  particularly  if  tubercu- 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     649 

lous,  develop  independently  and  progress  slowly.  Inspection  and  Palpa- 
tion. Indrawing  of  the  interspaces  may  be  seen  at  the  time  of  the  systole 
of  the  ventricles  ;  even  the  ribs  are  said  to  be  drawn  in.  This  indrawing 
is  most  marked  at  the  apex,  and  must  not  be  confounded  with  the  retrac- 
tion that  occurs  in  the  third  and  fourth  interspaces  with  the  ventricular 
systole.  The  recession  is  synchronous  with  the  systolic  shock.  In  some 
cases  the  systolic  movement  over  the  prsecordia  is  of  an  undulatory 
character.  Walter  Broadbent  calls  attention  to  systolic  retraction  of  the 
back  in  the  region  of  the  eleventh  or  twelfth  rib  as  a  valuable  sign. 
The  apex  is  displaced  outward  and  the  area  of  impulse  is  increased.  The 
increase  in  area  of  impulse  is  due  to  the  hypertrophy  which  always 
attends  universal  adhesion  of  the  pericardium.  After  the  systole  there 
is  frequently  felt  a  quick  rebound,  known  as  the  diastolic  shock,  which 
is  said  to  be  characteristic  of  pericardial  adhesions. 

In  pericardial  adhesions  Friedreich's  sign,  collapse  of  the  cervical 
veins,  during  the  diastole  of  the  heart,  is  seen.  We  may  also  see  in- 
spiratory swelling  (Kussmaul).  In  addition,  the  pulsus  paradoxus 
is  significant  of  the  presence  of  pericardial  adhesions,  or  rather  of  the 
dilatation  that  succeeds  the  adhesions.  The  pulse  is  small  and  feeble 
during  inspiration,  assuming  greater  strength  during  the  period  of  ex- 
piration. 

Percussion.  The  area  of  cardiac  dulness  is  increased  usually  up- 
ward, extending  as  high  as  the  first  interspace.  The  area  of  dulness 
is  frequently  not  modified  by  respiration — that  is,  it  is  not  lessened 
when  the  patient  takes  a  full  breath,  when  the  lungs  should  expand 
over  the  precordial  region.  This  is  particularly  the  case  when  there 
is  pleuritis  associated  with  pericarditis,  a  common  association  in  the 
lar ^e  majority  of  cases. 

Auscultation.  On  auscultation  the  signs  vary.  The  sounds  are  due 
to  hypertrophy  or  to  dilatation  ;  and  it  must  not  be  forgotten  that 
they  frequently  arise  on  account  of  pericardial  adhesions.  In  the 
former  condition  the  first  and  second  sounds  are  accentuated  ;  in  the 
latter,  a  murmur  may  be  heard  at  the  apex,  loud  and  systolic  in  time. 

In  pericardial  adhesions  the  physical  signs  depend  upon  the  condi- 
tion of  the  heart  muscle  at  the  time  of  the  examination.  At  first  we 
have  the  physical  signs  of  hypertrophy,  with  retraction  of  the  inter- 
spaces, particularly  at  the  apex,  or  the  space  at  the  xiphoid  cartilage. 
This  is  particularly  the  case  in  young  subjects.  In  the  later  period  of 
the  disease  the  physical  signs  of  dilatation  arise,  indicated  by  increase 
in  transverse  dulness,  enfeeblement  of  impulse  and  of  sounds,  with  the 
development  of  a  murmur  at  the  apex,  undulation  of  the  veins  in  the 
neck,  and  the  pulsus  paradoxus.  The  physical  signs  of  associate  pleu- 
risy aid  in  the  recognition  of  adherent  pericardium.  Diminution  of 
the  breath-sounds,  increase  in  the  area  of  cardiac  dulnessj  lessened 
fremitus  in  the  neighborhood  of  the  heart  pointing  to  pleural  thickening, 
are  associate  evidence.  Sansom  considers  the  presence  of  pulmonary 
tuberculosis  of  value,  as  pointing  to  the  occurrence  of  pericardial  adhe- 
sions, for  the  associate  pleural  adhesions  are  likely  to  be  attended  by 
tuberculous  pericarditis. 


650  SPECIAL  DIAGNOSIS. 

I  have  learned  to  suspect  adhesive  pericarditis  in  a  young  subject 
the  victim  of  valvulitis,  when  the  symptoms  do  not  yield  to  treatment — 
in  short,  when  the  heart  is  not  affected  by  digitalis.  Unfortunately, 
the  physical  signs  are  often  not  conclusive. 

The  subjective  symptoms  of  adherent  pericardium  are  those  of  dilata- 
tion or  hypertrophy  of  the  heart,  whichever  one  of  the  two  is  in  excess. 

Indurative  mediastino-periearditis  with  adhesion  may  occur  with  or 
without  fibrous  inflammation  and  adhesion  of  the  structures  in  the 
anterior  mediastinum.  The  pericardium  is  adherent  and  thickened. 
Rarely  the  anterior  mediastinum  alone  is  a  mass  of  fibrous  inflamma- 
tion. Peritonitis  and  perihepatitis  may  be  found.  The  entire  process 
may  be  tuberculous.  The  symptoms  are  dyspnoea,  venous  engorgement, 
cyanosis,  enlargement  of  the  liver,  ascites,  and  dropsy.  The  physical 
signs  are  those  of  extreme  cardiac  dilatation  ;  the  pulsus  paradoxus  ; 
collapsing  jugular  veins  during  diastole,  due  to  the  dragging  upon  the 
innominate  veins  and  cava  by  the  fibrous  adhesions,  or  to  stretching 
and  narrowing  of  the  aortic  arch  by  these  adhesions  ;  or  inspiratory 
swelling  of  the  veins  of  the  neck.  A  friction-sound,  systolic  in  time, 
heard  over  the  sternum,  increased  when  the  arm  is  held  up — mediasti- 
nal friction,  so  called,  has  been  described  in  this  affection. 

It  usually  follows  an  acute  chest-affection,  occurs  most  frequently  in 
young  adults,  and  in  males.  It  should  also  always  be  suspected  in 
cases  of  dilatation  and  valvulitis  in  which  compensation  does  not  take 
place,  notwithstanding  the  best  treatment. 

Endocarditis. 

Endocarditis  may  be  acute  or  chronic.  In  either  form  it  is  usually 
secondary.  The  acute  form  is  divided  into  simple  and  so-called  malig- 
nant, infectious,  or  mycotic  endocarditis. 

Simple  Endocarditis.  Acute  endocarditis  rarely  occurs  primarily. 
It  usually  occurs  secondarily  to  general  morbid  processes.  The  patho- 
logical antecedents  are  acute  rheumatism,  tonsillitis,  whooping-cough, 
scarlet  fever,  gonorrhoea,  rarely  smallpox  and  typhoid  fever.  It  is  of 
common  occurrence  in  pneumonia  and  tuberculosis.  It  is  frequent  in 
chorea.  In  the  simple  form  it  occurs  in  septic  inflammations  and  in 
debilitating  diseases,  as  cancer.  It  may  occur  in  gout  and  develop  in 
the  course  of  Bright' s  disease. 

Symptoms.  The  symptoms  of  simple  endocarditis  are  scarcely  ob- 
served during  the  early  course  of  the  disease.  The  process  is  latent, 
and  there  are  no  indications  of  cardiac  disease.  The  physical  signs 
alone  betray  its  presence.  Unless  these  are  sought  for  the  disease  is 
overlooked.  The  subjective  symptoms  are  negative.  In  the  course 
of  rheumatism  or  chorea,  or  during  convalescence  from  the  former,  the 
patient  may  complain  of  palpitation,  and  increased  frequency  and 
irregularity  of  the  heart.  At  the  same  time  there  may  be  a  rise  in 
temperature,  not  attended  by  any  increase  of  the  rheumatic  symptoms, 
which  should  call  attention  to  the  cardiac  complication.  The  rise  is 
not  marked,  and  may  not  assert  itself  during  the  severity  of  the  disease. 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     651 

Physical  Signs.  On  examination  a  murmur  is  detected  in  one  of 
the  cardiac  areas.  The  murmur  is  soft,  low  in  pitch,  and  follows  the 
laws  of  transmission,  according  to  its  situation.  Instead  of  a  distinct 
murmur  a  roughening  of  the  first  sound  alone  may  be  heard.  Pre- 
ceding the  murmur  the  heart's  action  may  be  quickened  and  arhythmi- 
cal ;  the  first  sound  may  change  in  character  from  day  to  day  or  be 
accentuated  ;  the  second  reduplicated  at  the  apex  and  accentuated. 
The  new  sounds  may  disappear  at  first  when  the  patient  sits  up  ;  later 
they  persist.  The  murmur  must  not  be  mistaken  for  the  murmur  at 
the  apex  in  cardiac  dilatation  ;  or  the  murmur  which  may  be  heard  in 
the  course  of  fevers ;  or  the  murmur  of  anaemia,  which  may  rapidly 
develop  in  rheumatism  and  other  affections. 

Malignant  Endocarditis.  Unlike  simple  endocarditis,  the  malig- 
nant form  very  rarely  develops  in  the  course  of  rheumatism  and 
chorea.  (See  the  Infections.)  It  occurs  more  frequently  in  pneumonia 
than  in  any  other  disease.  It  arises  in  the  course  of  erysipelas,  septi- 
caemia, puerperal  fever,  and  gonorrhoea.  It  may  occur  in  dysentery. 
It  is  usually  a  streptococcus  infection. 

Symptoms.  The  symptoms  are  (1)  those  due  to  the  morbid  process 
— the  infection  ;  (2)  the  physical  signs  ;  (3)  those  due  to  emboli.  The 
general  symptoms  due  to  the  specific  morbid  process  are  septic  in  nature. 
The  febrile  phenomena  may  be  one  of  four  groups  :  (1)  The  fever  is 
paroxysmal.  Chills  and  fever  occur  daily  or  at  intervals  of  two  or 
three  days,  resembling  types  of  malarial  fever.  Each  paroxysm  is 
attended  by  profuse  sweats.  Rapid  exhaustion  ensues.  The  fever, 
instead  of  being  distinctly  intermittent,  may  be  irregularly  intermit- 
tent. (2)  The  fever  is  excessive  and  continued,  and  a  typhoid  state 
frequently  sets  in.  The  temperature  is  irregular  ;  extreme  prostration, 
low  delirium,  sordes,  subsultus,  and  other  symptoms  of  that  state  arise. 
(3)  The  fever  is  moderate  and  continued.  Physical  examination,  how- 
ever, reveals  the  presence  of  marked  endocarditis.  In  this  group 
chronic  heart  disease  has  usually  preceded  the  affection.  The  duration 
may  be  prolonged.  (4)  The  fever  may  be  remittent.  Petechial  rashes 
and  erythema  are  common,  so  that,  as  pointed  out  by  Osier,  the  disease 
may  resemble  the  eruptive  fevers.  The  sweating  is  profuse,  contrib- 
uting to  the  profound  exhaustion  which  usually  ensues.  A  septic 
diarrhoea  occurs.  In  a  few  rapidly  fatal  cases  jaundice  has  occurred. 
Again,  the  symptoms  may  be  almost  exclusively  cerebral,  resembling 
cerebro-spinal  or  basilar  meningitis. 

The  embolic  phenomena  are  due  to  escape  into  the  blood-current  of  soft 
vegetations  from  the  valves  of  the  left  heart  (for  the  right  heart  is 
rarely  affected),  which  are  carried  by  the  blood-stream  into  distant 
points  of  the  circulation.  Emboli  occur  in  the  brain,  producing 
aphasia  or  hemiplegia  ;  they  occur  in  the  retina,  causing  some  com- 
plaint as  to  vision,  but  are  accurately  recognized  by  ophthalmoscopic 
examination.  They  occur  in  the  kidneys,  producing  bloody  urine  and 
renal  pain.  In  nearly  all  cases  the  spleen  is  the  seat  of  embolism,  and 
in  some  instances  infarctions  may  take  place  in  this  organ  alone.  The 
spleen  is  always  enlarged,  and  the  infarct  may  cause  pain  and  increased 


652  SPECIAL  DIAGNOSIS. 

tenderness  on  pressure.  Emboli  in  the  skin  and  mucous  membranes 
present  the  most  striking  phenomena.  The  hemorrhages  underneath 
the  skin  are  minute.  They  are  seen  in  the  extremities,  but  may  also  be 
found  on  the  trunk.  They  occur  in  the  mucous  membranes,  as  those  of 
the  mouth  and  tongue.  They  are  seen  in  the  bulbar  conjunctiva?,  and 
in  the  conjunctivae  of  the  lids. 

Physical  Signs.  Repeated  examinations  are  necessary  in  some  cases, 
to  determine  the  presence  of  a  murmur,  or  to  decide  whether  a  previ- 
ously existing  organic  lesion  is  the  seat  of  an  acute  process.  Varia- 
tions in  the  character  of  the  murmur  from  day  to  day  are  characteristic 
of  malignant  endocarditis.  In  organic  heart  disease  with  dilatation  and 
failure  of  compensation,  irregular  fever  followed  by  embolic  phenom- 
ena points  to  the  occurrence  of  an  infectious  process  on  the  antecedent 
valvulitis. 

Diagnosis.  This  form  of  endocarditis  is  of  infectious  origin.  The 
diagnosis  rests  upon  proof  that  an  infection  is  present,  and  is  made  by 
the  methods  described  in  Chapter  XIX.,  Part  I.,  which  should  be 
reviewed  by  the  reader.  The  history  of  an  infection  in  some  part  of  the 
body  is  most  important  in  the  diagnosis.  The  presence  of  the  infection, 
as  well  as  its  nature,  may  be  disclosed  by  an  examination  of  the  blood. 
When  embolic  phenomena  are  present  the  diagnosis  is  made  without 
much  difficulty.  The  more  pronounced  general  symptoms  distinguish 
it  from  simple  endocarditis.  The  temperature-range,  the  septic  and 
typhoid  symptoms,  belong  to  the  malignant  form.  The  more  pro- 
longed cases  with  moderately  continuous  fever,  without  apparent 
primary  cause,  are  frequently  confounded  with  typhoid  fever.  This  is 
readily  appreciated  when  the  symptoms  of  the  two  are  compared.  In 
both  there  is  fever  of  a  continued  type,  with  the  symptoms  of  the 
typhoid  state,  including  delirium.  In  both  there  are  enlargement  of 
the  spleen,  diarrhoea,  and  abdominal  tenderness.  In  both  there  may 
be  infarctions,  although  they  are  extremely  rare  in  typhoid  fever,  and 
only  occur  late  in  the  disease.  In  both  there  is  progressive  exhaus- 
tion. But  in  endocarditis  the  onset  may  be  more  abrupt.  The  fever 
does  not  present  the.  regularity  of  type  that  is  seen  in  the  development 
of  typhoid.  In  endocarditis  there  is  more  chest  oppression  and 
dyspnoea  early  in  the  disease  than  in  typhoid  fever.  In  endocarditis 
the  source  of  the  infection  may  be  discovered  in  the  genito-urinary 
organs,  the  lungs,  the  bones,  etc.  The  diazo-reaction  is  found  in 
typhoid  fever  after  the  fifth  day,  but  rarely,  if  ever,  in  endocarditis. 
The  results  of  bacteriological  examination,  and  especially  of  serum, 
diagnosis,  distinguish  the  two  affections.  This  ought  to  be  of  value  in 
endocarditis,  because  the  process  is  usually  due  to  a  staphylococcus  or 
streptococcus  infection.  Either  micro-organism  may  be  found  in  any 
suppurations  which  may  possibly  be  present  or  in  the  blood.  In  a  child 
recently  seen  by  me  in  the  relapse  of  an  attack  of  typhoid  fever,  malig- 
nant endocarditis  was  thought  to  be  present,  because  of  a  loud  and  rough 
murmur  at  the  pulmonary  orifice.  Fortunately  the  murmur  was  present 
in  the  apyretic  period,  and  as  the  child  was  anaemic  its  exaggeration 
was  ascribed  to  the  fever. 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     653 

Malignant  endocarditis  must  be  distinguished  from  cerebrospinal 
fever,  and  from  smallpox  of  the  hemorrhagic  type.  We  must  rely  on  the 
local  cardiac  symptoms  and  physical  signs,  and  the  preponderance  of 
these  over  the  other  symptoms.  Of  course,  the  prevalence  of  an 
epidemic  and  a  history  of  exposure  are  of  service  in  the  distinction 
between  the  diseases.  Examination  of  the  blood  excludes  the  forms 
of  malaria  which  formerly  were  mistaken  for  endocarditis. 

Chronic  Endocarditis.  Chronic  endocarditis  may  follow  the  acute 
form  or  develop  in  the  course  of  atheroma  or  of  endarteritis  due  to 
alcoholism,  the  poison  of  syphilis  or  of  gout.  If  associated  with  endar- 
teritis, the  endocardial  change  may  be  part  of  the  general  degenerative 
changes  which  occur  in  the  aging  process.  It  may  be  of  dynamic 
origin,  often  following  prolonged  heavy  muscular  exertion,  by  which 
the  valves,  particularly  at  the  aortic  orifice,  have  been  subjected  to 
strain.  The  process  is  slow  and  insidious,  and  leads  to  the  changes  in 
the  valve-segments  which  constitute  chronic  valvular  disease. 

Symptoms.  The  symptoms  of  chronic,  or  sclerotic,  endocarditis  are 
the  symptoms  of  chronic  valvular  disease.  Insufficiency  or  obstruc- 
tion, or  both  combined,  take  place  at  the  affected  valve-orifice.  The 
outflow  of  blood  is  retarded  in  obstruction.  Backward  flow,  or  regur- 
gitation, takes  place  in  insufficiency  in  the  opposite  direction  from 
the  normal  blood-current.  When  there  is  obstruction  hypertrophy 
usually  develops  to  meet  it.  If  the  obstruction  is  moderate,  and  the 
person  remains  in  good  health,  the  hypertrophy  is  sufficient  to  over- 
come the  obstruction.  In  this  manner  the  effect  of  the  valve  lesion  is 
compensated.  On  the  other  hand,  when  blood  is  permitted  to  flow 
by  regurgitation  backward  into  the  cavity — that  is,  in  the  opposite 
direction  to  its  usual  course — it  meets  a  blood-current  flowing  to  this 
cavity  in  the  normal  direction,  and  the  result  is  overdistention,  or  over- 
filling, of  the  cavity.  Dilatation  ensues,  and  may  persist.  If  the  re- 
gurgitation takes  place  suddenly,  the  dilatation  continues  ;  if  gradually, 
as  in  chronic  endocarditis,  the  dilatation  is  attended  with  hypertrophy. 
Thus,  when  there  is  regurgitation  from  the  left  ventricle  into  the  left 
auricle,  on  account  of  incompetency  at  the  mitral  orifice,  the  auricle 
becomes  overdistended  with  blood,  for  it  is  filling  with  blood  from  the 
pulmonary  veins  at  the  same  time.  This  overdistention  can  only  be 
overcome  by  some  hypertrophy.  When  this  is  not  sufficient  the  blood 
is  obstructed  in  the  pulmonary  circulation,  with  the  consequences  here- 
after to  be  mentioned. 

The  symptoms  of  chronic  endocarditis  are  latent  if  the  lesions  are 
compensated  ;  if  not,  symptoms  of  failure  in  compensation  occur  or 
dilatation  of  the  heart  arises.  The  physical  signs  are  those  of  chronic 
valvulitis.  The  character  of  the  signs  depends  upon  the  lesion  of  the 
affected  valve. 

Disease  of  the  Coronary  Arteries. 

Atheroma,  associated  with  the  process  in  other  vessels,  or  distinctly 
localized  to  the  coronary  arteries,  affects  these  vessels.  Its  causal 
factors  are  those  of  endarteritis  elsewhere.     Its  influence  on  the  nutri- 


654  SPECIAL  DIAGNOSIS. 

tion  of  the  heart,  either  by  sudden  obstruction  of  the  vessels  by  an 
embolus  or  by  their  gradual  closure,  is  apparent. 

Symptoms.  If  an  atheromatous  coronary  artery  is  suddenly  ob- 
structed by  an  embolus,  death  may  be  immediate.  This  is  a  common 
cause  of  sudden  death.  In  other  instances  thrombosis  may  take  place, 
followed  by  anaemic  infarction,  myocarditis,  and  mural  aneurism.  In 
this  class  of  cases  the  onset  of  the  symptoms  may  be  sudden.  Precor- 
dial oppression  or  angina  pectoris  may  be  the  first  indication.  Succeed- 
ing this,  dyspnoea,  dilatation  of  the  heart,  and  venous  stasis  occur.  The 
presence  of  an  aneurism  may  be  made  out.  The  heart's  action  is  per- 
sistently rapid  and  may  be  arhythmical.  If  there  has  not  been  pre- 
vious valvulitis,  no  murmurs  are  heard  until  dilatation  ensues.  The 
patient  may  live  three  or  four  weeks,  or  as  many  months. 

In  a  third  group  of  cases  occlusion,  either  from  the  endarteritis  or 
from  a  slowly  forming  thrombus,  is  so  gradual  as  to  lead  to  myocar- 
ditis only  with  the  attending  symptoms. 

Diagnosis.  Unfortunately,  too  often  the  diagnosis  can  only  be  pro- 
visional. Sudden  death  may  be  attributed  to  coronary  artery  disease 
if  there  has  been  a  history  of  previous  attacks  of  angina,  if  there  is 
evidence  of  arterial  disease  elsewhere,  and  if  dyspnoea  or  anginoid 
symptoms  preceded  the  fatal  termination.  Thrombosis,  secondary  to 
atheroma,  may  be  suspected  if  a  patient,  in  whom  there  is  no  valvular 
disease,  no  pulmonary  or  renal  disease,  is  seized  with  angina  pectoris 
or  dyspnoea  ;  providing  tachycardia  and  arhythmia  follow,  and  in  a 
short  time  cardiac  dilatation,  venous  stasis,  etc.  In  a  male,  aged  forty- 
three  years,  without  syphilis,  but  with  a  history  of  antecedent  rheuma- 
tism, an  attack  of  angina  pectoris  followed  some  unusual  exertion. 
Prior  to  this  he  had  been  in  the  most  perfect  health.  The  attack  was 
followed  by  dyspnoea  and  remarkably  rapid  heart-action  without  appar- 
ent cause.  The  physical  signs  of  acute  congestion  of  the  lower  lobe  of 
the  right  lung  followed  within  twenty-four  hours  of  the  attack  of  angina. 
The  patient  was  ill  three  months.  He  improved  somewhat,  but  rapidity 
of  the  heart's  action  and  some  stasis  in  the  lung  persisted.  Gradually 
cardiac  dilatation  ensued,  with  a  murmur  in  the  tricuspid  area.  Death 
took  place  from  pulmonary  congestion.  At  the  autopsy  the  coronary 
arteries  were  atheromatous  ;  the  left  was  filled  with  an  old  thrombus  ; 
there  was  extensive  myocarditis  and  an  aneurism  of  the  left  ventricle. 

In  another  case,  male,  aged  seventy-two  years,  with  general  atheroma 
but  no  valvulitis,  sudden  precordial  distress,  tachycardia,  and  persist- 
ent dyspnoea  were  followed  by  cardiac  dilatation,  mitral  incompetency, 
general  anasarca. 

I  have  said  elsewhere,  a  persistently  rapid  pulse,  uninfluenced  by 
digitalis,  indicates  pericardial  adhesion  in  the  young  ;  the  same  pulse 
uninfluenced  by  treatment  points  to  coronary  artery  disease  in  the 
middle-aged  and  senile. 

Myocarditis. 

Myocarditis  may  be  acute  or  chronic.  The  entire  muscle  or  only 
a  portion  may  be  affected.     General  myocarditis  is  always  acute.     The 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     655 

local  form  may  be  acute  or  chronic,  depending  upon  the  degree  of 
the  primary  cause.  The  local  variety  is  usually  due  to  a  thrombus 
in  the  terminal  endings  of  the  coronary  artery,  which  cuts  off  the 
blood-supply.  The  changes  are  those  of  myocarditis,  to  which  may  be 
added  necrosis  of  small  areas  and  the  development  of  aneurism. 
Etiology.  Pathological  antecedents  of  acute  general  myocarditis  are 
the  fevers,  particularly  typhoid  and  typhus  fever,  pneumonia,  diphthe- 
ria, and  septic  fevers  generally.  Chronic  myocarditis  is  usually  asso- 
ciated with  atheroma,  one  of  the  causes  of  which  occurs  in  the  later 
stages  of  Bright' s  disease.  (See  Atheroma.)  The  result  of  myocar- 
ditis, when  acute,  is  dilatation  of  the  heart,  fatty  heart,  or  aneurism  of 
the  heart.  Chronic  myocarditis  is  followed  by  fatty  heart,  by  dilata- 
tion, by  the  so-called  fibroid  heart  or  fibrous  myocarditis,  and  by  aneu- 
rism.    The  above  facts  in  etiology  are  important  in  diagnosis. 

Symptoms.  The  symptoms  of  acute  myocarditis  are  vague.  In 
the  course  of,  or  in  the  convalescence  from,  an  infection  the  patient  may 
complain  of  some  oppression  in  the  prsecordia  and  suffer  from  dyspnoea  ; 
attacks  of  syncope  may  occur,  and  sighing  may  be  frequent.  The 
pulse  becomes  more  rapid  and  weak,  but  is  usually  not  irregular.  The 
circulation  is  much  depressed,  the  hands  may  be  cold,  the  face  pallid. 
These  symptoms  may  be  accounted  for  by  the  extreme  exhaustion  alone 
that  follows  fever.  No  doubt  some  myocarditis  accounting  for  the 
symptoms  exists  in  all  cases,  particularly  if  there  is  prolonged  high 
temperature.  Often  the  patient  does  not  complain  of  any  cardiac  symp- 
toms. Death  takes  place  suddenly,  either  in  the  course  of  the  dis- 
ease or  after  it  has  spent  its  force,  from  acute  dilatation  or  cardiac 
paralysis.  This  is  particularly  true  in  pneumonia  and  diphtheria.  In 
the  latter  affection  the  sudden  appearance  of  cardiac  symptoms,  dysp- 
noea, cyanosis,  and  cold  extremities  may  be  due  to  paralysis  of  the 
heart. 

Physical  Signs.  Enfeeblement  of  the  heart-sounds,  sometimes  with 
accentuation  of  the  mitral  first  sound,  is  observed.  The  impulse  and 
apex-beat  are  scarcely  perceptible,  or  absent  altogether.  If  acute  dila- 
tation supervenes  the  area  of  dulness  may  be  ii:  creased. 

The  symptoms  of  chronic  myocarditis  are  obscure  and  indefinite,  and 
in  the  majority  of  cases  depend  upon  the  secondary  changes  that  have 
taken  place  in  the  heart  muscle.  If  there  is  atrophy  of  the  fibroid 
heart,  the  pulse  is  feeble,  slow,  and  irregular.  It  may  be  as  slow  as 
thirty  or  forty  beats  to  the  minute.  Irregularity  is  not  neoessarily 
present,  but  intermittency  is  of  frequent  occurrence.  The  patient  com- 
plains of  dyspnoea  aggravated  by  exertion.  Attacks  of  angina  pectoris 
are  likely  to  occur.  The  symptoms  of  dilatation  of  the  heart  may 
ensue  later,  with  oedema,  cyanosis,  and  congestions.  A  symptom-com- 
plex, known  as  the  Stokes-Adams  syndrome,  is  often  seen,  character- 
ized by  dyspnoea,  coma,  and  slow  pulse — a  pseudo-apoplexy.  In  fatty 
degeneration  of  the  heart  the  pulse  is  increased  in  frequency ;  there  are 
cardiac  irregularity,  palpitation,  and  dyspnoea.  These,  however,  are  also 
the  symptoms  of  dilatation,  which  usually  succeeds  the  degeneration. 
The  heart-sounds  are  weak.    If  dilatation  has  set  in,  a  murmur  is  heard 


656  SPECIAL  DIAGNOSIS. 

at  the  apex,  with  gallop-rhythm  of  the  heart.  In  fatty  degeneration 
attacks  of  collapse  with  slow  pulse  are  common.  Shortness  of  breath 
on  exertion  may  occur.  Cardiac  asthma  occurs  at  night,  and  sighing 
and  yawning  are  of  frequent  occurrence  during  the  day.  The  patient 
usually  sleeps  badly.  The  cerebral  functions  are  more  or  less  in  abey- 
ance, the  action  of  the  mind  is  sluggish ;  the  patient  may  have  delu- 
sions or  become  maniacal.  Cheyne-Stokes  breathing  was  formerly 
thought  to  be  of  diagnostic  significance. 

Chronic  myocarditis  must  be  distinguished  from  fatty  overgrowth  of 
the  heart.  This  cardiac  change  is  frequently  seen  in  brewers  and 
saloon-keepers,  and  is  usually  associated  with  obesity.  The  pulse  may 
be  feeble,  the  heart-sounds  weak  and  muffled.  The  patients  are  sub- 
ject to  attacks  of  asthma,  and  frequently  have  bronchitis  and  emphy- 
sema. Vertigo  is  of  common  occurrence.  Death  may  occur  during 
syncope. 

Aneurism  of  the  Heart. 

Aneurism  of  the  valves,  following  endocarditis,  cannot  be  recognized 
during  life.  Aneurism  of  the  walls  usually  results  from  chronic  myo- 
carditis. The  aneurism  develops  in  the  left  ventricle  at  the  apex. 
The  symptoms  are  indefinite.  In  rare  cases  a  marked  bulging  has 
been  noted  in  the  region  of  the  apex,  and  the  tumor  may  perforate  the 
chest-wall.  A  projection  beyond  the  normal  line  of  cardiac  dulness 
may  be  detected  by  stethoscopic  or  plessimetric  percussion.  The 
symptoms  are  those  of  myocarditis  and  of  dilatation  of  the  heart. 

Rupture  of  the  heart  is  one  of  the  causes  of  sudden  death,  often 
without  previous  symptoms.  The  accideut  takes  place  during  exer- 
tion. Quain  collected  one  hundred  cases,  in  seventy-one  of  which 
death  took  place  without  previous  warning.  In  other  instances  there 
was  a  sense  of  anguish,  and  suffocation  in  the  cardiac  region.  The 
physical  signs  of  slowly  developing  pericardial  effusion  may  be  ascer- 
tained if  the  leakage  from  rupture  is  slow  in  progress. 

Chronic  Valvular  Disease. 

Valvular  disease  includes  valvulitis  and  valvular  incompetency  ; 
there  is  either  obstruction  or  regurgitation  at  the  orifices  affected. 
Valvulitis  may  exist  with  or  without  symptoms  ;  valvular  incompe- 
tency is  always  accompanied  by  symptoms.  Valvulitis  implies  organic 
disease  of  the  valves  ;  valvular  incompetency,  regurgitation  through 
orifices,  the  valves  of  which  cannot  close  it,  but  they  may  or  may  not 
be  diseased.  Valvulitis  may  be  recognized  by  physical  signs  of  (1) 
the  lesion,  (2)  the  secondary  effects  of  the  lesion  on  the  heart  and  cir- 
culalion — hypertrophy  or  dilatation.  Valvular  incompetency  occurs 
usually  in  dilatation,  and  may  be  secondary  to  valvulitis.  It  is  recog- 
nized by  both  signs  and  symptoms.  Valvular  disease  is  without  symp- 
toms as  long  as  the  heart-muscle  enlarges  sufficiently  to  keep  in  balance 
the  impaired  circulation  ;   compensation  is  then  said  to  be  complete. 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     657 

When  compensation  is  broken  we  then  have  the  subjective  symptoms 
enumerated  above,  all  in  consequence  of  dilatation  of  the  heart.  It 
may  be  said  that  valvulitis  is  of  no  significance  as  long  as  compensation 
is  perfect.  To  review — valvulitis  may  be  attended  by  physical  signs 
in  the  heart  and  vessels  only,  or  by  its  own  physical  signs,  the  physical 
signs  of  dilatation,  and  the  symptoms  of  the  latter.  In  the  considera- 
tion of  valvular  disease  it  is  more  profitable  to  take  up  the  symptoms 
of  each  valve-lesion,  bearing  in  mind  that  two  or  more  of  the  valves 
may  be  diseased  at  the  same  time,  or  that  both  obstruction  and  regur- 
gitation may  be  present  at  the  same  time  at  the  same  valve-orifice. 

Aortic  Regurgitation,  Insufficiency  or  Incompetency.  This  may 
exist  for  a  long  time  without  presenting  any  symptoms.  It  occurs 
more  frequently  in  men  than  in  women,  and  is  more  common  in  the 
later  periods  of  life.  It  may  be  due  to  congenital  malformation,  to 
acute  endocarditis,  or,  as  is  most  frequently  the  case,  to  chronic  endo- 
carditis, particularly  when  it  follows  strain  or  undue  exertion ;  alco- 
holism and  syphilis  are  also  frequent  antecedents.  In  rare  cases  it 
follows  rupture  of  the  valves.  Relative  insufficiency  or  incompetency 
is  of  very  rare  occurrence.  Insufficiency  is  frequently  combined  with 
obstruction. 

On  account  of  regurgitation,  or  insufficiency,  at  the  aortic  orifice  the 
blood  falls  directly  into  the  left  ventricle  during  the  diastole.  There 
is,  first,  a  relative  diminution  in  the  amount  of  blood  in  the  artery ; 
and,  second,  an  increased  amount  of  blood  in  the  ventricle,  because  the 
regurgitated  column  of  blood  meets  the  blood  from  the  auricle  which 
is  filling  the  chamber  at  the  same  time.  Dilatation  of  the  left  ventri- 
cle ensues,  and  is  followed  by  hypertrophy.  Dilated  hypertrophy  thus 
arises.  The  heart  becomes  enormously  enlarged.  This  is  one  of  the 
conditions  in  which  enormous  cardiac  enlargement  takes  place — so- 
called  got  bovinum.  If  this  valve-lesion  occurs  at  the  period  of  life 
and  from  the  causes  above  mentioned,  it  is  attended  by  more  or  less 
sclerosis  of  the  arteries. 

Symptoms.  They  may  be  entirely  absent  as  long  as  perfect  com- 
pensation exists.  This  is  particularly  the  case  if  there  is  but  little 
general  arterial  sclerosis.  Coincident  lesions  of  other  valves  tend  to 
break  the  compensation.  The  earlier  symptoms  are  those  due  to 
arterial  anaemia,  particularly  anaemia  of  the  brain.  They  are  head- 
ache, dizziness,  and  flashes  of  light  before  the  eyes.  The  patient  has 
an  anaemic  appearance,  and  soon  begins  to  suffer  from  shortness  of 
breath.  This  at  first  develops  upon  slight  exertion.  Palpitation  and 
oppression  about  the  chest  are  complained  of,  readily  excited  by  undue 
exertion.  Pain  is  a  common  symptom.  It  may  be  in  the  region  of 
the  prsecordia,  of  a  dull,  aching  character,  and  radiate  to  the  neck  and 
down  the  arms,  particularly  on  the  left  side.  The  anginoid  pains  may 
be  followed  by  attacks  of  true  angina  pectoris.  The  latter  are  more 
common  in  aortic  regurgitation  than  in  any  other  valve-lesion. 

As  compensation  fails  venous  stasis  occurs  and  the  dyspnoea  in- 
creases. The  latter  is  worse  at  night  and  compels  the  patient  to  sleep 
in  a  semi-erect  posture.  Congestion  of  the  lungs  takes  place,  giving 
rise  to  cough.     Hemorrhage  occurs,  but  not  so  frequently  as  in  mitral 

42 


g58  SPECIAL  DIAGNOSIS. 

disease.  (Edenia  of  the  feet  sets  in,  but  general  anasarca  is  not  com- 
mon.    CEderoa  of  the  feet  ma}'  be  due  to  the  attendant  anaemia. 

In  aortic  insufficiency  sudden  death  is  of  common  occurrence.  This 
may  take  place  at  night  during  an  attack  of  dyspnoea,  or  occur  sud- 
denly upon  the  slightest  exertion,  such  as  straining  at  stool,  or  ascend- 
ing a  height,  or  walking  more  quickly  than  usual. 

The  Physical  Signs  of  Aortic  Regurgitation.  (Plate  XXIX.,  Fig.  1.) 
Inspection.  The  apex  beat  is  downward,  outward,  and  to  the  left.  It 
may  be  as  low  as  the  seventh  interspace,  and  as  far  out  as  the  anterior 
axillary  line.  The  area  of  cardiac  impulse  is  increased.  It  occupies 
the  whole  prrecordia,  and  heaving  of  the  lower  half  of  the  chest  may 
be  seen.     In  young  subjects  there  is  precordial  bulging. 

Palpation.  The  impulse  is  strong  and  heaving.  After  compensa- 
tion fails  it  is  indefinite  and  wavy.  A  thrill,  diastolic  in  time,  may 
be  felt  if  the  hand  is  placed  about  the  middle  of  the  sternum. 

Percussion.  The  area  of  dulness  is  increased.  The  extent  is  greater 
than  that  in  any  other  valve-lesion,  and  the  enlargement  is  more  par- 
ticularly downward  and  to  the  left. 

Auscultation.  At  the  second  costal  cartilage  on  the  right  a  murmur 
is  heard,  diastolic  in  time.  This  may  be  its  seat  of  maximum  inten- 
sity. (See  Fig.  175.)  It  is  transmitted  along  the  course  of  the  ster- 
num toward  the  apex.  In  some  instances  the  seat  of  maximum  intensity 
is  at  the  fourth  left  costal  cartilage,  or  even  at  the  apex.  The  second 
sound  is  absent  in  the  large  majority  of  cases.  In  some  instances, 
however,  both  murmur  and  second  sound  may  be  heard  at  the  same 
time.  Other  murmurs  also  may  be  associated  with  aortic  regurgita- 
tion, not  always  due  to  disease  of  the  aortic  valves  : 

1.  A  systolic  murmur  at  the  second  costal  cartilage  on  the  right, 
transmitted  into  the  vessels  of  the  neck,  short,  rough,  and  high  in 
pitch.  It  is  due  to  roughening  of  the  valve-segments,  or  to  atheroma 
of  the  aorta. 

2.  A  murmur  at  the  apex,  rumbling  in  character,  localized  to  this 
area,  usually  presystolic  in  time.  It  is  the  murmur  described  by 
Flint,  who  attributes  it  to  flapping  of  the  mitral  segments,  which 
during  diastole  are  not  forced  back  against  the  heart-wall,  on  account 
of  the  dilatation  of  the  ventricle.  They  remain  in  the  blood-current 
and  produce  relative  narrowing. 

3.  A  systolic  murmur  in  the  mitral  area,  low  in  pitch,  due  to  dila- 
tation.    This  occurs  when  failure  in  compensation  takes  place. 

Examination  of  the  Arteries.  Pulsation  of  the  peripheral  vessels  is 
more  common  in  aortic  regurgitation  than  in  any  other  valve-lesion. 
The  carotids  throb,  the  temporals  pulsate,  the  brachial  and  radial  arte- 
ries are  conspicuous.  Pulsation  of  the  retinal  arteries  is  seen  with  the 
ophthalmoscope,  and  has  often  led  to  the  recognition  of  the  disease  by 
the  ophthalmologist  who  had  been  consulted  for  other  conditions.  The 
pulsation  is  of  a  jerking  character  ;  in  the  neck  it  may  simulate  the 
pulsation  of  an  aneurism.  The  aorta  can  be  seen  and  felt  at  the  supra- 
sternal notch.  The  abdominal  aorta  pulsates  vigorously  in  the  epigas- 
trium. The  pulse  is  significant  in  aortic  regurgitation.  The  so-called 
water-hammer,  or  Corrigan's,  pulse  is  observed.     The  pulse  is  quick 


PLATE    XXIX. 

FIO.  1. 


Aortic  Regurgitation. 

FIO.  2. 


Aortic  Obstruction. 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     659 

and  jerking,  and  after  striking  the  finger  immediately  recedes.  It  is 
most  marked  when  the  arm  is  held  up.  On  auscultation  of  the  arteries 
double  murmurs  may  be  heard  in  the  carotids  and  subclavians,  and  in 
rare  instances  they  are  present  in  the  femorals.     (See  Pulse.) 

The  Capillary  Pulse.  This  is  seen  beneath  the  finger-nails,  or  on  the 
surface  of  the  skin,  as  the  forehead,  when  a  line  is  drawn  across  it.  The 
hypersemia  produced  on  either  side  of  the  line  becomes  alternately  red 
and  pale.  Capillary  pulse  also  occurs  in  anaemia,  and  at  times  in 
neurasthenia. 

Aortic  Obstruction.  Aortic  obstruction  occurs  in  the  aged,  and 
with  atheroma  of  the  arteries.  It  causes  some  diminution  in  the 
amount  of  blood  in  the  peripheral  circulation,  resulting  in  poor  nutri- 
tion and  the  development  of  ansemia. 

Symptoms.  Ansemia  develops  first,  and  embolic  phenomena  may 
occur  later.  The  symptoms  may  be  latent  until  the  occurrence  of  em- 
bolism. This  accident  is  not  uncommon,  on  account  of  the  position  of 
the  aortic  valve.  The  emboli  are  distributed  throughout  the  arterial 
circuit,  and  may  lodge  in  the  brain,  kidneys,  or  spleen.  When  the 
obstruction  is  pronounced  the  blood-supply  in  the  arteries  is  dimin- 
ished. Cerebral  ansemia  takes  place,  causing  dizziness  and  fainting. 
Sleep  is  more  disturbed  than  in  other  valve  affections,  because  of  the 
cerebral  anseruia.  Palpitation  and  cardiac  pain  occur,  but  are  not  so 
common  as  in  aortic  regurgitation.  When  compensation  fails,  dilata- 
tion of  the  left  Ventricle  ensues,  followed  by  pulmonary  congestion 
and  stasis  in  the  systemic  circulation. 

The  Physical  Signs.  (Plate  XXIX.,  Fig.  2.)  There  is  hyper- 
trophy of  the  left  ventricle.  Inspection.  The  apex-beat  is  displaced 
downward  and  outward.  The  impulse  is  strong  during  the  period  of 
hypertrophy.  When  compensation  fails  the  physical  signs  of  dilatation 
ensue.  In  many  cases,  from  the  very  first,  there  may  be  considerable 
hypertrophy  without  the  visible  impulse,  because  of  associate  emphy- 
sema, which  is  common  to  old  men  with  this  lesion. 

Palpation.  At  the  base  of  the  heart,  and  in  the  aortic  area,  a  thrill, 
systolic  in  time,  may  be  felt.  When  present,  it  is  usually  very  distinct, 
and  is  transmitted  along  the  course  of  the  vessels.  The  impulse  is  slow 
and  heaving,  if  hypertrophy  is  present ;  if  dilatation,  feeble  and  indis- 
tinct. 

Percussion.  The  area  of  dulness  is  increased,  in  the  earlier  stages, 
to  the  left  and  downward.  After  compensation  is  broken,  dilatation 
with  increased  area  of  dulness  ensues. 

Auscultation.  A  murmur  is  heard  of  maximum  intensity  at  the 
second  costal  cartilage  to  the  right,  systolic  in  time,  and  transmitted  in 
the  course  of  the  bloodvessels.  (See  Fig.  174.)  It  is  usually  harsh 
and  loud,  but  may  be  musical.  As  the  heart  weakens,  the  intensity 
of  the  murmur  lessens  and  its  roughening  disappears.  It  becomes  soft 
and  low  in  pitch.  The  second  sound,  if  there  is  no  regurgitation,  is 
muffled  or  may  be  absent.  The  pulse  is  small  and  regular.  The  ten- 
sion is  usually  increased. 

Diagnosis.  A  systolic  murmur  at  the  aortic  orifice  may  be  due  to 
aortic  obstruction,  atheroma  or  dilatation  of  the  aorta,  ulcerative  aor- 


660  SPECIAL  DIAGNOSIS. 

titis,  or  anaemia.  Huchard  describes  a  murmur  iu  this  situation,  with 
vibratory  thrill,  due  to  aberrant  chorda?  tendineae.  The  murmur  of 
aortic  stenosis  is  distinguished  from  the  others  by  its  character,  by 
the  presence  of  thrill,  by  the  character  of  the  pulse,  and  by  its  associa- 
tion with  hypertrophy  of  the  left  ventricle.  A  murmur  due  to  athe- 
roma of  the  aorta,  particularly  iu  the  course  of  renal  disease,  is  also 
associated  with  hypertrophy  of  the  left,  ventricle.  The  diagnosis  from 
aortic  obstruction  is  often  difficult  or  impossible.  Slowness  of  the  pulse 
is  more  characteristic  of  aortic  obstruction.  The  murmur  of  anaemia  is 
softer  and  low  in  pitch.  There  is  no  thrill,  and  the  left  ventricle  is  not 
hvpertrophied.  Anaemic  murmurs  may  be  heard  elsewhere.  In  athe- 
roma the  second  sound  is  usually  accentuated,  and  in  anaemia  also  it  is 
intensified. 

Mitral  Incompetency  or  Regurgitation.  The  regurgitation  may 
be  due  to  disease  of  the  valves  (organic)  from  previous  endocarditis, 
or  to  inability  of  the  segments  to  close  the  orifice  (incompetency),  which 
has  become  enlarged  as  part  of  the  dilatation  of  the  cavities.  The  latter 
occurs  in  dilatation  of  the  left  ventricle.  It  takes  place  when  the 
muscle  is  weak  in  fevers  and  in  anaemia.  It  is  thus  seen  that  the  mur- 
mur of  mitral  insufficiency  is  one  of  the  most  commonly  observed  of  all 
valve-murmurs.  Its  ready  production  and  often  equally  ready  removal 
with  treatment  make  it  the  least  serious.  It  must  not  be  forgotten 
that  insufficiency  from  disease  of  the  valves  and  from  disease  of  the 
muscles  must,  if  possible,  be  distinguished  from  each  other.  The 
historv  of  the  case  is  essential  in  determining  the  diagnosis. 

Disease  at  the  mitral  orifice  producing  insufficiency  has  more  serious 
effect  upon  the  pulmonic  and  arterial  circulation  than  disease  at  any  of 
the  other  orifices.  These  effects  must  be  understood  in  order  to  appre- 
ciate the  symptoms  of  mitral  incompetency.  They  are  as  follows  :  1. 
With  each  systolic  contraction  the  blood  flows  back,  on  account  of  the 
insufficiency,  to  the  auricle,  where  it  soon  meets  a  volume  of  blood 
coming  from  the  lungs.  The  combined  volumes  of  blood  overdistend 
the  auricle.  Dilatation  ensues,  and  because  of  increased  work  to  get 
rid  of  the  increased  contents,  hypertrophy  follows.  Dilated  hypertro- 
phy of  the  left  auricle  is  the  first  effect.  2.  As  a  result  of  the  above, 
a  larger  amount  of  blood  is  forced  from  the  left  auricle  into  the  left 
ventricle  ;  dilatation  and  subsequent  hypertrophy  of  this  chamber  also 
follow,  to  remove  the  fluid.  3.  On  account  of  the  overdist ended  auri- 
cle the  pulmonary  veins  are  not  fully  emptied  during  the  diastole  of 
that  chamber.  The  veins  are  therefore  engorged  and  interfere  with 
the  flow  of  blood  through  the  pulmonary  circuit.  In  consequence  of 
the  impeded  flow  of  blood  the  vessels  in  the  pulmonary  circuit  are 
dilated  and  overdistended.  The  right  ventricle  is  compelled  to  act 
more  vigorously,  and  even  then  cannot  empty  itself  freely.  Dila- 
tation and  hypertrophy  of  the  right  ventricle  ensue.  4.  This  causes 
obstruction  of  the  flow  of  blood  from  the  right  auricle  to  the  right 
ventricle  ;  dilatation  and  hypertrophy  of  its  chambers  follow.  If 
perfect  compensation  ensues  through  hypertrophy  of  both  ventricles, 
engorgement  in  the  lungs  may  not  be  observed.  Moreover,  the  left 
ventricle  is  allowed  to  send  out  sufficient  blood  to  supply  the  wants  of 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     661 

the  system.  This  compensation  may  continue  for  years.  If  it  fails, 
either  from  increase  in  the  valve-lesion,  or  valvular  incompetency,  or 
from  weakening  of  the  muscle,  a  normal  amount  of  blood  is  not  dis- 
tributed throughout  the  aortic  area,  but  is  thrown  back  upon  (1)  the 
left  auricle  ;  (2)  the  pulmonary  circulation  ;  (3)  the  right  heart  ;  and, 
finally,  the  systemic  veins.  For  a  time  the  pulmonary  circuit  will 
alone  be  engorged,  subsequently  the  systemic  veins  become  congested 
because  of  dilatation  of  the  right  auricle  and  incompetency  of  the  tri- 
cuspid valves.  We  then  have  the  secondary  effects  of  stasis  upon  the 
various  organs  of  the  body,  with  cyanotic  induration  and  the  develop- 
ment of  dropsies.  Mitral  incompetency  without  disease  of  the  valves  is 
of  frequent  occurrence  in  emphysema  of  the  lungs  and  in  Bright' s  dis- 
ease, and  is  a  condition  which  always  attends  hypertrophy  and  dilata- 
tion, or  may  take  place  from  various  causes.  (See  Hypertrophy  and 
Dilatation.) 

Symptoms.  As  to  the  general  symptoms  :  In  a  large  number  of 
cases  perfect  compensation  may  continue  for  a  long  time.  Xo  subjec- 
tive symptoms  arise  nor  are  there  symptoms  due  to  dilatation.  If 
compensation  is  not  perfectly  effected  from  the  first,  or  is  broken  sud- 
denly or  gradually,  the  symptoms  of  dilatation  arise. 

In  patients  in  whom  compensation  remains  only  fairly  good  we  have 
the  characteristic  appearances  of  heart  disease.  It  is  to  this  class  of 
patients  that  the  general  descriptions  of  heart  disease  apply.  The  face  is 
pale  and  pinched,  the  lips  and  ears  dusky,  the  capillaries  of  the  cheeks 
enlarged,  the  finger-nails  clubbed,  particularly  in  children  ;  shortness  of 
breath  on  exertion  may  be  the  only  symptom  complained  of,  and  this 
may  exist  for  years.  The  patients  are,  however,  liable  to  attacks  of 
bronchitis  and  of  pulmonary  hemorrhage.  Palpitation  may  occur  in 
this  as  in  other  forms  of  heart  disease,  and  from  the  same  cause. 

When  the  compensation  is  broken,  symptoms  referable  to  the  heart 
and  to  engorgement  of  systemic  and  pulmonary  veins  occur.  Of  the 
former  palpitation  with  a  sense  of  oppression  is  the  most  common  ; 
pain  is  rare. 

Venous  engorgement  leads  to  congestions,  cyanosis,  and  dropsies. 
We  now  have  the  symptoms  of  dilated  right  heart  superadded.  The 
lungs  are  the  first  to  be  congested.  Dyspnoea  becomes  constant  and 
is  aggravated  by  exertion.  Cough  is  present,  excited  by  exertion  or 
speaking.  With  the  cough  there  is  bloody  expectoration.  Cyanosis 
occurs.  Congestion  of  other  organs  follows.  The  liver  is  enlarged  ; 
obstruction  in  the  portal  area  is  prominent ;  chronic  gastritis  or  gastro- 
intestinal catarrh  ensues.  The  spleen  is  enlarged  ;  ascites  develops, 
and  hemorrhoids  and  congestion  in  the  rest  of  the  portal  area  are  seen. 
The  kidneys  are  congested  ;  the  urine  is  scanty,  albuminous,  and  con- 
tains casts  and  blood-corpuscles.  At  the  same  time  that  the  internal 
viscera  are  congested  dropsies  take  place,  beginning  in  the  feet  and 
extending  to  the  rest  of  the  body.  Dropsy  may  have  been  present  in 
the  feet  before  symptoms  of  portal  congestion  ensued. 

The  patient  may  be  relieved  and  compensation  continue  for  a  long 
time.  Frequent  attacks  of  dilatation  of  this  character  may  take  place, 
their  recurrence   being  due  to   lack  of   care  in  hygienic  matters,  or 


662  SPECIAL  DIAGNOSIS. 

failure  in  health  from  other  causes.  Finally,  however,  the  compen- 
sation cannot  be  restored  ;  the  stases  persist ;  the  dropsies  become 
more  marked,  and  the  symptoms  of  cyanotic  induration  and  secondary 
scleroses  of  the  internal  organs  follow.  It  must  not  be  forgotten  that 
this  is  the  chief  form  of  organic  heart  disease  seen  in  children. 

Physical  Signs.  (Plate  XXX.,  Fig.  1.)  On  inspection  the  pre- 
cordial area  appears  prominent ;  the  apex-beat  is  displaced  to  the  left 
and  downward,  rarefy  below  the  sixth  interspace.  It  may  extend  to 
the  anterior  axillary  line.  The  cervical  veins  pulsate  and  are  dis- 
tended.    The  area  of  impulse  is  increased. 

Palpation.  The  character  of  the  impulse  depends  upon  the  stage 
of  the  disease  at  which  the  case  is  examined.  At  the  time  of  full  com- 
pensation it  is  strong  and  even.  When  this  is  broken,  it  is  feeble  and 
diffuse.     A  thrill  is  extremely  rare. 

The  Bloodvessels.  The  amount  of  blood  in  the  arteries  is  dimin- 
ished. There  is  notable  absence  of  visible  pulsation  in  the  arteries. 
The  pulse  at  first  is  full  and  regular.  It  is  notably  small  in  volume 
and  soft.  As  soon  as  failure  of  compensation  takes  place  the  pulse 
becomes  irregular.  The  irregularity  may  be  that  of  time  as  well  as  of 
volume. 

Percussion.  The  area  of  dulness  is  increased  to  the  left.  The  trans- 
verse diameter  of  the  heart  is  much  increased  because  of  dilatation 
of  both  chambers.  The  area  extends  beyond  the  right  margin  of  the 
sternum  to  the  extent  of  an  inch  or  more  and  to  the  left  as  far  as  the 
mid-clavicular  line,  sometimes  to  the  anterior  axillary  line.  The 
cardio-hepatic  triangle  is  preserved. 

Auscultation  At  the  apex,  the  mitral  area,  a  murmur  is  heard. 
The  point  of  maximum  intensity  is  in  this  region.  It  is  systolic  in 
time  ;  it  may  replace  the  first  sound  entirely.  It  may  be  soft  and  low 
in  pitch,  or  rough,  high  in  pitch,  even  musical  in  character.  It  is 
transmitted  to  the  axilla  and  the  angle  of  the  scapula.  (See  Fig.  171.) 
In  some  instances  it  may  be  heard  loudest  along  the  left  border  of  the 
sternum.  The  pulmonary  second  sound  is  accentuated  ;  the  accentu- 
ation is  loudest  in  the  pulmonary  area  at  the  second  left  interspace. 
It  may  be  very  loud  over  the  right  ventricle,  between  the  paraster- 
nal line  and  the  left  edge  of  the  sternum.  The  murmur  of  mitral 
insufficiency  is  modified  by  the  position  of  the  patient  and  intensified 
after  exertion.  It  may  be  present  when  the  patient  is  lying  down, 
and  disappear  in  an  erect  posture.  It  may  disappear  when  the  patient 
is  cpiiet  and  return  after  exertion.    Other  murmurs  are  sometimes  heard  : 

1.  A  presystolic  murmur,  soft  or  rumbling.  2.  When  dilatation 
ensues  a  low-pitched  systolic  murmur  is  heard  at  the  ensiform  carti- 
lage and  at  the  lower  left  border  of  the  sternum.  It  is  due  to  tricus- 
pid regurgitation. 

Of  special  diagnostic  significance  are  :  the  position  of  the  murmur 
and  the  direction  of  its  transmission  ;  accentuation  of  the  pulmonary 
second  sound  ;  enlargement  of  the  transverse  diameter  of  the  heart, 
due  to  dilatation  of  both  ventricles. 

Diagnosis.  This  is  usually  easy  if  the  physical  signs  are  sought 
for.    Very  often  examination  of  the  heart  is  neglected,  and  the  patient 


PLATE    XXX. 


Ci  J 


Mf 


Mitral   Regurgitation. 

FIO.  2. 


Mitral    Stenosis. 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     663 

is  treated  for  the  symptoms  that  arise  from  congestion  of  the  viscera. 
We  have  often  seen  chronic  gastritis  or  gastro-intestinal  catarrh,  due 
to  mitral  insufficiency,  not  relieved  because  the  primary  lesions  had 
not  been  ascertained.  In  the  same  way  cardiac  cough  or  dyspnoea  may 
be  overlooked.  It  is  important  in  the  diagnosis  to  determine,  if  possi- 
ble, the  nature  of  the  insufficiency,  whether  it  is  due  to  disease  or 
incompetency  of  the  valves.  As  previously  mentioned,  the  history  is 
possibly  the  only  means  by  which  a  diagnosis  can  be  made.  If  a 
mitral  murmur  ensues  in  old  people,  in  whom  there  has  been  physical 
cause  for  the  development  of  dilatation  and  hypertrophy,  as  in  emphy- 
sema or  arterio-sclerosis,  it  is  usually  due  to  relative  incompetency  of 
the  valve.  It  must  not  be  forgotten  that  the  mitral  area  is  the  seat  of 
a  number  of  murmurs  due  to  various  causes.     (See  Auscultation.) 

Mitral  Stenosis.  Obstruction  to  the  flow  of  blood  from  the  auricle 
to  the  ventricle  is  due  to  valvulitis,  or  endocarditis,  and  particularly 
the  endocarditis  of  early  life.  It  is  of  much  more  frequent  occurrence 
in  women  than  aortic  disease.  It  is  much  more  often  seen  in  young 
adults  and  children,  because  its  etiological  factors,  rheumatism  and 
chorea,  are  then  more  prevalent. 

On  account  of  the  obstruction  at  the  orifice  changes  ensue  in  the 
auricle.  These  changes  depend  in  a  measure  upon  the  nature  of  the 
lesion.  In  the  so-called  buttonhole  contraction  they  are  very  marked. 
The  orifice  may  be  so  obliterated  in  rare  cases  as  to  admit  only  a  small 
probe.  Dilatation  and  hypertrophy  of  the  left  auricle  ensue  if  the 
valve-changes  take  place  gradually.  The  walls  of  the  auricle  are 
thickened  to  three  or  four  times  their  natural  size.  On  account  of  the 
dilatation  of  this  auricle  the  outflow  from  the  pulmonary  veins  is  im- 
peded, which  in  turn  obstructs  the  circulation  of  blood  through  the 
lungs.  As  a  consequence,  dilatation  and  hypertrophy  of  the  right  ven- 
tricle occur.  As  a  result  of  this  we  have,  later  on,  the  occurrence  of 
relative  incompetency  at  the  tricuspid  orifice,  with  engorgement  of  the 
systemic  veins.  The  left  ventricle  does  not  take  part  in  any  changes. 
It  retains  its  normal  size,  but  it  may  look  small  in  comparison  with 
the  right  ventricle. 

Symptoms.  If  hypertrophy  of  the  right  ventricle  ensues,  the  com- 
pensation may  be  sufficient  to  prevent  the  occurrence  of  symptoms  for 
many  years.  The  disease  may  exist  for  a  number  of  years  without 
discomfort  to  the  patient.  Because  of  its  rheumatic  origin  a  fresh 
endocarditis  may  develop,  particularly  as  most  of  the  subjects  are 
young.  The  old  valve  lesion  invites  infection,  and  so  a  recurrent  form 
of  endocarditis  is  induced.  If  fresh  endocarditis  occurs,  embolic  symp- 
toms are  likely  to  follow.  Embolism  takes  place  particularly  in  the 
brain,  causing  hemiplegia  or  aphasia.  When  failure  of  compensation 
takes  place  the  symptoms  described  in  mitral  incompetency  arise. 
They  are  the  symptoms  of  dilatation  of  the  heart,  and  may  recur 
frequently  during  a  long  period  of  years. 

Dropsy,  however,  is  not  so  common  as  in  mitral  regurgitation. 
Visceral  stases  are  common  when  compensation  fails,  and  in  many 
cases  we  find  enlargement  of  the  liver  continuing  for  a  long  period. 
Ascites  may  in  rare  cases  be  the  only  manifestation  of  mitral  obstruction. 


664  SPECIAL  DIAGNOSIS. 

Physical  Sigxs.  (Plate  XXX.,  Fig.  2.)  The  physical  signs  of 
mitral  obstruction  are  more  striking  and  more  diagnostic  of  the  lesion 
than  the  physical  signs  of  any  other  form  of  organic  heart  disease. 

Inspection.  As  the  disease  develops  in  children  with  soft  ribs  the 
local  deformities  are  very  marked.  For  the  same  reason  precordial 
bulging  is  more  prominent.  Because  the  right  ventricle  is  hypertro- 
phied,  the  sternum  and  the  fourth,  fifth,  and  sixth  costal  cartilages  pro- 
trude. The  apex  impulse  is  not  usually  displaced,  certainly  not  beyond 
the  mid-clavicular  line.  The  impulse  is  not  marked  at  the  apex.  In 
the  third  and  fourth  interspaces  a  visible  impulse  is  seen  along  the 
margin  of  the  sternum.  After  dilatation  the  extent  of  impulse  dimin- 
ishes and  the  veins  of  the  neck  become  engorged,  the  blood  regurgi- 
tating into  them  during  the  systole. 

Palpation.  In  the  "large  majority  of  cases  a  distinct  fremitus  or 
thrill  is  felt — more  marked  in  the  fourth  or  fifth  interspace,  inside  of 
the  nipple.  It  is  usually  localized  to  a  small  area,  is  increased  during 
expiration,  and  is  of  a  twisting,  grating,  or  grinding  character.  It  is 
made  up  of  a  series  of  small  shocks  increasing  in  intensity,  culminating 
in  a  sudden,  sharp  shock,  which  occurs  at  the  time  of  the  impulse. 
The  thrill  and  systolic  shock  are  pathognomonic,  and  may  be  present 
when  other  signs,  as  the  murmur,  are  absent  or  indistinct.  The  car- 
diac impulse  is  felt  strongest  at  the  lower  margin  of  the  sternum  and 
in  the  third  and  fourth  interspaces,  in  some  cases  even  in  the  second. 
It  is  due  to  an  enlarged  and  dilated  right  ventricle. 

The  Pulse.  With  perfect  compensation  the  pulse  is  slow,  regular, 
and  firm,  although  small.  If  the  orifice  is  much  narrowed,  small, 
weak,  and  irregular  in  force  and  rhythm.  When  compensation  fails 
and  the  right  heart  is  dilated  the  pulse  becomes  rapid,  quick,  weak, 
small  in  size,  and  irregular  in  force  and  rhythm.  The  dilatation 
may  be  so  great  that  the  right  auricle  and  overdistended  veins  may 
press  upon  the  aorta  or  the  innominate  and  subclavian  arteries.  The 
pulse  on  that  side  will  be  lessened  in  volume.1 

Percussion.  The  area  of  cardiac  dulness  is  increased  upward  and 
to  the  right  and  left  of  the  margin  of  the  sternum.  Sometimes  it  ex- 
tends upward  as  high  as  the  second  rib  ;  this  increase  is  quite  charac- 
teristic. 

Auscultation.  At  the  apex,  or  just  inside  of  the  position  of  the 
apex-beat,  a  murmur  is  heard,  its  point  of  maximum  intensity  dis- 
tinctly localized  to  this  spot.  It  is  usually  not  transmitted.  (See  Fig. 
172.)  It  is  of  a  churning  and  grinding  character,  or  vibratory  and 
purring.  It  is  usually  high  in  pitch  and  rough.  It  occurs  synchro- 
nously with  the  thrill,  and  terminates  with  a  loud  shock  that  is  heard 
simultaneously  with  the  first  sound.  It  is,  therefore,  presystolic  in 
time.  As  has  been  said  of  the  thrill,  so  it  may  be  said  of  this  murmur, 
that  it  is  the  only  murmur  that  is  pathognomonic  of  a  special  lesion. 
It  indicates  narrowing  of  the  mitral  orifice.  The  only  exception,  in 
which  the  lesion  is  absent,  although  the  murmur  is  present,  is  found 
in  the  class  of  cases  described  by  Flint,  referred  to  in  the  section  on 

1  PopofT:  British  Medical  Journal,  1893. 


PLATE    XXXI. 


Tricuspid   Regurgitation. 

FIO.  2. 


¥       X  ^ 


Tricuspid    Stenosis. 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     665 

aortic  regurgitation.  The  first  sound  is  loud,  clear,  and  abrupt ;  it 
may  be  thumping. 

The  presystolic  murmur  may  occupy  the  entire  period  of  the  dias- 
tole, but  in  the  large  majority  of  cases  it  occurs  in  the  latter  half  only, 
during  which  the  auricular  systole  occurs.  In  some  instances  it  is 
heard  in  the  middle  of  the  diastole. 

Associate  Murmurs.  1.  At  the  same  time  a  systolic  murmur  may 
be  heard  at  the  apex,  soft  and  low  in  pitch.  It  may  be  transmitted 
into  the  axilla.  It  is  usually  due  to  associate  mitral  regurgitation.  2. 
At  the  lower  portion  of  the  sternum  a  systolic  murmur  may  be  heard, 
due  to  dilatation  and  incompetency  at  the  tricuspid  orifice.  Murmurs 
in  the  aortic  region  are  not  usually  heard. 

The  second  sound  at  the  pulmonary  orifice  is  usually  accentuated.  It 
is  heard  in  the  second  and  third  interspaces  along  the  left  edge  of  the 
sternum  ;  it  may  be  heard  at  the  apex.  Reduplication  of  the  first 
sound  is  often  observed.  Reduplication  of  the  second  sound  is  very 
common.  After  compensation  is  broken  other  murmurs  may  be  heard, 
and  the  presystolic  murmur  changes  hi  character.  It  may  disappear 
entirely  and  be  replaced  by  a  sharp  first  sound.  The  short,  high- 
pitched  systolic  shock  may  continue,  although  the  murmur  disappears. 
It  disappears  probably  because  the  left  auricle  has  become  weakened. 
The  tricuspid  murmur  continues  during  this  period. 

The  points  of  distinction  of  mitral  obstruction  are  (1)  the  position  of 
the  murmur  ;  (2)  its  restricted  area  ;  (3)  its  peculiar  character ;  (4)  the 
systolic  shock  which  takes  the  place  of  the  first  sound  ;  (5)  the  thrill ;  (6) 
the  impulse  and  increased  area  of  dulness  upward  ;  (7)  accentuated 
pulmonary  second  sound  ;  (8)  reduplication  ;  (9)  the  absence  of  the  pulse 
of  aortic  regurgitation  and  of  hypertrophy  of  the  left  ventricle. 

Presystolic  Murmur  not  due  to  Valvulitis.  A  presystolic 
murmur  without  mitral  obstruction  may  occur  in  aortic  regurgitation 
and  in  adherent  pericardium. 

Tricuspid  Regurgitation  or  Incompetency.  Structural  disease  at 
the  tricuspid  orifice  is  of  comparatively  rare  occurrence.  Insufficiency 
is  more  frequent,  and  is  due  to  dilatation,  with  relative  insufficiency  of 
the  valve-orifice.  It  occurs  secondarily  to  obstructive  lung  diseases, 
as  emphysema  and  cirrhosis,  and  is  secondary  to  regurgitation  at  the 
mitral  orifice,  which  leads  to  stasis  in  the  lungs. 

Symptoms.  The  symptoms  were  detailed  in  speaking  of  the  mitral 
valve  affections.  They  are  those  of  obstruction  in  the  pulmonary  cir- 
culation and  engorgement  of  the  systemic  veins. 

Physical  Signs.  (Plate  XXXI. ,  Fig.  1.)  Inspection.  The  physical 
signs  of  dilatation  of  the  right  heart  are  seen.  An  impulse  in  the  epi- 
gastrium is  noted.  This  is  seen  especially  between  the  xiphoid  cartilage 
and  the  left  margin  of  the  ribs.  Pulsation  to  the  right  of  the  sternum 
and  in  the  second  and  third  intercostal  spaces  may  also  be  observed. 
The  veins  of  the  neck  are  also  seen  to  pulsate.  In  addition  to  the  wavy 
pulsation,  regurgitation  of  the  blood  into  the  right  auricle  causes  trans- 
mission of  the  pulse-wave  into  the  veins.  The  pulsation  is  systolic  in 
time.  It  is  more  marked  in  the  right  jugular  than  in  the  left,  and  in 
the  external  than  in  the  internal  veins.     With  the  pulsation,  regurgi- 


QQQ  SPECIAL  DIAGNOSIS. 

tation  is  readily  observed  by  emptying  the  external  vein.  Place  the 
finger  firmly  on  the  vein  just  above  the  clavicle,  move  it  along  the 
course  of  the  vein  in  the  direction  of  the  inferior  maxillary  bone.  The 
vein  is  thus  emptied  of  blood,  and  with  each  systole  of  the  heart  it  will 
be  seen  to  fill  up  from  below  in  rhythmical  pulsation.  The  veins  are 
increased  in  size.  This  is  more  noticeable  during  the  act  of  coughing 
or  when  the  patient  holds  his  breath  in  full  inspiration.  In  rare  in- 
stances the  pulsation  is  transmitted  to  the  subclavian  and  axillary  veins. 

Palpation.  By  palpation  the  above  conditions  are  also  determined. 
The  impulse  over  the  lower  sternum  and  in  the  epigastrium  is  noted 
to  be  forcible. 

The  regurgitant  pulsation  is  transmitted  to  the  descending  vena  cava 
as  well  as  to  the  ascending.  The  hepatic  veins  also  distend  during 
the  systole.  So-called  pulsation  of  the  liver  is  produced.  With  one 
hand  on  the  fifth  and  sixth  costal  cartilages  and  the  other  over  the 
liver  in  the  axillary  region,  rhythmical  expansile  pulsation  may  be 
recognized.  It  is  not  of  common  occurrence,  but  is  absolutely  diag- 
nostic of  regurgitation  at  the  tricuspid  orifice. 

Percussion.  The  area  of  cardiac  dulness  is  increased  transversely 
and  upward,  as  described  in  mitral  stenosis.  It  extends  often  far  be- 
yond the  right  edge  of  the  sternum. 

Auscultation.  At  the  xiphoid  cartilage,  the  lower  end  of  the  ster- 
num or  the  head  of  the  fourth  rib,  a  murmur  is  heard.  It  is  sys- 
tolic in  time,  usually  low  in  pitch,  and  is  heard  loud  to  the  left  of  the 
sternum,  within  an  inch  of  the  apex,  and  to  the  right  of  the  sternum 
and  the  outer  limits  of  percussion-dulness.  (See  Fig.  173.)  It  is  not 
further  transmitted.  Other  murmurs  are  heard,  due  to  the  primary 
organic  disease.  If  the  heart  is  weak,  the  lesion  may  not  be  produc- 
tive of  a  murmur.     The  pulmonary  second  sound  is  accentuated. 

Tricuspid  Stenosis.  Stenosis  at  this  valve-orifice  is  generally  of 
congenital  origin.  In  rare  instances  it  may  be  secondary  to  lesions  in 
the  left  heart.     It  is  accompanied  by  dilatation  of  the  right  auricle. 

The  physical  signs  (Plate  XXXI. ,  Fig.  2)  are  the  same  as  in  stenosis 
at  the  mitral  orifice,  except  for  the  alteration  in  their  position.  In 
some  instances  a  presystolic  thrill  has  been  observed,  and  with  it  a 
presystolic  murmur  at  the  lower  end  of  the  sternum  or  toward  the  right 
of  it.  The  area  of  dulness  is  increased  as  in  right-sided  dilatation. 
Cyanosis  is  a  prominent  symptom  and  may  be  intense. 

Disease  of  the  Pulmonary  Valve.  Diseases  of  the  pulmonary 
valve  are  extremely  rare  and  are  almost  always  congenital. 

Pulmonary  Insufficiency.  (Plate  XXXII.,  Fig.  1.)  The  physical 
signs  are  due  to  regurgitation  into  the  right  ventricle.  The  maximum 
intensity  of  the  murmur  is  in  the  second  pulmonary  interspace,  and  it 
is  transmitted  down  the  sternum.  It  cannot  be  distinguished  from 
aortic  regurgitation,  except  by  the  pulse. 

Pulmonary  Stenosis.  (Plate  XXXIL,  Fig.  2.)  In  stenosis  of  the 
pulmonary  valve  a  systolic  murmur  and  thrill  are  detected  to  the  left  of 
the  sternum  in  the  second  interspace.  The  murmur  is  not  transmitted 
to  the  vessels  of  the  neck.  The  pulmonary  second  sound  is  weak. 
The  effect  on  the  heart  is  the  production  of  right-sided  hypertrophy. 


PLATE    XXXII. 


***. 


Pulmonary  Insufficiency. 


FIG.    2. 


Pulmonary  Stenosis. 


PLATE    XXXIII. 


FIG.    1. 


Combined  Mitral  and  Aortic  Insufficiency  and  Stenosis. 


Combined  Mitral  and  Tricuspid  Insufficiency. 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     667 

Combined  Valvular  Lesions.  (Plate  XXXIII.)  It  must  not  be 
forgotten  that  there  may  be  disease  causing  both  obstruction  and  re- 
gurgitation at  the  same  time  and  at  the  same  orifice,  or  that  two  or 
more  valves  may  be  the  seat  of  disease  in  the  same  individual.  It  is 
not  impossible,  for  instance,  to  have  aortic  obstruction  and  regurgita- 
tion, mitral  obstruction  and  regurgitation,  and  tricuspid  regurgitation. 
Aortic  obstruction  or  insufficiency  is  frequently  combined  with  mitral 
insufficiency.  Aortic  and  mitral  insufficiency  occur  together  most  fre- 
quently in  children  ;  aortic  obstruction  and  mitral  obstruction  in  adults. 

When  more  than  one  valve  is  diseased  the  site  of  the  various  lesions 
is  based  upon  the  time,  the  position  of  maximum  intensity,  and  the 
direction  of  transmission  of  the  murmurs.  Students  often  experience 
difficulty  here.  A  systolic  murmur  may  be  heard  in  the  aortic  area  and 
in  the  mitral  area  at  the  same  time.  If  it  is  observed  that  each  pro- 
gressively weakens  as  the  stethoscope  is  moved  toward  the  middle  of 
the  precordial  area,  it  may  be  inferred  that  the  murmur,  systolic  in 
time,  is  due  to  two  lesions.  As  previously  intimated,  the  direction  of 
the  transmission  of  the  murmur  further  aids  in  the  diagnosis. 

Enlargement  of  the  Heart. 

Enlargement  of  the  heart  is  due  to  hypertrophy  or  to  dilatation.  In 
hypertrophy  there  is  increased  thickness  of  the  muscular  walls.  This 
may  be  general  or  limited  to  the  walls  of  one  chamber.  Hypertrophy 
is  further  divided  into  simple  hypertrophy,  in  which  the  cavity  or 
cavities  are  of  normal  size,  and  eccentric  hypertrophy,  in  which,  with 
increase  in  the  wall,  there  is  enlargement  of  the  cavities.  This  is 
hypertrophy  with  dilatation.  The  left  ventricle  is  most  frequently  the 
seat  of  hypertrophy  when  one  chamber  is  involved.  The  cause  of 
hypertrophy  is  obstruction  to  the  flow  of  blood  ;  increased  work  is  fol- 
lowed by  increased  size  of  the  muscle.  General  hypertrophy  or  hyper- 
trophy of  the  left  ventricle  occurs  from  diseases  of  the  heart  itself,  or 
from  affections  of  the  bloodvessels. 

A.  Diseases  of  the  heart.  1.  Disease  of  the  aortic  valves.  Hyper- 
trophy of  the  left  ventricle  always  follows.  2.  Mitral  regurgitation. 
3.  Pericardial  adhesions.  4.  Myocarditis  of  the  fibrous  variety.  5. 
Neuroses  with  overaction  and  frequent  palpitation,  as  in  exophthal- 
mic goitre  and  from  the  effects  of  tea,  tobacco,  and  alcohol.  In  peri- 
cardial adhesions  and  myocarditis  hypertrophy  arises  because  of  the 
inability  of  the  heart  to  do  the  work  expected  of  it.  There  is  no  ob- 
struction in  the  course  of  the  vessels  or  at  the  orifices.  The  struggle 
to  keep  up  causes  the  hypertrophy.  In  neuroses  there  is  absence  of 
obstruction,  but  the  rapid  action  causes  hypertrophy. 

B.  Affections  of  the  bloodvessels  which  cause  hypertrophy  are  :  1. 
General  arterial  sclerosis.  2.  Increased  arterial  tension  due  to  con- 
traction of  the  peripheral  arteries,  as  in  Bright's  disease,  and  in  tox- 
aemias from  lead,  the  poison  of  gout  and  of  syphilis.  3.  Increased 
blood-pressure  from  prolonged  muscular  exertion.  4.  Narrowing  of 
the  aorta  from  external  pressure  and  from  congenital  stenosis  or  the 
development  of  an  aneurism. 


668  SPECIAL  DIAGNOSIS. 

Hypertrophy  of  the  Right  Ventricle.  Obstruction  to  the  flow  of  blood 
in  the  pulmonary  area  is  the  usual  cause  of  hypertrophy  of  the  right 
ventricle.  This  obstruction  occurs  in  lesions  of  the  mitral  valve,  caus- 
ing pulmonary  stasis  ;  and  disease  of  the  lungs,  causing  compression 
of  the  bloodvessels,  as  in  emphysema  or  cirrhosis.  It  occurs  if  there 
is  disease  of  the  right  heart  with  obstruction  of  the  valves.  Thus  in 
obstruction  at  the  pulmonary  orifice  the  right  ventricle  undergoes 
secondary  hypertrophy. 

Hypertrophy  of  the  Auricles.  Simple  hypertrophy  of  the  left  auri- 
cle with  dilatation  develops  in  mitral  stenosis.  Hypertrophy  of  the 
right  auricle  occurs  in  tricuspid  obstruction  and  in  right-sided  dilata- 
tion with  tricuspid  regurgitation. 

Symptoms.  The  symptoms  of  hypertrophy  of  the  heart  are  general 
and  local.  The  former  are  not  common.  They  are  due  to  increased 
tension  in  the  cerebral  vessels  because  of  increased  force  of  the  heart, 
usually  causing  congestive  headaches,  noises  in  the  ears,  flashes  of  light, 
and  flushing  of  the  face. 

General  symptoms  arise  in  hypertrophy  of  the  left  ventricle  because 
the  increased  force  causes  reactive  spasm  of  peripheral  vessels,  and 
hence  increased  tension  in  the  vascular  system.  In  Bright' s  disease, 
for  instance,  or  heightened  arterial  tension  from  other  causes,  endarter- 
itis develops  in  the  large  vessels,  on  account  of  the  strain  put  upon  them. 
This  is  seen  particularly  in  the  aorta  and  its  divisions.  Whether 
atheroma  is  primary  or  secondary,  its  presence,  with  hypertrophy  of 
the  left  ventricle,  indicates  that  rupture  of  the  vessels  somewhere  in  the 
periphery  may  take  place.  This  occurs  most  frequently  in  the  brain, 
causing  apoplexy. 

Locally,  the  patient  complains  of  fulness  and  discomfort,  particularly 
marked  when  lying  down  on  the  left  side.  In  the  hypertrophy  that 
accompanies  the  tobacco-heart,  or  the  irritable  heart  of  soldiers,  there 
may  be  some  pain.  On  the  other  hand,  the  organ  may  be  enormously 
enlarged  without  the  patient  complaining  of  discomfort  about  the  heart. 
Palpitation  is  not  of  common  occurrence  except  in  neurasthenic  subjects. 

Physical  Sig-xs.  The  hypertrophy  causes  precordial  bulging,  if 
it  has  developed  early  in  life,  when  the  ribs  are  soft.  The  intercostal 
spaces  are  widened  and  the  area  of  impulse  is  much  increased.  The 
normal  impulse  is  changed  in  position.  It  is  downward  and  to  the 
left,  often  extending  as  far  as  the  axilla  in  hypertrophy  of  the  left 
ventricle. 

Palpation.  The  impulse  is  forcible  and  heaving.  The  head  is 
visibly  raised  with  each  systole  when  placed  upon  the  chest  for  auscul- 
tation. The  impulse  is  slow.  This  slow,  heaving  impulse  distin- 
guishes it  from  the  forcible  impulse  of  dilated  hypertrophy,  which  is 
sudden  and  abrupt.  Inspection  is  confirmed  as  to  the  position  of  the 
apex.  In  moderate  hypertrophy  the  apex  extends  to  the  sixth  inter- 
space in  the  mid-clavicular  line.  In  large-sized  hypertrophy  it  may 
extend  to  the  seventh  interspace.  The  heart  may  be  apparently 
hypertrophied  in  fibrous  and  fatty  myocarditis.  The  impulse  may  be 
absent  in  emphysema,  in  fatty  overgroAvth  of  the  heart,  and  in  persons 
with  thick  chest-walls. 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     669 

TJie  Pulse.  The  frequency  of  the  pulse  is  not  affected.  It  is  full, 
regular,  and  strong.  The  tension  is  increased.  In  dilated  hyper- 
trophy the  pulse  is  full  but  soft,  and  more  rapid  than  in  simple  hyper- 
trophy. When  failure  of  the  heart  takes  place  the  pulse  increases  hi 
frequency  and  becomes  intermittent  and  irregular.  When  valve-lesions 
are  present  the  pulse  is  modified  accordingly. 

Percussion.  The  area  of  dulness  is  increased  both  upward  and 
transversely.  It  may  begin  as  high  as  the  second  interspace  and  ex- 
tend two  inches  beyond  the  left  mid-clavicular  line,  and  an  inch  beyond 
the  right  edge  of  the  sternum  transversely.  In  simple  hypertrophy 
the  area  is  ovoid. 

Auscultation.  When  the  valves  are  healthy,  prolongations  of  the  first 
sounds  occur.  They  are  also  at  times  duller  than  in  health.  The  dull, 
prolonged  first  sounds  distinguish  hypertrophy  from  dilatation,  for  in 
the  latter  they  are  clear  and  sharp.  The  second  sounds  are  clear  and 
loud.  The  degree  of  accentuation  depends  upon  the  state  of  the  per- 
ipheral arteries.  If  there  is  heightened  tension,  the  second  sound  may 
be  reduplicated.    If  valvular  disease  is  present,  the  sounds  are  modified. 

Hypertrophy  of  the  Right  Ventricle.  Increased  pulmonary 
tension  from  resistance  in  the  pulmonary  circulation  may  always  be 
looked  for.  If  there  is  complete  compensation,  no  symptoms  are  ob- 
served, or  only  those  of  dyspnoea  on  extra  exertion.  Hypertrophy  of 
this  ventricle  persists  for  a  long  period  of  time  without  the  grave  local 
changes  in  the  heart,  or  secondary  changes  in  the  peripheral  vessels, 
which  occur  in  left  ventricle  hypertrophy.  In  dilated  hypertrophy, 
when  the  dilatation  is  in  excess,  tricuspid  regurgitation  takes  place, 
with  the  development  of  venous  stases.  Induration  of  the  lungs  may 
succeed  the  persistent  engorgement  of  the  capillaries.  Pulmonary  con- 
gestions and  apoplexy  may  also  occur. 

Physical  Signs.  The  physical  signs  of  hypertrophy  of  the  right 
ventricle  have  been  partially  referred  to  under  the  various  valve  affec- 
tions. There  is  bulging  of  the  lower  part  of  the  sternum  and  carti- 
lages. The  epigastric  impulse  in  the  angle  between  the  ensiform  carti- 
lage and  the  ribs  has  been  referred  to.  The  impulse  may  be  in  the 
sixth  interspace.  It  is  diffuse  ;  it  may  extend  upward  as  in  mitral 
stenosis.  Cardiac  dulness  is  increased  toward  the  right  an  inch  or 
more  beyond  the  border  of  the  sternum.  The  heart-sounds  are  not 
much  changed  unless  there  is  dilatation.  The  tricuspid  sound  is  clear 
and  sharp  when  this  occurs.  The  pulmonary  second  sound  is  accentu- 
ated, and  reduplication  may  take  place.  The  radial  pulse  is  small. 
If  there  is  tricuspid  regurgitation,  the  physical  signs  that  attend  it 
are  present. 

Hypertrophy  of  the  Left  Auricle.  This  is  present  in  mitral 
stenosis,  but  cannot  be  determined  by  physical  signs,  save  possibly  by 
greater  increase  of  dulness  to  the  left  of  the  sternum  in  the  second 
and  third  interspaces.  Barr  states  that  dulness  above  the  "  supraster- 
nal mammillary  line  "  toward  the  left  clavicle  indicates  enlargement  <  >f 
the  left  auricle,  as  in  mitral  stenosis.  The  line  above  mentioned  is 
drawn  from  the  middle  of  the  suprasternal  notch  to  the  normal  site  of 
the  left  nipple  on  the  fourth  rib. 


670  SPECIAL  DIAGNOSIS. 

Hypertrophy  of  the  right  auricle  with  dilatation  occurs 
under  the  same  circumstances  as  hypertrophy  of  the  ventricle.  It 
usually  dilates  more  than  the  left  auricle  in  left  ventricle  hypertrophy. 
There  is  increased  area  of  dulness  in  the  third  and  fourth  right  inter- 
spaces ;  abnormal  pulsation  is  sometimes  observed  in  this  situation 
before  the  systole,  with  the  signs  of  tricuspid  regurgitation. 

Diagnosis.  The  forcible  impulse  in  nervous  palpitation  of  the 
heart  must  not  be  confounded  with  true  hypertrophy,  although  it 
must  not  be  forgotten  that  hypertrophy  frequently  follows  neurotic 
palpitation,  as  in  the  smoker's  heart,  or  in  exophthalmic  goitre. 
The  enlargement  must  not  be  confounded  with  enlargement  of  the 
area  of  cardiac  dulness  in  the  precordial  region  from  other  causes, 
such  as  pericardial  effusion  ;  aneurism  and  mediastinal  tumor,  push- 
ing the  heart  against  the  chest-wall ;  disease  of  the  lungs,  on  ac- 
count of  which  they  are  withdrawn  from  the  surface  of  the  heart,  as 
in  phthisis  or  chronic  pleurisy  ;  and  displacement  of  the  heart  from 
pressure,  as  in  effusion  on  the  left  side  of  the  chest,  or  in  disease  below 
the  diaphragm.  The  cause  of  hypertrophy  should  be  ascertained,  for 
it  is  a  valuable  aid  in  diagnosis.  It  must  not  be  forgotten  that  emphy- 
sema of  the  lung  may  mask  a  considerable  hypertrophy  of  the  heart 
by  causing  diminution  of  the  area  of  dulness. 

Dilatation  of  the  Heart.  Enlargement  due  to  dilatation  of  the 
heart  is  common.  The  condition  usually  succeeds  hypertrophy. 
Thickening  of  the  muscles  attends  dilatation  of  the  cavities,  as  in 
dilated  or  eccentric  hypertrophy.  The  dilatation  occurs  because  of  in- 
creased pressure  within  the  cavities  or  because  of  weakening  of  the 
heart-walls,  the  pressure  within  being  normal. 

1.  Increased  pressure  within  the  walls  is  due  to  an  increased  amount 
of  blood  within  the  chamber  from  regurgitation,  or  from  an  obstacle 
to  the  outward  flow  of  blood.  Simple  hypertrophy  occurs  first  in 
many  cases  ;  in  others,  hypertrophy  with  dilatation  ;  in  not  a  few, 
dilatation  takes  place  at  once.  In  dilatation  the  chamber  does  not 
empty  itself  during  the  systole.  It  is  seen  physiologically  after  the 
exertion  of  ascending  a  great  height.  It  may  remain  within  the 
bounds  of  physiological  action.  Temporarily,  as  any  one  can  show 
by  running  violently,  the  dilatation  is  attended  by  increased  epi- 
gastric pulsation  and  increased  cardiac  dulness.  The  tricuspid  valves 
temporarily  become  incompetent,  owing  to  their  safety-valve  action. 
The  latter  may  continue  after  the  acute  strain,  the  heart  always  show- 
ing symptoms  of  the  condition,  or  it  may  disappear  entirely.  An 
excessive  dilatation  results  in  heart-strain,  with  cardiac  distress  and 
dyspnoea,  symptoms  due  to  overdistention  and  paralysis  of  the  heart. 
(See  Symptoms.)  Dilatation  occurs  in  all  forms  of  heart-lesions  pre- 
viously described.  The  most  typical  is  seen  in  aortic  regurgitation, 
when  the  left  ventricle  becomes  the  seat  of  dilatation,  and  hi  mitral 
regurgitation  when  the  left  auricle  becomes  the  seat  of  dilatation. 

2.  Disease  of  the  heart-walls,  lessening  the  resisting  power,  the  nor- 
mal pressure  Avithin  the  cavities  being  maintained,  invites  dilatation. 
In  myocarditis,  in  infections,  acute  dilatation  may  ensue.  It  occurs  in 
scarlatinal   dropsy,  typhoid    fever,    rheumatic    fever,    and    erysipelas. 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     671 

The  heart-muscle  changes  in  acute  endocarditis  and  pericarditis,  on 
account  of  which  dilatation  may  ensue.  In  anaemia  and  chlorosis  the 
same  process  may  take  place.  In  chronic  myocarditis  dilatation  takes 
place  at  the  apex.  When  pericardial  adhesions  are  present  the  fibrous 
overgrowth  invades  the  interstices  of  the  myocardium,  thereby  weaken- 
ing the  heart-muscle.     Dilatation  may  follow. 

Symptoms.  The  symptoms  of  dilatation  are  the  reverse  of  those 
of  hypertrophy.  When  the  latter  fails  the  blood  is  not  expelled  from 
the  chambers  in  systole,  so  that  the  cavity  is  overdistended  with 
blood  that  accumulates  in  the  diastole.  Weakening  of  the  muscles 
also  favors  the  development  of  dilatation.  As  soon  as  dilatation  be- 
comes permanent,  incompetency  of  the  valves  takes  place.  In  obstruc- 
tive heart  disease  the  left  side  is  first  affected.  It  may  be  compen- 
sated for  by  hypertrophy  of  the  right  side.  When  this  fails  venous 
engorgement  and  dropsy  ensue.  The  symptoms  have  been  described 
under  chronic  valvular  disease.  In  acute  dilatation  there  is  a  sudden 
occurrence  of  dyspnoea.  Pain,  or  at  least  precordial  oppression,  may 
be  complained  of.  The  heart's  action  increases  in  frequency.  The 
pulse  is  rapid,  feeble,  irregular,  and  may  scarcely  be  felt  at  the  wrist. 

Physical  Signs.  Inspection.  The  apex  is  displaced  to  the  left, 
even  as  far  as  the  axillary  line,  but  rarely  downward,  unless  hypertro- 
phy precedes  the  dilatation.  The  impulse  is  diffused  and  undulatory 
in  appearance.  The  apex-beat  may  be  defined  with  extreme  difficulty. 
It  may  be  visible  when  the  patient  leans  forward,  yet  not  felt. 

With  the  diffused  area  of  impulse  a  quick  apex-beat  may  be  felt — 
much  weakened,  however.  When  the  right  ventricle  is  dilated,  the 
impulse  is  seen  and  felt  to  the  right  or  left  of  the  xiphoid  cartilage, 
and  there  is  a  wavy  pulsation  along  the  left  edge  of  the  sternum 
in  the  fourth,  fifth,  and  sixth  interspaces.  If  the  dilatation  is  extreme, 
involving  the  right  auricle,  a  pulsation  at  the  third  right  interspace 
close  to  the  sternum  may  be  felt.  Tricuspid  regurgitation  is  then 
present. 

The  area  of  dulness  is  increased  in  the  same  directions  as  in  hyper- 
trophy, if  the  two  coexist.  In  general,  it  may  be  said  the  increase 
extends  outward  to  the  right  or  left,  the  direction  corresponding  to 
the  ventricle  affected.  It  is  increased  upward  along  the  left  edge  of 
the  sternum  in  left  auricle  dilatation.  (See  Mitral  Valvulitis.)  When 
the  whole  heart  is  dilated  the  increase  of  dulness  is  in  a  transverse 
direction  on  both  sides.  The  apex  is  rounded  or  square,  not  pointed, 
as  in  hypertrophy  ;  indeed,  it  retains  the  oval  shape  of  the  dulness 
of  a  normal  heart.  As  dilatation  occurs  so  frequently  in  emphysema 
of  the  lungs,  the  modification  of  the  percussion-sound  must  be  re- 
membered. 

Auscultation.  The  systolic  sounds  are  short  and  sharp.  They  are 
high-pitched  and  resemble  the  diastolic.  The  latter  may  become 
enfeebled  when  the  dilatation  becomes  excessive.  The  right  and  left 
first  sounds  may  differ  somewhat  in  intensity,  and  reduplication  may 
occur.  The  sounds  may  be  obscured  by  murmurs.  The  murmurs 
are  due  to  previous  valve  disease  or  to  incompetency,  on  account  of 
dilatation.    The  action  of  the  heart  is  irregular  and  intermittent.     The 


g72  SPECIAL  DIAGNOSIS. 

pulse  is  correspondingly  small.  In  dilatation  the  alteration  of  the 
rhythm  is  extreme.  There  may  be  embryoeardia  or  foetal-heart  rhythm, 
in  which  the  first  and  second  sounds  are  alike,  and  the  long  pause  is 
shortened.  More  frequently  we  have  galloping  rhythm  of  the  heart. 
It  must  not  be  forgotten  that,  as  dilatation  ensues,  murmurs  of  various 
valve-lesions  may  disappear,  particularly  the  murmur  of  mitral  steno- 
sis. On  the  other  hand,  in  the  earlier  stages  particularly,  murmurs 
develop,  on  account  of  incompetency  at  the  auriculo- ventricular  orifices, 
in  addition  to  the  primary  organic  murmur.  These  murmurs  in  turn 
may  disappear,  if  the  dilatation  is  controlled  by  careful  treatment. 

Diseases  of  the  Arteries. 

Arterial  Sclerosis  or  Arterio-capillary  Fibrosis.  This 
occurs  as  the  result  of  wear  and  tear  of  life  and  as  the  accompaniment 
of  age.  The  time  of  its  onset  depends  upon  the  quality  of  the  arterial 
tissue  which  the  individual  inherited,  and  upon  the  amount  of  wear 
and  tear.  It  may  occur  early  in  life,  and  entire  families  may  show 
this  tendency.  Very  frequently  the  sclerosis  develops  from  intoxica- 
tions of  the  system,  on  account  of  which  persistent  spasm  of  the  small 
vessels  is  set  up — for  blood  of  an  impaired  quality  is  passed  with  greater 
difficulty  through  the  capillaries,  as  was  taught  by  Bright.  The  blood- 
tension  is  raised  thereby.  The  poison  of  alcohol,  of  lead,  of  gout,  and 
of  syphilis  leads  to  this  condition.  The  poison  of  syphilis  and  of  gout 
may  set  up  directly  an  inflammation  and  degeneration  of  the  arteries. 
In  renal  disease  arterial  sclerosis  is  of  common  occurrence.  The  rela- 
tion to  the  renal  lesion  differs.  It  may  be  primary  or  secondary. 
When  primary,  the  morbid  cause  operates  upon  the  kidneys  as  well  as 
the  arteries.  When  secondary  a  morbid  poison  is  retained  within  the 
system  by  the  diseased  kidneys,  the  action  of  which  is  such  as  to  cause 
peripheral  spasm  and  heightened  tension. 

Overfilling  of  the  bloodvessels  from  excessive  eating  and  drinking 
is  thought  by  some  to  cause  arterial  sclerosis  through  constant  overdis- 
tention  of  the  vessels.  In  overwork  of  the  vessels  and  excessive  strain 
there  is  either  heightened  tension  or  increased  peripheral  resistance, 
the  effect  upon  the  bloodvessels  being  the  same  in  either  case.  The 
result  of  the  above  causes  is  thickening  of  the  intima,  followed  by 
changes  in  the  media  and  adventitia,  terminating  in  endarteritis  de- 
formans of  the  large  arteries. 

Symptoms.  The  symptoms  vary.  They  may  be  general  or  local. 
The  disease  may  be  present  and  the  patients  die  from  other  causes. 
Local  symptoms  are  due  to  rupture  of  the  vessels,  as  in  apoplexy  from 
cerebral  hemorrhage,  or  to  their  obstruction,  as  the  coronary  artery,  or 
to  rupture  of  an  aneurism. 

Physical  Signs.  Arterio-sclerosis  is  recognized  by  inspection, 
palpation,  and  auscultation  of  the  bloodvessels,  and  by  observation 
of  the  condition  of  the  heart.  The  superficial  bloodvessels  are  elon- 
gated and  tortuous,  and  pulsate  visibly.  On  palpation  the  artery  feels 
very  hard  to  the  touch  ;  it  resists  compression  ;  it  is  corded  or  rounded 
underneath  the  finger,  and  readily  rolled  about.     The  pulse  shows  at 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     673 

once  high  tension  ;  the  wave  is  slow  in  ascent,  continues  long  under- 
neath the  finger,  and  subsides  slowly.  If  in  the  interval  of  the  beats 
the  vessel  remains  full,  the  pulse,  as  previously  noted,  is  obliterated 
with  difficulty.  Sphygmographic  tracings  are  characteristic.  (See 
Pulse.)  If,  after  pressure  on  the  radial  artery,  it  can  still  be  felt  be- 
yond the  point  of  compression,  its  walls  are  sclerosed  ;  whereas,  if 
after  such  compression  the  artery  is  obliterated  beyond  the  point  of 
compression,  the  hardness  and  firmness  of  the  pulse  previously  ob- 
served are  due  to  vascular  tension  and  not  to  thickened  walls.  The 
two  conditions  should  be  distinguished.  Hypertrophy  of  the  heart 
occurs  early  in  the  course  of  the  sclerosis,  on  account  of  peripheral 
resistance.  The  hypertrophy  involves  the  left  ventricle,  and  is  not 
attended  by  dilatation.  The  apex-beat  is  out  beyond  the  mid-clavicu- 
lar line  ;  the  impulse  is  heaving  and  forcible.  The  second  sound  at 
the  aortic  cartilage  is  characteristic.  It  is  clear  and  ringing  ;  it  is  heard 
in  the  course  of  the  bloodvessels,  and  is  most  distinct  at  or  just  beyond 
the  apex.  Right-sided  hypertrophy  and  dilatation  are  not  generally 
present.  Auscultation  of  the  larger  arteries,  as  the  carotids,  the  abdom- 
inal aorta,  and  femorals,  shows  a  systolic  murmur  usually  rough  and 
high  in  pitch.  All  the  above-mentioned  conditions  may  be  present, 
and  yet  the  patient  remain  in  good  health.  The  hypertrophy  appar- 
ently compensates  for  the  arterial  occlusion.  There  may  be  no  renal 
disease,  or  moderate  renal  cirrhosis  may  be  present,  indicated  by  tran- 
sient albuminuria,  polyuria,  and  hyaline  tube-casts.  The  subsequent 
symptoms  are  due  largely  to  closure  of  one  or  more  vessels  in  the 
peripheral  circulation,  to  the  development  of  an  aneurism  or  dilatation 
of  the  aorta,  to  failing  hypertrophy  of  the  heart,  or  to  the  development 
of  renal  cirrhosis. 

The  blocking  of  peripheral  arteries  is  due  to  embolism  or  throm- 
bosis, more  frequently  the  latter,  and  to  rupture  of  peripheral  vessels, 
or,  in  all  probability,  miliary  aneurisms.  When  occlusion  of  the 
vessels  takes  place  in  arteries  which  supply  the  extremities  gangrene 
may  occur.  Sometimes  the  occlusion  is  due  to  simple  narrowing  of 
the  vessels  alone.  Gangrene  of  the  feet  is  frequently  seen  secondary 
to  bad  arteries.  If  the  occlusion  takes  place  in  the  vessels  of  the 
brain,  various  secondary  lesions  are  produced.  In  more  or  less  gen- 
eral occlusion  from  sclerosis  of  the  smaller  arteries  acute  and  chronic 
softening  occur.  Hemiplegia,  monoplegia,  or  aphasia  may  occur  tem- 
porarily, if  relieved  by  collateral  circulation,  or  permanently,  from 
embolism,  thrombosis,  or  rupture  of  the  vessels.  Hence,  apoplexy  is 
almost  always  due  to  primary  disease  of  the  arteries,  upon  which,  in 
the  large  majority  of  cases,  miliary  aneurisms  have  existed.  If  the 
coronary  arteries  are  blocked,  thrombosis  with  sudden  death  takes 
place,  or  chronic  myocarditis  may  develop,  with  subsequent  aneurism 
and  rupture.  Angina  pectoris,  with  or  without  thrombosis  of  the 
coronary  artery,  is  always  associated  with  arterial  sclerosis. 

Failure  of  the  hypertrophied  heart  leads  to  dilatation  with  all  the 
symptoms  as  previously  described,  including  cyanosis,  visceral  conges- 
tions, and  dropsies.  The  murmur  at  the  apex,  due  to  incompetency 
from  dilatation,  may  simulate  chronic  valvular  disease,  although  the 

43 


674  SPECIAL  DIAGNOSIS. 

latter  may  never  have  been  present,     The  sclerosis  may  advance  more 
rapidly  in  the  kidneys  than  in  the  other  portions  of  the  circulation  ; 
later,  on  account  of  the  contracted  kidney,  symptoms  of  interstitial  . 
nephritis  may  arise. 

Aneurism. 

A  true  aneurism  is  formed  by  the  distention  of  one  or  more  of  the 
arterial  coats.  It  is  usually  fusiform,  but  may  be  cylindrical.  It  may 
be  circumscribed  or  sacculated.  The  fusiform  and  saccular  are  the 
forms  most  commonly  seen.  False  aneurism  or  dissecting-aneurism 
arises  from  laceration  of  the  internal  coat  of  the  artery.  The  blood 
dissects  between  the  layers.  It  occurs  in  the  aorta.  It  may  begin  at 
the  heart  and  separate  the  coats  as  far  down  as  the  iliac  arteries. 
Arterio-venous  aneurism  is  seen  when  communication  between  an  artery 
and  a  vein  has  been  set  up.  If  a  sac  intervenes,  it  is  called  a  vari- 
cose aneurism.  Sometimes  communication  is  direct,  the  vein  becoming 
dilated,  tortuous,  and  pulsating.     It  is  known  as  an  aneurismal  varix. 

An  aneurism  may  occur  in  the  course  of  arterial  sclerosis  from 
diffuse  distention  of  the  coats.  Its  typical  form  is  seen  in  dilatation  of 
the  aorta  with  one  or  more  sacculated  aneurisms  on  its  surface. 

Sacculated  aneurism  occurs  from  rupture  of  the  tunica  media,  indepen- 
dently of  general  disease  of  the  arteries,  and  in  arterial  sclerosis.  The 
most  common  seat  is  the  ascending  portion  of  the  aorta.  It  occurs 
early  in  the  course  of  arterial  sclerosis.  Such  form  of  aneurism  is 
seen  in  the  smaller  vessels.  Aneurisms  also  arise  after  the  lodgement 
of  an  embolus,  permanently  plugging  the  vessel.  The  proximal  end 
of  the  vessel  becomes  dilated. 

Mycotic  aneurism,  first  described  by  Osier  and  exhaustively  by 
Eppinger,  occurs  in  malignant  endocarditis.  The  aneurisms  are  small 
in  size  and  multiple,  and  not  recognized  during  life.  They  arise  from 
the  injury  produced  by  the  local  infection  of  bacteria  in  different  por- 
tions of  the  vascular  system. 

Aneurism  of  the  Thoracic  Aorta.  The  causes  which  produce 
arterial  sclerosis  are  operative  in  the  thoracic  portion  of  the  aorta — 
chiefly  physical  overwork,  alcohol,  syphilis,  and  gout.  It  may  be 
situated  just  beyond  the  aortic  ring,  at  the  junction  of  the  ascending 
and  transverse  aorta,  in  the  transverse,  or  at  the  beginning  of  the 
descending,  portion  of  the  thoracic  aorta.  The  larger  aneurisms  are  at 
the  two  bends  of  the  aorta. 

Symptoms.  The  symptoms  of  aneurism  are  largely  due  to  press- 
ure, and  depend  upon  the  position  of  the  aneurism  and  the  direction  of 
its  growth. 

Aneurisms,  however,  may  exist  without  symptoms  or  appreciable 
physical  signs.  Even  in  a  patient  who  has  been  under  careful  obser- 
vation, sudden  death  may  take  place  from  rupture  of  a  concealed 
aneurism,  the  presence  of  which  had  not  been  suspected  during  life. 
On  the  other  hand,  cases  occur  with  characteristic  pressure-symptoms 
and  with  no  physical  signs.  Pressure -symptoms  depend  entirely  upon 
the  position  of  the  tumor. 

Aneurisms  of  the  ascending  portion  of  the  arch  cause  dislocation  of 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     675 

the  heart  outward,  or  toward  the  right  pleura  or  forward,  appearing 
at  the  second  or  third  interspace,  causing  erosion  of  the  ribs  and  ster- 
num. The  vena  cava  is  compressed,  causing  enlargement  of  the  veins 
of  the  head  and  arms  ;  the  subclavian  vein  may  be  compressed  alone, 
causing  enlargement  and  oedema  of  the  right  arm.  Localized  oedema 
may  result,  confined  to  the  thorax.  (See  (Edema.)  If  the  aneurism 
is  large,  the  inferior  vena  cava  may  be  pressed  upon,  causing  oedema 
of  the  feet.  The  right  laryngeal  nerve  may  be  involved,  causing 
aphonia  and  dyspnoea.     Pain  attends  the  aneurismal  process. 

Fig.  177. 


Aneurism  of  ascending  portion  of  arch  of  aorta.    Tumor  in  first  and  second  interspaces, 
extending  into  neck.    Portion  of  sternum  atrophied. 

Aneurisms  of  the  transverse  portion  of  the  aorta  project  below,  for- 
ward, or  backward.  When  forward,  they  produce  tumors  behind  the 
manubrium,  which  from  pressure  cause  destruction  of  the  bone ;  if  the 
aneurism  projects  backward,  marked  pressure-symptoms  are  produced. 
When  the  trachea  is  pressed  upon,  it  causes  dyspnoea  and  cough,  which 


676  SPECIAL  DIAGNOSIS. 

is  paroxysmal.  (See  Dyspnoea.)  The  oesophagus  may  be  pressed 
upon,  causing  dysphagia.  The  left  recurrent  laryngeal  nerve  may  be 
pressed  upon,  causing  paralysis  of  the  corresponding  cord,  with  aphonia. 
(See  Larynx.)  Pressure  on  a  bronchus  may  produce  bronchorrhoea 
and  dilatation,  which  in  turn  may  lead  to  localized^  abscess.  The 
growth  may  extend  upward,  involving  the  coats  of  the  innominate  and 
carotid  arteries  on  the  right  side,  or  carotid  and  subclavian  on  the  left, 
markedly  interfering  with  the  pulse  of  the  two  sides.  Pressure  on 
the  sympathetic  nerve  is  likely  to  take  place  in  this  situation,  with 
contraction  of  one  of  the  pupils,  although  at  first  it  is  sometimes 
dilated.  The  thoracic  duct  is  sometimes  compressed,  leading  to  rapid 
wasting. 

In  the  descending  portion  the  pressure-signs  of  aneurism  are  often  not 
so  marked.  The  vertebras  are  likely  to  be  pressed  upon  in  this  situation. 
The  pain,  therefore,  is  most  intense.  The  oesophagus  and  left  bronchus 
are  compressed.  Dysphagia  and  bronchiectasis,  the  latter  causing 
bronchorrhoea  with  subsequent  gangrene,  are  likely  to  occur.  The 
cough  and  the  fever  in  bronchorrhoea,  together  with  emaciation,  simu- 
late phthisis,  for  Avhich  aneurism  is  often  mistaken.  The  physical 
signs  of  phthisis  are  usually  pronounced  in  this  situation,  and,  with  the 
presence  of  bacilli  in  the  sputum,  render  the  diagnosis  easy.  In  these 
cases  rupture  takes  place  into  the  bronchus  or  into  the  oesophagus. 
In  one  of  my  cases,  which  had  been  treated  for  tuberculosis  because  of 
small  hemorrhages,  with  the  conditions  above-mentioned,  death  took 
place  from  rupture  into  the  bronchus,  causing  sudden  profuse  hemor- 
rhage. When  the  aneurism  is  adherent  to  the  oesophagus  and  slowly 
ulcerating  into  it,  rupture  may  take  place,  followed  by  instantaneous 
death.  The  vertebrae  may  be  eroded  and  symptoms  of  spinal  com- 
pression arise. 

I  once  saw  an  autopsy  performed  by  a  medico-legal  expert  on  a  case  of 
sudden  death  from  gastric  hemorrhage.  The  source  of  the  hemorrhage 
could  not  be  ascertained.  There  was  blood  in  the  stomach.  When  he 
was  about  to  give  up  the  search,  the  oesophagus  and  aorta  were  sug- 
gested for  examination.  A  small  aneurism  was  found  which  had 
ulcerated  and  then  ruptured  into  the  gullet.  In  another  the  aneurism 
had  ruptured  into  the  pleural  sac,  causing  internal  concealed  hemor- 
rhage and  death. 

Special  Symptoms.  While  pressure-symptoms  are  the  most  striking 
symptoms  of  this  affection,  pain,  which  is  usually  due  to  pressure, 
must  be  referred  to.  It  is  an  important  constant  symptom.  It  is 
sharp  and  lancinating,  and  may  occur  in  paroxysms.  It  is  more 
severe  and  constant  when  bone  is  eroded  by  pressure  on  the  vertebras, 
or  the  thorax  in  front.  The  gnawing  pain  that  attends  ulceration  of 
bone  is  relieved,  if  it,  as  the  sternum,  is  perforated.  Anginal  attacks 
may  attend  the  neuralgic  pains  just  described.  Pain  sometimes  fol- 
lows the  course  of  the  nerves,  extending  down  the  arm  or  to  the  neck, 
or  along  the  course  of  the  intercostal  nerves. 

Cough.  The  cough  is  peculiar.  It  is  paroxysmal  in  many  cases 
and  of  a  brazen,  ringing  character,  indicating  its  laryngeal  origin,  due 
to  pressure  upon  the  recurrent  laryngeal  nerves.     It   is    frequently 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     677 

paroxysmal  when  the  pressure  is  directed  upon  the  windpipe  or  bron- 
chus. In  the  former  instance  the  cough  is  dry,  in  the  latter  tracheal 
and  bronchial.  It  is  attended  by  a  thin,  watery  expectoration  which, 
if  bronchiectasis  with  fermentation  ensues,  becomes  thick  and  ropy. 
Dyspnoea  occurs  more  frequently  in  aneurism  of  the  transverse  portion, 
due  (1)  to  pressure  on  the  recurrent  laryngeal  nerves  ;  (2)  to  compres- 
sion of  the  trachea  ;  (3)  to  compression  of  the  left  bronchus.  Marked 
stridor  attends  the  first  form.  When  one  of  the  recurrent  laryngeal 
nerves,  more  particularly  the  left,  is  pressed  upon,  there  is  spasm  or 
paralysis  of  the  muscles  of  the  vocal  cord,  causing  hoarseness  and  loss 
of  voice.  Laryngoscopic  examination  should  not  be  neglected,  for 
paralysis  of  the  abductor  muscles  without  symptoms  may  be  present. 

Hemorrhage.  The  hemorrhage  may  be  gradual  when  there  is 
slight  leakage  into  the  trachea  at  the  point  of  compression.  The 
amount  of  blood  lost  is  small.  It  may  take  place  externally.  (See 
Fig.  178.)     Profuse  hemorrhages,  causing  sudden  death,  occur  from 

Fig.  178. 


Aneurism  of  ascending  and  transverse  portions  of  aorta  projecting  forward,  destroying  ribs  and 
sternum.  The  skin  ulcerated,  and  gradual  external  leakage  took  place.  The  bleeding  continued 
in  small  amounts  for  a  long  time. 


rupture  into  the  trachea  or  bronchus,  and  from  perforation  into  the 
lung.  With  regard  to  difficulty  of  deglutition,  it  may  be  said  that  the 
sound  should  never  be  passed  in  suspected  cases  of  aneurism,  on 
account  of  the  danger  of  rupturing  the  sac. 

Clubbed  Fingers.  In  intrathoracic  aneurism  clubbing  of  the  fingers 
and  incurvation  of  the  nails  of  one  hand  are  sometimes  seen,  although 
comparatively  rarely. 

Compression  and  pressure  on  the  sympathetic  system  of  nerves  has 
been  referred  to.     In  addition  to  pupillary  changes  there  may  be  pallor 


678 


SPECIAL  DIAGNOSIS. 


of  one  side  of  the  face.  When  the  pupil  is  dilated  this  pallor  may 
accompany  it,  on  account  of  stimulation  of  the  vaso-dilator  fibres. 
When  the  cilio-spinal  branches  of  the  sympathetic  are  pressed  upon, 
the  dilator  fibres  are  paralyzed.  If  the  pupil  contracts,  there  are  also 
hypersemia  of  the  side  of  the  face  and  unilateral  sweating. 

Physical  Signs.  (Plate  XXXIV.,  Fig.  1.)  Inspection.  In 
health  the  position  of  the  aorta  cannot  be  recognized.  Pulsation  may 
be  seen  at  the  episternal  notch  in  rare  instances,  particularly  in  women, 
independently  of  disease  of  the  aorta  ;  it  is  due  to  nervous  palpitation. 
An  aneurism  may  exist  without  any  external  visible  signs.     On  the 


Fig.  179. 


Aneurism.    General  endarteritis  and  valvulitis. 
■   TR.  =  Thrill  and  impulse.     +  =  Murmur. 


other  hand,  pulsation  may  be  seen  at  either  side  of  the  sternum  above 
the  level  of  the  third  rib,  most  commonly  in  the  second  interspace  on 
the  right  side.  The  impulse  may  be  seen  alone  without  visible  swell- 
ing ;  the  chest  must  be  viewed  from  different  situations  in  order  to 
detect  it.  An  oblique  light  falling  on  the  surface  is  sometimes  neces- 
sary. When  the  innominate  artery  is  involved  the  pulsation  is  observed 
in  the  neck,  above  the  sterno-clavicular  junction,  or  above  the  sternum. 
With  the  abnormal  impulse  a  swelling  or  tumor  is  often  present. 
It  may  be  large  enough  to  press  the  upper  portion  of  the  sternum  and 
adjacent  ribs  forward.     In  other  instances  a  tumor  the  size  of  the  half 


PLATE    XXXIV. 


fiq.  1 


\ 


Aneurism  of  the  Arch  of  the  Aorta. 


Tumor       /  t 


Tumor  of  the  Anterior  Mediastinum. 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     679 

of  a  lemon  may  be  seen  along  the  edge  of  the  sternum.  The  most  fre- 
quent site  is  the  first  and  second  right,  or  the  second  left  interspace. 
The  skin  over  the  tumor,  as  in  the  case  of  which  an  illustration  is 
given,  may  ulcerate  and  be  the  seat  of  persistent  small  hemorrhages. 
The  apex-beat  of  the  heart  is  displaced  downward  and  outward  from 
pressure. 

If  the  aneurism  is  seated  in  the  ascending  portion  of  the  aorta,  just 
beyond  the  aortic  ring,  a  pulsating  tumor  may  be  seen  in  the  third 
interspace  at  the  left  edge  of  the  sternum.  If  in  the  ascending  por- 
tion, beyond  the  heart,  the  tumor  is  in  the  first  or  second  interspace 
along  the  right  edge  of  the  sternum.  If  the  aneurism  is  in  the  trans- 
verse portion  of  the  aorta,  the  upper  portion  of  the  sternum  is  fre- 
quently made  to  protrude,  or  the  tumor  projects  upward  into  the  fossa? 
of  the  neck.  If  in  the  descending  portion,  it  is  in  the  second  or  third 
interspace  on  the  left  side.  In  this  portion  of  the  aorta  a  tumor  is 
seen  in  the  left  scapular  region  in  rare  instances. 

Palpation.  Palpation  must  be  employed  by  the  usual  method  ; 
bimanual  palpation  must  also  be  used,  one  hand  placed  upon  the  ster- 
num and  the  other  upon  the  vertebrae.  Moderate  pressure  should  be 
exerted.  Palpation  should  also  be  employed  at  different  periods  of 
respiration.  At  times  signs  are  only  yielded  at  the  end  of  complete 
expiration".  It  must  further  be  said  that  palpation  must  be  employed 
both  with  the  tips  of  the  fingers  and  with  the  palm  of  the  hand  applied 
to  the  surface. 

Fig.  180. 


Possible  position  of  impulse  in  aneurism ;  arranged  in  order  of  frequency. 

By  palpation  the  area  and  degree  of  pulsation  are  determined.  If 
the  aneurism  is  large  or  has  perforated,  the  impulse  is  expansile  and 
heaving  in  character.  The  sac  may  be  soft  and  fluctuating,  but  usually 
presents  considerable  resistance.  In  addition  to  the  systolic  impulse 
the  diastolic  shock  is  also  felt.  This  is  a  most  conclusive  physical 
sign.  A  thrill  is  frequently  present,  systolic  in  time,  usually  due  to 
dilatation  of  the  arch  ;  at  times,  to  sacculated  aneurism.  Without 
visible  tumor,  pulsation  and  thrill  may  be  felt  in  the  suprasternal 
notch,  if  the  head  is  bent  forward,  so  that  the  tissues  are  relaxed,  and 


680  SPECIAL  DIAGNOSIS. 

the  fingers  pushed  down  toward  the  aorta.  When  the  aneurism  is 
filled  or  filling  with  clot,  the  tumor  may  be  seen  and  felt,  but  no  im- 
pulse will  be  transmitted  to  the  hand  or  thrill  be  felt  by  the  fingers. 

Percussion.  Percussion  furnishes  the  most  reliable  evidence  of  the 
presence  of  an  aneurism  or  aneurismal  dilatation  in  cases  in  which  the 
tumor  is  not  too  deep-seated  or  small  in  size.  The  dulness  may  be 
relative  only.  (See  Cardiac  Percussion.)  The  area  of  dulness  is 
increased  somewhere  in  the  course  of  the  aorta.  It  may  be  observed 
projecting  outward  at  the  right  edge  of  the  sternum  when  the  ascend- 
ing portion  of  the  aorta  is  the  seat  of  disease,  or  over  the  entire  upper 
part  of  the  sternum,  extending  toward  the  left,  when  the  transverse 
portion  is  diseased.  It  may  be  observed  as  an  extension  of  cardiac 
dulness  upward  in  the  second  and  third  interspaces.  Sometimes  dul- 
ness is  detected  in  the  scapular  regions,  particularly  of  the  left  side. 
The  percussion-tone  is  flat,  and  there  is  marked  sense  of  resistance. 
Percussion  must  be  employed  with  the  patient  in  the  upright  and  in 
the  recmnbent  posture. 

Respiratory  Percussion.  The  character  of  the  tone  and  the  shape  of 
the  dulness  must  be  noted  at  the  end  of  full  inspiration  and  of  full 
expiration. 

Fig.  181. 


Aneurism  of  aorta. 
Area  of  absolute  dulness,  dark  line.    Area  of  relative  dulness,  broken  line. 

Auscultatory  -percussion  is  of  the  utmost  value,  and  the  method  of 
percussion  taught  by  Sansom  and  Ewart  must  be  carefully  followed. 
An  aneurismal  tumor  may  be  present  without  thrill  or  murmur,  but 
yields  signs  of  dulness  on  percussion. 

Auscultation.  As  just  stated,  murmurs  may  not  always  be  pres- 
ent. They  depend  upon  the  amount  of  fibrin  in  the  sac.  When  pres- 
ent the  murmur  is  systolic  in  time,  heard  with  maximum  intensity 
usually  over  the  abnormal  area  of  impulse  or  tumor,  or  over  the  in- 
creasing area  of  dulness.     It  is  transmitted  in  the  direction  of  the 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     681 

vessels,  and  may  be  heard  louder  in  the  vessels  of  the  neck  and  along 
the  course  of  the  aorta.  Often  a  double  murmur  is  heard,  the  diastolic 
sound  being-  due  to  associated  regurgitation  at  the  aortic  orifice.  Some- 
times the  diastolic  murmur  alone  may  be  heard.  Increase  in  intensity 
or  accentuation  of  the  aortic  second  sound  is  pronounced.  The  sound 
is  ringing  in  character,  and  is  rarely  absent  in  large  aneurisms. 

The  Peripheral  Vessels  in  Aneurism.  The  pulse  in  the  two  radial 
arteries  may  show  a  marked  difference  both  in  volume  and  in  time. 
The  difference  may  indicate  the  position  of  the  aneurism.  If  the 
pulse  of  the  right  radial  is  smaller  than  the  left,  the  aneurism  may 
be  in  or  near  the  innominate  artery  ;  if  the  opposite,  it  is  near  or  in- 
cludes the  orifice  of  the  left  subclavian.  In  the  same  way  the  differ- 
ence in  time  may  also  aid  in  determining  the  location.  Osier  refers 
to  obliteration  of  the  pulse  in  the  abdominal  aorta  and  its  branches. 
In  one  case  he  could  not  feel  throbbing  in  the  aorta  and  the  femorals, 
although  the  circulation  was  unimpaired.  The  aneurism  was  in  the 
descending  portion  of  the  aorta,  and  its  pulsation  was  seen  in  the  left 
scapular  region.  The  sac  was  sufficiently  large  to  act  as  a  reservoir, 
which  filled  during  the  ventricular  systole,  and  from  which  the  blood 
poured  toward  the  periphery  in  a  continuous  stream  instead  of  being 
intermittent. 

Tracheal  Tugging.  Tracheal  tugging  may  be  obtained  in  one  of  two 
ways.  By  the  old  method  the  patient  should  be  sitting  or  standing, 
while  the  observer  sits  or  stands  to  one  side,  and  faces  him.  With  the 
hand  furthest  from  the  patient  steadying  the  head,  the  observer  gently 
but  firmly  grasps  the  surface  of  the  cricoid  cartilage  with  the  thumb 
and  finger  of  the  other  hand,  while  the  head  is  slightly  thrown  back. 
The  head  is  then  flexed,  so  that  the  neck  is  no  longer  stretched.  The 
patient  is  then  told  to  hold  his  breath  completely,  and  any  up-and-down 
movement  of  the  trachea  is  immediately  transmitted  to  the  observer's 
fingers.  One  must  not  mistake  the  transmitted  pulsation  in  the 
cervical  vessels  for  such  movement ;  and  great  care  should  be  exer- 
cised to  see  that  the  breathing  is  entirely  stopped. 

In  the  other  method,  as  proposed  and  practised  by  Ewart  (British 
Medical  Journal,  March  19,  1892),  the  observer  stands  behind  the 
patient,  steadying  the  latter's  head  against  his  body,  and  the  cricoid  is 
firmly  held  between  the  tips  of  the  first  or  middle  fingers.  The 
writer,  after  considerable  experience,  prefers  this  second  method,  on 
account  of  delicacy  of  touch,  firmness  of  grasp,  and  comfort  to  the 
patient. 

Diagnosis.  The  special  points  of  diagnosis  are  :  the  etiological 
factors  ;  the  antecedent  pathological  conditions,  as  arterial  sclerosis  ; 
the  occurrence  of  pain  ;  the  occurrence  of  pressure-symptoms  ;  and 
the  physical  signs.  These  have  been  sufficiently  dwelt  upon,  and  it  is 
not  necessary  to  consider  them  again.  It  must  not  be  forgotten  that 
aneurism  may  be  present  without  diagnostic  physical  signs,  and,  on 
the  other  hand,  the  pressure-symptoms  may  also  be  in  abeyance.  If 
one  of  the  two  is  present  in  the  male  subject  past  forty,  with  a  pre- 
vious history  of  syphilis,  gout,  alcoholism,  or  muscular  strain,  the 
probability    is    that    an    aneurism    exists.       The    pressure-symptoms 


682 


SPECIAL  DIAGNOSIS. 


always  point  to  some  form  of  intrathoracic  disease  as  the  cause  of  this 
group  of  symptoms.  Thus,  in  cancerous  disease  of  the  lymphatic 
glands,  or  other  tumors  within  the  mediastinum,  pressure-symptoms 
exactly  simulating  aneurism  may  be  present  and  also  the  physical  signs 
of  a  tumor.  The  tumor,  however,  rarely  projects  externally,  and  still 
more  rarely  pulsates.  If  pulsation  is  present,  it  is  not  of  the  expan- 
sile character  seen  in  aneurism,  nor  is  there  as  decided  a  systolic  shock 
when  the  ear  is  held  against  the  chest.     By  the  same  method  we  ob- 


FlG.  182. 


X-ray  appearance  in  aneurism.    (Pepper  and  Leonaed.) 

serve  the  shock  of  the  heart-sounds,  which  are  notably  lessened  or 
absent  in  tumors  from  other  causes  than  aneurism.  In  deep-seated 
tumors  with  pressure-symptoms  the  condition  of  the  arteries,  apart 
from  aneurism,  is  of  diagnostic  importance.  Accentuation  of  the 
aortic  second  sound,  with  hypertrophy  of  the  heart,  points  to  aneu- 
rism. The  presence  of  tracheal  tugging  is  also  a  valuable  diagnostic 
point  in  its  favor.  In  tumor,  and  .  especially  in  cancer,  there  are 
emaciation  and  development  of  a  cachexia,  which  is,  as  is  well  known, 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     683 

most  pronounced  in  cancer  of  the  oesophagus.  Cancer  of  the  oesopha- 
gus, from  its  frequent  point  of  election  near  the  left  bronchus,  often 
simulates  the  pressure-symptoms  of  aneurism. 

Aneurism  must  be  distinguished  from  the  pulsation  of  the  aorta 
which  is  seen  in  aortic  regurgitation.  This  pulsation  is  usually  asso- 
ciated with  dilatation,  the  latter  causing  increased  dulness,  which  may 
add  further  to  the  confusion.  Exaggerated  pulsation  without  dilata- 
tion may,  as  Bramwell  has  recorded,  be  the  cause  of  dulness  and  pul- 
sation over  the  aorta.  The  subjects  are  under  forty,  neurotic,  and 
usually  ansemic. 

It  is  not,  as  a  rule,  difficult  to  distinguish  between  pulsating  empy- 
ema and  aneurism.  Wilson  points  out  that  aneurism  bears  a  definite 
relation  to  the  central  long  axis  of  the  chest.  The  area  of  dulness  of 
aneurism  is  circumscribed,  and  is  usually  the  seat  of  murmurs  or  other 
sounds  synchronous  with  the  rhythm  of  the  heart.  The  signs  of  pul- 
sating empyema  are  usually  upon  the  left  side  and  at  a  distance  from 
the  median  line.  The  percussion-dulness  is  at  the  base  of  the  chest  and 
quite  extensive.  Arterial  murmurs  are  not  present.  The  pulsation 
is  influenced  by  pressure  and  by  respiratory  movements. 

In  mediastinal  cancer  we  are  aided  by  the  discovery  of  enlargement 
of  the  glands  in  the  axillary  or  some  other  situation,  or  by  a  history 
of  the  growth  elsewhere. 

Aneurism  must  not  be  confounded  with  phthisis.  The  diseased 
vessel  may  occlude  a  bronchus  and  cause  collapse  and  bronchial  dila- 
tation ;  hemorrhage  may  occur ;  bronchorrhcea  and  cough  always 
ensue.  Fever  is  not  marked,  which  fact,  with  tracheal  tugging,  vas- 
cular physical  signs,  and  the  absence  of  tubercle  bacilli,  points  to 
aneurism. 

X-ray  Examination.  By  virtue  of  the  large  amount  of  blood  in  an 
aneurism,  the  tumor  is  not  pervious  to  the  X-rays,  and  in  consequence 
is  readily  seen  by  fluoroscopic  examination.  Williams  and  others  have 
been  very  successful  in  recognizing  an  aneurism  even  when  it  could 
not  be  made  out  by  physical  signs.  Such  examination  must  be  resorted 
to  in  all  cases.     (Fig.  182.) 

Diseases  of  the  Mediastinum. 

Inflammation  of  the  mediastinum  may  be  limited  to  the  glands  or 
the  connective  tissue.  Moderate  inflammation  of  the  glands,  lymph- 
adenitis, occurs  in  bronchitis  and  pneumonia,  particularly  if  bronchitis 
is  of  specific  origin,  as  in  measles  or  influenza.  It  is  said  that  such 
inflammation  is  of  common  occurrence  in  whooping-cough,  and  may 
be  the  exciting  cause  of  the  paroxysms.  DeMussy  and  Guiteras  have 
found  physical  signs  of  enlargement,  characterized  by  dulness  in  the 
upper  part  of  the  interscapular  region,  in  cases  of  this  disease  and  of 
influenza.  Other  authorities,  as  Osier,  dispute  the  possibility  of  this 
occurrence,  or  at  least  of  its  recognition  by  physical  signs.  Tubercu- 
lous inflammation  of  the  lymphatic  glands  of  the  mediastinum  may 
give  rise,  however,  to  local  physical  signs.  Abscess  of  the  glands 
cannot  be  distinguished  during  life. 


684  SPECIAL  DIAGNOSIS. 

Tumors  of  the  Mediastinum. 

Cancer  and  sarcoma  are  the  most  frequent  forms  of  tumor  in  this 
locality.  Hare  found  the  proportion  in  520  cases  to  be  as  follows  : 
134  of  cancer,  98  of  sarcoma,  21  of  lymphoma,  7  of  fibroma,  11  of 
dermoid  cyst,  8  of  hydatid  cyst,  and  the  remainder  of  lipoma,  gumma, 
and  enchondroma.  With  the  application  of  more  correct  histological 
methods  we  now  know  that  sarcoma  is  more  common  than  carcinoma. 
The  tmnor  is  most  frequently  found  in  the  anterior  mediastinum  when 
one  region  alone  is  affected.  The  disease  may  be  either  primary  or 
secondary.  In  sarcoma  it  is  usually  primary.  Males  are  chiefly 
affected,  and  most  often  between  thirty  and  forty.  The  thymus  gland, 
the  lymphatic  glands,  the  pleura,  or  the  oesophagus  is  the  source  of 
origin  in  all  cases,  the  former  the  most  frequent. 

The  symptoms  of  mediastinal  tumor  are  chiefly  due  to  pressure. 
Dyspnoea  is  early  and  constant,  and  may  be  laryngeal,  or  tracheal 
from  pressure  on  that  tube.  In  some  instances  encroachment  upon 
the  heart  or  the  vessels  causes  dyspncea.  Again,  the  dyspnoea  may 
be  due  to  a  pleural  effusion  which  accompanies  the  growths.  Cough 
of  a  peculiar  character  occurs.  It  is  laryngeal,  and  of  a  dry,  brazen 
quality.  Aphonia  may  arise  from  pressure  upon  the  recurrent  laryn- 
geal nerves.  (See  Diseases  of  the  Larynx.)  If  the  bloodvessels  are 
pressed  upon  symptoms  of  obstruction  occur,  depending  upon  the  ves- 
sel occluded.  GEdema  of  the  upper  extremities  may  occur.  If  the 
oesophagus  is  pressed  upon,  there  is  difficulty  in  deglutition.  In  some 
instances  the  sympathetic  nerve  is  presseol  upon,  causing  hyperemias 
and  pupillary  changes. 

The  physical  signs  (Plate  XXXIV.,  Fig.  2)  are  those  of  a  tumor 
in  the  anterior  portion  of  the  chest,  frequently  in  the  precordial  area, 
which  may  or  may  not  pulsate ;  dislocation  of  the  heart,  not  limited 
to  any  position ;  great  dulness  and  resistance  ;  frequently  conduction 
of  lung-sounds  and  heart-sounds  to  some  distance ;  at  times  a  systolic 
murmur ;  increased  size  and  pulsation  of  the  veins  ;  and  physical  signs 
from  pressure.  (See  Aneurism.)  It  must  be  remembered  that  pain  is 
more  common  in  aneurism,  fever  and  emaciation  in  mediastinal  growths. 

Tumors  of  the  anterior  mediastinum  present  the  phvsical  signs,  in 
front,  of  a  prominence  more  or  less  marked,  often  including  projection 
of  the  sternum  ;  an  irregular  area  of  dulness  ;  rarely  transmitted  pul- 
sation ;  more  frequently  transmitted  heart-sounds  and  lung-sounds. 
It  is  the  form  in  which  phenomena  from  pressure  upon  the  veins  are 
most  marked.  Symptoms  from  arterial  pressure  (difference  in  pulse), 
pressure  on  the  vagus  anol  sympathetic  are  less  frequent.  Dyspnoea 
may  occur. 

Tumors  of  the  middle  and  posterior  mediastinum  are  characterized  by 
pressure  upon  the  bronchi  and  structures  adjacent  thereto,  hence  we 
have  symptoms  from  pressure  upon  the  oesophagus,  aorta,  and  the  nerves. 
Dyspnoea  and  cough  are  the  most  pronounced  symptoms,  while  phe- 
nomena from  pressure  on  the  vagus,  cardiac  palpitation,  vomiting, 
etc.,  are  not  uncommon.     Emaciation  and  a  cachexia  are  more  marked 


DISEASES  OF  HEART,  BLOODVESSELS  AND  MEDIASTINUM.     685 

than  in  tumors  in  other  regions.     Pepper  and  Stengel  consider  that 
fever  attends  growths  in  this  region  with  greater  frequency. 

Tumors  of  pleural  origin  have  symptoms  of  acute  or  subacute  pleu- 
ritis,  with  or  without  effusion.  The  fluid  secured  by  puncture  is 
usually  bloody,  rarely  chylous,  and  may  contain  suspicious  vacuolated 
epithelial  cells.  A  mass  may  be  suspected  if  there  is  great  resistance 
to  the  trocar.  If  the  tmnor  ulcerate  into  the  lung,  the  sputa  may  con- 
tain characteristic  groups  of  cells,  while  hemorrhagic  oozing  mav  be 
suspicious. 


CHAPTEE    IV. 

DISEASES  OF  THE  MOUTH,  FAUCES,  PHAEYNX,  AND 

CESOPHAGUS. 

The  Mouth. 

The  mouth  is  affected  by  comparatively  few  diseases,  and  most  of 
these  are  the  result  of  infection  or  of  trauma,  or,  rarely,  are  tropho- 
neurotic. The  cavity  forms  a  good  breeding-place  for  all  forms  of 
organisms,  and  were  it  not  for  the  secretions  and  constant  cleansing  of 
the  mouth  by  the  passage  of  food  and  its  physiological  labors,  diseases 
would  be  very  common.  Indeed,  it  is  possible  that  such  diseases  do 
not  take  place  at  all  unless  there  is  such  perversion  of  the  normal 
secretion  as  destroys  its  antiseptic  or  antimicrobic  qualities.  We  know 
but  little  specifically  concerning  the  changes  in  the  secretions.  Clini- 
cally, we  do  know,  however,  that  in  conditions  of  poor  nutrition,  in 
wasting  diseases  generally.,  and  probably  in  connection  with  the  rheu- 
matic diathesis,  there  is  such  change  in  the  secretions  as  permits  patho- 
genic micro-organisms  to  exercise  their  influence  upon  the  mucous 
membrane.  The  result  of  their  action  is  seen  in  various  forms  of  in- 
flammation. 

Symptomatology.  The  symptomatology  of  mouth-affections  is 
the  symptomatology  of  inflammation  :  pain,  heat,  redness,  and  swelling. 

The  Data  Obtained  by  Inquiry. 

The  subjective  symptoms  are  not  characterized  by  great  gravity, 
but  they  are  most  annoying. 

Pain.  This  symptom  is  most  aggravating,  because  it  is  excited  by 
the  many  functional  acts  connected  with  the  mouth.  It  occurs  in  all 
inflammations  and  ulcerations  except  those  due  to  syphilis.  It  is 
aggravated  by  food,  by  movements  of  the  lips,  cheeks,  or  tongue,  and 
by  attempts  to  discharge  saliva.  The  absence  of  pain  is  observed  in 
gangrene. 

Heat.    The  patient  complains  of  heat  of  the  mouth  in  inflammations. 

Dryness.  This  symptom  is  complained  of  in  fevers,  and  by  those 
who  are  compelled  to  sleep  with  the  mouth  open.  It  may  be  a  condi- 
tion of  itself,  as  the  following  shows  : 

Dry  Mouth.  Xerostoma.  Hutchinson  first  described  a  condition 
of  the  mouth  in  which  dryness  was  the  chief  complaint.  The  secre- 
tions are  suppressed  entirely,  the  tongue  red  and  dry,  the  mucous  mem- 
brane of  the  cheeks  and  palate  smooth,  shining,  and  dry.  Functional 
movements  are  very  difficult.  The  majority  of  the  cases  are  in  women 
in  whom  the  general  health  is  always  impaired.     Hayden  thinks  that 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,  (ESOPHAGUS.     687 

the  secretion  of  the  salivary  and  buccal  glands  is  modified  as  the  result 
of  a  central  nervous  disturbance.  In  xerostoma  there  is  also  dry- 
ness of  the  nostrils  and  eyes,  with  intolerable  itching.  In  a  case  which 
Harris  reported  both  parotid  glands  were  enlarged  and  firm  but  painless. 
There  is  some  dryness  of  the  mouth  in  fevers.  It  is  also  symptom- 
atic of  chronic  gastritis,  and  may  occur  in  diabetes. 

The  Data  Obtained  by  Observation. 

The  objective  symptoms  are  determined  by  inspection  and  palpation. 

By  these  means  we  observe  the  color  of  the  parts  of  the  mouth, 
changes  in  temperature,  as  well  as  in  the  size  and  shape  (swelling). 
The  teeth,  gums,  and  tongue  are  also  examined. 

Color.  The  normal  redness  of  the  mucous  membrane  may  be  in- 
creased or  diminished  in  intensity.  Pallor  is  associated  with  anaemia. 
Increased  redness  attends  inflammation,  and  with  it  the  temperature 
is  raised.  The  mucous  membrane  is  yellow  in  jaundice,  bluish  in 
cyanosis.  Both  of  the  latter  changes  are  observed  to  greater  advan- 
tage under  the  tongue.  The  mucous  membrane  is  the  seat  of  pig- 
mentation hi  Addison's  disease  and  in  argyria.  In  the  former,  small 
oval  purplish  spots  are  seen.  They  must  not  be  confounded  with  the 
pigmented  spots  common  after  stomatitis  in  negroes.  Eruptions  occur 
in  the  mouth  and  may  precede  external  eruptions.  This  is  notably  so 
in  measles.  In  this  affection  the  eruption  is  seen  on  the  hard  and  soft 
palate  twenty-four  hours  before  the  development  of  the  rash.  In 
smallpox  and  chickenpox  the  vesicles  are  seen. 

Shape.  Swellings  are  seen  usually  as  the  result  of  disease  of  struc- 
tures about  the  mouth.  The  floor  of  the  mouth  is  encroached  upon  by 
glands  underneath  or  by  swelling  of  the  cellular  tissue.  Bone  diseases 
and  some  teeth  affections  cause  swellings.  The  dental  arch  must  be 
observed.  Narrowing  of  the  arch  is  due  to  adenoid  disease  or  to  the 
habit  of  thumb-sucking  in  childhood,  much  more  likely  the  former. 

Foetor.  The  odor  imparted  to  exhaled  air  is  peculiar  in  mouth- 
affections.  It  may  be  a  simple  foetor  or  of  a  metallic  or  gangrenous 
odor.  Foetor  attends  all  inflammations  ;  it  is  more  pronounced  in 
ulcerative  and  mercurial  stomatitis.     In  the  latter  it  may  be  metallic. 

Hemorrhage.  Petechias  in  jjurpura  hemorrhagica  ;  submucous  hemor- 
rhages in  scorbutus  and  severe  forms  of  purpura — morbus  maculosus 
werlhofii — are  common  on  the  cheeks  and  on  the  gums.  In  ulcerative 
endocarditis  hemorrhagic  infarcts  are  seen.  In  grave  anaemias  petechias 
are  also  seen. 

Capillary  oozing  of  blood  takes  place  from  the  mucous  membranes 
in  low  typhoid  states.  The  accumulated  blood  collects  about  the 
teeth,  on  the  tongue,  etc.,  and  in  febrile  states  becomes  dry.  Dry 
incrustations  are  known  as  sordes. 

Salivation.  Increased  flow  of  saliva  occurs  in  all  inflammations 
unless  attended  by  high  fever.  It  may  be  constantly  discharged  by 
the  patient  or  dribble  in  a  continuous  stream.     (See  Saliva.) 

Secretions  of  the  Mouth.  The  Saliva.  The  saliva  is  derived  from  the 
parotid,  submaxillary,  and  sublingual  glands,  and  from   the  mucous 


688 


SPECIAL  DIAGNOSIS. 


glands  within  the  mouth.  The  mouth  should  be  washed  with  a  warm 
alkaline  solution  and  afterward  with  cold  water,  in  order  that  the  saliva 
obtained  may  be  perfectly  pure  for  examination.  After  the  washing  the 
glands  may  be  stimulated  by  the  application  of  dilute  acid  on  a  glass 
rod.  The  normal  amount  secreted  in  twenty-four  hours  varies  from 
two  to  three  pints.  It  is  of  a  light  bluish  color,  or  colorless.  It  is 
somewhat  stringy.  On  standing,  two  layers  form  in  a  conical  glass, 
the  upper  clear,  the  lower  cloudy.     The  reaction  of  saliva  is  alkaline. 

Microscopical  Examination.  The  following  formed  elements  are 
observed  :  1.  Salivary  corpuscles  of  the  appearance  of,  but  larger  and 
more  granular  than,  a  white  corpuscle.  2.  Epithelium.  The  squa- 
mous variety  derived  from  the  mouth  is  seen.  The  cells  are  large  in 
size  and  of  polygonal  shape.  3.  Fungi.  In  health  the  mould  and 
yeast  fungi  are  seldom  found.  In  disease  they  are  present  in  large 
numbers  ;  fission-fungi  are  met  with  in  great  numbers,  both  in  health 
and  in  disease.  In  health  small  and  large  colonies  of  micrococci  are 
found  along  with  abundant  bacilli.  Miller  has  studied  the  micro- 
organisms of  the  mouth  carefully  and  exhaustively  (see  The  Dental 
Cosmos),  both  by  microscopical  examination  and  culture-methods. 
The  following  are  found  to  be  pathogenetic  :  (1)  The  leptothrix  buc- 
calis  ;  ( 2)  vibrio  buccalis  ;  (3)  spirochete  dentium  ;  (4)  micrococcus 
tetragenus  ;  (5)  the  micrococcus  de  la  rage  ;  (6)  the  micrococcus  of 
sputum  septicaemia ;  (7)  the  bacillus  of  decaying  teeth,  three  varieties 
of  the  staphylococcus  ;  (8)  the  bacillus  crassus  sputigenus ;  (9)  the 
bacillus  salivarius  septicus  and  bacillus  septicus  sputigenus. 


Fig.  183. 


Buccal  secretion.  (Eye-piece  III.,  obj.,  Reichert,  1/15,  homogeneous  immersion  ;  Abbe  illumina- 
tion, open  condenser.)    FriedlSnder's  and  GUnther's  method.    (Von  Jaksch.) 

a,  epithelial  cells  ;  6,  salivary  corpuscles ;  c,  fat-drops  ;  d,  leucocytes ;  e,  spirochete  buccalis  ; 
/,  common  bacilli  of  mouth ;  g,  leptothrix  buccalis  ;  h,  i,  k,  different  fungi. 

Of  course,  in  the  saliva  the  thrush-fungus,  actinomyces,  the  tubercle 
bacillus,  and  the  bacillus  of  diphtheria  are  found.  It  must  not  be 
forgotten  that  the  diplococcus  pneumoniae  or  micrococcus  lanceolatus, 
which  is  the  specific  cause  of  pneumonia,  is  found  in  the  saliva  of  some 
persons  in  health.     It  is  also  called  the  bacillus  sputi  septicaemici. 

Chemical  Examination.  The  chemical  characters  of  the  secretion 
depend    upon  the  activity  of  the  different  glands.     The  saliva  con- 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,   (ESOPHAGUS.     689 


tains  a  trace  of  albumin,  found  by  heating  ;  a  ferment  which  changes 
starch  into  sugar ;  mucin  ;  and  occasionally  sulphocyanide  of  potas- 
sium. In  disease,  as  the  quantity  is  diminished  rather  than  increased, 
examinations  have  rarely  been  made.  In  ptyalism  the  saliva  should 
be  collected  after  rinsing  the  mouth  frequently,  especially  after  eating. 
The  reaction  is  found  to  be  alkaline,  and  the  specific  gravity  low,  1002 
to  1006.  Albumin  is  tested  for  by  the  usual  methods.  The  sulpho- 
cvanides  are  detected  by  a  solution  of  chloride  of  iron.  When  this  is 
added  to  the  fluid  a  bright  red  color  appears  which  does  not  disappear 
with  heat ;  a  similar  color,  due  to  the  precipitation  of  meconic  acid, 
may  be  obtained  by  the  same  test  from  the  saliva  in  opium-poisoning. 

Sugar  is  tested  for  by  the  methods  used  in  the  examination  of  the 
blood.  The  di astatic  ferment  is  detected  by  adding  5  c.cm.  of  saliva 
to  50  c.cm.  of  starch  solution  and  placing  the  mixture  in  a  warm 
chamber  or  a  water-bath  heated  to  40°  C.  After  an  hour's  time  the 
fluid  will  show  the  presence  of  grape-sugar.  Xitrites  are  detected  by 
adding  a  little  saliva  to  a  mixture  of  starch  paste,  iodide  of  potassium, 
and  dilute  sulphuric  acid.  If  the  nitrites  are  present,  a  blue  color 
results. 

Saliva  in  Disease.  In  catarrhal  stomatitis  the  secretion  is  in- 
creased. It  is  acid  and  contains  epithelium  in  excess.  In  ulcerative 
stomatitis  it  is  also  increased,  is  of  a  dark-brown  color,  foetid,  and  alka- 
line. It  contains  degenerated  epithelium,  leucocytes,  blood-corpuscles, 
and  many  forms  of  fungi.  It  is  increased  in  pregnancy,  in  rabies,  and 
in  glosso-labio-laryngeal  palsy.  I  have  seen  it  in  excess  in  the  con- 
valescence of  typhoid  fever.  It  is  increased  by  the  internal  use  of 
jaborancli. 

Fig.  184. 


■  ■■••Cp./a. -.■::'■-. 


^3 


O'idium  albicans,  the  vegetable  parasite  of  muguet  or  thrush.    (Reduced  from  Ch.  Robin.) 

The  reaction  becomes  acid  in  diabetes,  gout,  rheumatism,  and  mer- 
curial poisoning.  Urea  may  be  found  in  cases  of  nephritis,  particu- 
larly in  uraemia.  There  is  no  sugar  in  diabetes.  Fenwick  has  inves- 
tigated the  changes  in  the  sulphocyanide  of  potassium  in  disease.  By 
a  scale  of  colors  he  was  enabled  to  compare  the  saliva  in  which  sulpho- 
cyanide of  potassium  had  been  detected  in  health  with  the  saliva  in 
various  diseases.  He  believes  that  the  amount  of  this  ingredient  is 
indicative  of  the  degree  of  functional  activity  of  the  organs  of  nutri- 

44 


690  SPECIAL  DIAGNOSIS. 

tion.  It  is  increased  in  acute  inflammation  and  in  the  earlier  stages  of 
cancer  and  phthisis  ;  in  acute  congestion  of  the  liver  from  stimulants 
or  food  excess ;  and  in  rheumatism,  gout,  and  the  convalescence  of 
typhoid  fever.  Where  the  power  of  the  nutritive  organs  is  diminished 
the  sulphocyanide  of  potassium  is  lessened,  as  in  late  phthisis  and 
cancer,  the  later  stages  of  chronic  diarrhoea  and  dysentery,  chronic 
catarrhal  jaundice,  hi  ascites,  and  in  the  passive  congestion  of  the 
abdominal  viscera.  Fenwick  believes  that  tedious  recovery  and  fre- 
quent relapses  will  occur  if  this  element  is  found  in  excess  in  acute 
rheumatism. 

Thrush.  The  fungus  peculiar  to  this  disease  is  found.  Saliva  is 
increased  ;  it  is  usually  acid.  The  disease  is  characterized  by  the 
formation  of  small  patches  on  the  mucous  membrane,  which  in  a  few 
days  coalesce  and  form  a  mass  which  may  cover  the  entire  mouth  and 
extend  to  the  fauces.  Before  coalescing  they  are  firmly  adherent. 
Subsequently  they  loosen.  On  microscopical  examination,  in  addition 
to  epithelial  cells,  leucocytes,  and  unorganized  elements,  the  character- 
istic parasite  is  seen.  It  is  of  ribbon-shape,  varying  in  length,  and 
composed  of  long  segments  which  often  contain  highly  refractive  nuclei 
at  either  end.  The  segments  are  homogeneous  ;  they  vary  in  length, 
those  nearest  the  extremities  being  somewhat  shorter.  When  mounted 
in  glycerin  they  are  readily  seen.     Spores  are  also  seen. 

The  Leptothrix  Buccalis.  The  latter  is  seen  in  ribbon-like  bundles 
composed  of  numerous  segments  ;  it  stains  a  bluish-red  in  potassic  iodide 
solution.     It  is  most  frequently  seen  in  the  tartar  of  the  teeth. 


Fig.  185. 


f» 


/// 


Leptothrix  buccalis  from  the  gums  at  edges  of  teeth,    x  350. 
a,  the  filaments  separated  ;  b,  masses  of  filameuts. 

The  Gums.  The  gums  and  the  mucous  membrane  of  the  mouth  are 
involved  in  inflammations  and  ulcerations,  and  in  certain  metallic 
poisonings.     The  gums  swell  and  grow  spongy  in  inflammations. 

The  Gingival  Line.  In  cases  of  tuberculosis  a  red  line  at  the 
junction  of  the  gums  and  the  teeth  is  frequently  seen.  At  one  time  it 
was  thought  to  be  of  diagnostic  value.  It  is  seen,  however,  in  other 
cachectic  conditions,  as  carcinoma,  and  at  times  in  diabetes. 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,   CESOPHAGUS.     691 

The  Gums  in  Scurvy.  In  scurvy  the  gums  are  swollen  and  spongy. 
They  bleed  easily,  and  are  usually  streaked  with  blood.  Ulcers  form 
along  the  margin  of  the  teeth.  There  is  not  much  fcetor  of  the  breath. 
In  mild  cases  the  inflammation  may  be  limited  to  the  gums  of  four 
or  five  teeth.  The  gums  of  decayed  teeth  are  usually  the  seat  of  the 
most  marked  inflammation.  Infants  may  have  scurvy  as  well  as 
adults — especially  if  fed  exclusively  on  sterilized  milk  or  malt  prepa- 
rations.    (See  Scurvy-rickets.) 

The  Gums  in  Lead-poisoning.  The  Blue  Line.  In  lead-poisoning 
a  blue  line  is  seen  at  the  margin  of  the  gums.  The  line  is  preceded  by 
a  row  of  separate  black  dots  occupying  the  seat  of  the  papillae  of  the 
mucous  membrane.  If  examined  with  a  magnifying  glass,  the  line  is 
readily  seen  to  be  an  interrupted  one.  It  does  not  always  extend 
along  the  entire  margin,  but  may  be  limited  to  a  few  front  teeth  in  either 
the  upper  or  lower  jaw.  In  the  more  advanced  cases  there  is  some 
salivation  and  a  sweetish  metallic  taste  in  the  mouth  and  metallic  fcetor 
of  the  breath. 

The  Teeth.  In  all  diseases  of  the  gastro-intestinal  tract  it  is  im- 
portant to  investigate  the  state  of  the  teeth.  Cases  of  indigestion  are 
often  due  to  defective  mastication,  rendered  so  by  decayed  teeth.  Per- 
sistent aural,  nasal,  and  ophthalmic  affections  may  have  their  primary 
origin  in  disease  of  the  teeth.  Caries  of  the  teeth  may  cause  headaches 
or  neuralgias,  near  or  remote  (see  Headache),  and  may  explain  many 
cases  of  foul  breath.  Pitting  of  the  surface  of  the  teeth  and  thinning 
of  the  enamel  in  transverse  grooves  are  held  by  some  to  be  due  to  mer- 
cury. There  is  no  doubt  that  infantile  stomatitis,  independent  of  mer- 
cury, is  the  cause  of  these  changes.  They  must  be  distinguished  from 
the  so-called  Hutchinson's  teeth.  In  stomatitis  the  molars  are  often 
honeycombed  to  an  extreme  degree,  the  incisors  becoming  affected 
next.  In  addition  to  pitting  and  erosion  the  color  may  be  darker.  A 
transverse  furrow  crosses  all  the  teeth  at  the  same  level. 

The  Teeth  in  Gout.  Erosion  of  the  teeth  takes  place  in  gouty  sub- 
jects. There  are  wasting  and  loss  of  polish  of  the  labial  surface,  fol- 
lowed by  deep  grooves  which  extend  into  the  body  of  the  teeth. 
Pyorrhoea  alveolaris  is  another  expression  of  gout.  There  is,  first, 
usually  a  marginal  inflammation  of  the  gums  ;  second,  inflammation 
and  necrosis  of  the  pericementum  ;  third,  loosening  of  the  teeth  and 
the  formation  of  so-called  calculi. 

The  Teeth  of  Congenital  Syphilis.  The  upper  central  incisors  of  the 
permanent  set  are  affected.     They  are  dwarfed,  narrowed,  and  short. 

Fig.  186. 


Notched  teeth.    Malformation  of  permanent  teeth  found  in  hereditary  syphilis. 
(Me.  Jonathan  Hutchinson.) 

The  middle  lobe  of  the  tooth  is  so  atrophied  as  to  leave  a  single 
broad  vertical  notch  in  the  edge  of  the  tooth.     A  narrow  furrow  some- 


692 


SPECIAL  DIAGNOSIS. 


times  passes  upward  from  the  notch  on  both  anterior  and  posterior  sur- 
faces, nearly  to  the  gum.  It  is  seen  from  the  above  that  the  appear- 
ances of  the  permanent  teeth  may  be  an  index  of  the  condition  of 
nutrition  of  the  child  in  infancy. 

Teething.  During  the  period  of  infancy  it  is  well  to  remember 
the  influence  of  the  eruption  of  the  teeth  upon  the  general  constitution. 
While  many  prominent  authorities  believe  that  the  eruption  takes  place 
without  the  occurrence  of  general  or  reflex  symptoms,  equally  careful 
observers,  on  the  other  hand,  believe  that  nervous  phenomena  often 
attend  the  process.  The  latter  class  of  observers  attributes  the  fever- 
ishness,  insomnia,  restlessness,  loss  of  appetite,  and  gastro-intestinal 
disturbance  to  this  cause.  Convulsions  at  this  period  are  believed  to 
be  due  to  the  pressure  of  the  tooth,  which  cannot  break  through  the 
mucous  membrane,  upon  highly  sensitive  nerves  at  the  root.  Even  in 
later  life  reflex  convulsions  are  held  by  some  to  be  due  to  the  teeth. 

Slowness  in  the  development  of  the  teeth  may  be  due  to  rhachitis, 
which  should  be  looked  for.  The  student  should  be  familiar  with  the 
periods  of  development,  the  number  of  teeth  that  appear  at  each  period, 
and  the  date  of  the  eruption. 

Dates  of  Eruption  of  the  Teeth. 

Milk  Teeth. 


2  M    1C    41    1C    2  M 


2M    1C    41 
Eruption  of  central  incisors  about 
lateral  incisors      '' 
' '  first  molars 

"  canines 

' '  second  molars       ' ' 


1C    2M 


20 


7th  month.1 

9th  " 
15th  " 
18th  " 
24th       " 


Permanent  Teeth.. 
3M     2B     1C    41    1C    2B 


3M 


3M    2B     1C    41    1C    2B 

Eruption  of  anterior  molars  about 
"  central  incisors        " 

"  lateral  incisors         " 

' '  anterior  bicuspids   ' ' 

"  posterior  bicuspids  " 

' '  canines  ' ' 

"  second  molars  " 

third  molars  ( wisdom  teeth )  about 


3M 


32 

7th  year. 

8th     " 

9th  " 
10th  " 
11th  " 
11th     " 

12th  to  14th  year. 
18th  to  25th     " 


Stomatitis.  This  inflammation  is  not  limited  to  the  mouth  alone, 
but  extends  to  structures  within  the  mouth,  as  the  gums,  and  may 
invade  the  tongue.  The  inflammation  is  recognized  by  the  subjective 
and  objective  signs  common  to  such  inflammations.  There  is  pain, 
and  hence  the  child  (for  it  usually  occurs  in  children)  refuses  to  nurse 
or  take  the  bottle,  or  cries  when  food  is  given.  The  pain  is  accom- 
panied by  foetor  of  the  breath.  This  occurs  in  all  forms  of  stomatitis. 
Its  origin,  as  well  as  the  origin  of  the  pain,  is  readily  determined  by 
inspection. 

1  Lower  incisors  first. 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,  CESOPHAOUS.     693 

On  inspection  we  note  the  usual  signs  of  inflammation.  They  are 
rarely  general,  being,  as  a  rule,  localized  to  small  areas,  which  may 
rapidly  become  ulcerated.  When  general  the  mucous  membrane  is  red 
and  hot ;  the  color  extends  to  the  gums,  lips,  and  tongue.  This  is  seen 
in  the  catarrhal  form  ;  the  follicles  are  also  enlarged.  The  tongue  be- 
comes red  and  smooth,  or  may  be  covered  with  a  white  coating,  through 
which  the  prominent  red  fungiform  papilla?  project.  Accompanying  the 
inflammation  there  is  increased  secretion,  which  dribbles  from  the  mouth, 
or  is  constantly  discharged  by  older  patients.  The  red  hue  of  the  mucous 
membrane  is  attended  by  swelling.  The  heat  of  the  mouth  is  often  suffi- 
cient to  raise  the  temperature  of  the  exhaled  air,  so  that  the  breath  is  hot. 

A  peculiar  form  of  inflammation  of  the  mouth  is  seen  in  gouty  sub- 
jects. It  occurs  at  intervals.  Pain  is  not  so  marked,  but  the  heat, 
redness,  and  burning  are  associated  with  a  superficial  glossitis  and  sali- 
vation. The  saliva  is  highly  acid,  and  causes  a  dermatitis  on  the  chin. 
Other  mucous  membranes  are  involved  at  the  same  time,  as  the  vagina. 
An  acid  mucoid  discharge  sets  up  irritation  at  the  vaginal  outlet  and 
causes  much  distress. 

Aphthous  Stomatitis.  Local  areas  of  intense  inflammation  are 
sometimes  followed  by  ulceration.  Thus  in  aphthous  stomatitis  small 
yellowish-white  spots  appear,  at  first  discrete,  but  soon  dotted  over  the 
mucous  membrane  inside  of  the  cheeks,  in  the  roof  of  the  mouth,  along 
the  sides  of  the  gums,  and  on  the  tongue.  They  subsequently  break 
down  into  shallow  ulcers  with  raised  red  margins. 

Aphthous  ulceration  is  seen  in  foot-and-mouth  disease.  The  local 
process  is  characterized  by  greater  swelling,  with  softening  and  ulcera- 
tion of  the  soft  parts,  than  in  other  stomatitis.  In  foot-and-mouth 
disease  there  is  a  history  of  infection,  profuse  diarrhoea,  followed  by 
constipation,  and  considerable  physical  depression. 

Ulcerative  Stomatitis.  The  disease  occurs  in  ill-nourished  sub- 
jects, and  is  often  intercurrent  with  exhaustive  disease,  as  chronic  diar- 
rhoea. It  may  be  seen  in  epidemic  forms  in  camps  and  in  penal  and 
other  institutions,  on  account  of  unsanitary  conditions.  In  ulcerative 
stomatitis  the  inflammation  is  more  pronounceol  on  the  gums.  They 
are  swollen,  red,  and  covered  with  ulcers.  The  gums  in  which  teeth 
remain  are  affected,  and  the  ulcers  are  usually  at  the  gingival  border. 
Gums  without  teeth  are  not  affected.  The  ulcers  are  covered  with 
yellowish  material.  The  flow  of  saliva  is  much  increased  in  this  affec- 
tion. It  is  acid  in  reaction.  The  submaxillary  glands  are  enlarged. 
The  fcetor  of  the  breath  is  very  great. 

Parasitic  Stomatitis.  Thrush.  In  parasitic  stomatitis,  or  thrush, 
raised  white  patches  are  seen  looking  like  small  curds  of  milk.  The 
patches  vary  in  size,  and  on  the  tongue  may  cover  an  area  as  large  as 
a  three-cent  piece.  (See  page  690.)  The  white  patches  are  distinguished 
from  milk-curds  because  they  cannot  be  removed  by  the  napkin  or 
brush.  The  parasite  has  been  called  the  o'idium  albicans  (see  Fig.  184) ; 
but  Forchheimer  prefers  to  group  it  under  the  saccharomyces. 

Stomatitis  Materna.  Painful  ulcers  occur  in  the  mucous  mem- 
brane of  the  lips  and  cheeks  in  nursing- women.  They  are  solitary, 
and  interfere  with  mastication. 


694  SPECIAL  DIAGNOSIS. 

Gangrenous  Stomatitis.  The  affection  appears  as  a  gangrenous 
inflammation  of  the  gums,  mucous  membrane,  and  deeper  tissues  of 
the  cheek.  At  first  a  small,  dark  red,  hard  spot  is  seen,  which  in- 
creases in  size,  and  becomes  of  a  purplish  color.  The  cheek  rapidly  be- 
comes swollen,  tense,  and  brawny.  On  the  surface  of  the  more  indu- 
rated portions  a  bleb  forms  which  soon  breaks  with  rapid  ulceration. 
The  ulcer  is  dark  and  gangrenous  and  soon  perforates  the  cheek.  It 
extends  to  the  jaw  and  is  followed  by  necrosis  of  that  bone.  The 
characteristic  odor  of  gangrene  attends  the  process.  While  the  affec- 
tions previously  mentioned  are  generally  dependent  upon  poor  nutri- 
tion, gangrenous  stomatitis  is  always  secondary  to  depraved,  depressed, 
or  debilitated  states  of  the  system.  Cases  may  occur  simultaneously 
in  asylums  for  children  in  which  the  hygienic  conditions  are  bad  and 
the  food-supply  poor. 

Mercurial  Stomatitis.  Mercurial  stomatitis,  or  ptyalism,  par- 
ticularly affects  the  gums.  It  also  involves  the  salivary  glands. 
The  inflammation  is  caused  by  mercury.  It  may  occur  from  the 
medical  use  of  the  drug,  particularly  in  persons  who  are  unduly  sus- 
ceptible, or  are  not  particular  in  regard  to  mouth-cleansing.  The  in- 
flammation is  painful  and  attended  by  profuse  discharge  of  saliva, 
hence  the  name,  salivation.  The  tongue  is  swollen,  marked  on  the 
sides  by  the  teeth,  and  may  be  protruded  with  difficulty  on  account 
of  its  size.  It  is  tender  to  the  touch.  It  is  covered  with  a  heavy, 
creamy  coating.  The  gums  are  swollen,  red,  sore,  and  bleed  on  the 
slightest  touch.  Ulcers  along  the  border  occur,  may  become  diffused, 
and  in  some  instances  extend  to  the  jaw.  The  teeth  become  loosened. 
The  f oetor  of  the  breath  is  heavy,  offensive,  and  of  a  metallic  character. 
The  inflammation  is  usually  preceded  by  a  metallic  taste  in  the  mouth, 
and  the  patient  notices  pain  on  mastication,  which  increases  in  severity 
as  the  inflammation  develops.  In  mild  cases  it  is  limited  to  the  gums, 
in  others  the  tongue  and  salivary  glands  and  the  mucous  membrane  of 
the  mouth  are  affected. 

Leprosy.  This  affection  frequently  invades  the  mouth.  The  nod- 
ular and  ulcerative  lesions  are  seen.  It  is  always  associated  with  the 
characteristic  lesions  of  the  skin.  Scraping  or  sections  would  show 
the  characteristic  micro-organism. 

Glanders  may  invade  the  mouth  from  the  nasopharyngeal  space. 

Actinomycosis  results  from  the  entrance  of  the  ray-fungus  through 
carious  teeth  or  an  abraded  mucous  membrane.  Often  there  is  first 
disease  of  the  alveolus,  as  pyorrhoea,  or  a  periosteal  abscess ;  then  the 
jaw  is  involved.     Before  this  a  general  stomatitis  may  be  set  up. 

Ulcers.  In  addition  to  the  above  forms  of  ulcerative  stomatitis, 
solitary  ulcers  are  seen  in  herpes,  secondary  to  gastric  or  uterine  dis- 
turbances, and  syphilis.  The  herpetic  ulcers  are  of  frequent  occur- 
rence at  the  menstrual  period  or  during  the  course  of  lactation.  The 
tendency  to  their  formation  is  often  hereditary.  I  have  seen  them 
occur  at  the  menstrual  period  or  in  pregnancy  in  the  women  of  three 
generations.  In  the  secondary  stage  of  syphilis  mucous  patches  are 
seen  as  bright  red,  symmetrical,  oval,  or  crescentic  patches  or  erosions, 
occurring  on  the  mucous  membrane,  sometimes   on  the  tongue  and 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,  (ESOPHAGUS.     695 

fauces.     They  are  generally  covered  with  a  scanty  grayish-white  secre- 
tion, and  are  not  usually  painful. 

Sublingual  Ulcer.  This  form  occurs  on  the  frsenum  of  the  tongue. 
It  is  seen  in  whooping-cough,  and  is  due  to  the  rubbing  of  the  tongue 
against  the  teeth  in  the  act  of  coughing. 

Scleroderma.  This  rare  tropho-neurosis  occasionally  invades  the 
mouth.  It  is  characterized  by  a  submucous  infiltration  of  cartilaginous 
hardness,  the  surface  of  which  is  denuded  of  epithelium  or  covered 
with  crusts.  The  invasion  comes  from  the  nostrils  or  the  nasopharynx. 
Later  the  infiltration  changes  to  a  yellowish-red  or  a  tendinous-like 
scar. 

The  Tongue. 

Examination  of  the  tongue  is  made  for  diagnostic  purposes  with  a 
greater  show  of  wisdom  on  the  part  of  the  examiner,  and  greater  satis- 
faction to  the  patient,  but  with  less  satisfactory  results  from  a  diag- 
nostic stand-point,  than  the  examination  of  any  other  portion  of  the 
body.  The  mucous  membrane  of  the  tongue  is  examined  because  it 
is  the  only  mucous  membrane  of  the  body,  except  the  oral  and  faucial, 
which  is  open  to  inspection,  and  is,  therefore,  supposed  to  enable  us  to 
judge  of  the  effects  of  general  diseases  upon  mucous  membranes.  It 
is  thought  to  be  indicative  of  disorders  of  the  gastro-intestinal  tract 
because  of  its  relations  with  it,  but  recent  studies  by  Hutchinson, 
Butlin,  and  other  observers  have  resulted  in  the  promulgation  of  differ- 
ent views.  Both  the  above-mentioned  distinguished  gentlemen  are 
surgeons,  and  look  upon  the  tongue  as  a  local  organ.  Investigating 
it  as  such,  they  concluded  that  the  changes  in  the  coating,  which  had 
been  considered  to  have  so  much  clinical  significance,  depended  largely 
upon  parasitic  invasion,  and  were  not  due  to  changes  in  the  epithelium. 
The  parasitic  invasion,  they  hold,  is  largely  dependent  upon  local  con- 
ditions, which,  it  is  true,  are  on  their  part  dependent  upon  a  state  of 
the  system.  Since  the  writings  of  Hutchinson  and  Butlin,  Dickin- 
son returned  to  the  investigation  on  the  lines  laid  doAvn  by  older 
teachers,  and  has,  in  a  measure,  restored  the  tongue  to  its  original 
position  as  a  diagnostic  feature  in  an  estimation  of  the  state  of  the 
general  system  and  in   diseases  of  the  gastro-intestinal  tract. 

We  study  the  tongue  to  ascertain  its  color ;  the  character  of  erup- 
tions if  they  are  present ;  the  occurrence  of  indentations,  excoriations, 
furrows,  or  fissures  ;  the  occurrence  of  ulcers  and  of  patches.  Plaques, 
nodes,  and  nodules  are  also  seen  on  the  tongue.  Inflammation  of  the 
tongue  occurs,  and  it  is  the  seat  of  atrophy  and  hypertrophy  and  of  the 
various  tumors  in  the  parasitic  diseases.  The  movements  of  the  tongue 
are  also  observed,  as  an  indication  of  the  power  of  muscles  which  are 
under  centric  influence  closely  related  to  important  centres  in  the 
medulla  oblongata.  Surgical  affections  of  the  tongue  will  not  be  con- 
sidered ;  local  affections  will  only  be  referred  to  in  connection  with 
general  diseases. 

Discolorations  of  the  Tongue.  Yellowish-white,  oblong  patches, 
soft,  but  slightly  raised,  are  sometimes  seen  along  the  sides  of  the 
tongue — xanthelasma.    They  are  sharply  defined,  and  vary  in  size  from 


& 


696  SPECIAL  DIAGNOSIS. 

a  split  pea  to  a  three-cent  piece.  Xanthelasma  is  also  situated  upon 
the  eyelids  and  upon  the  palms  of  the  hands,  rarely  in  other  portions 
of  the  body.  It  occurs  in  jaundice,  or  in  persons  who  are  said  to  be 
subject  to  bilious  attacks. 

Pigmentations.  Dark  purple,  bluish-black,  or  black  marks  are 
seen  on  the  tongue  as  well  as  on  the  surface  of  the  lips,  where  they 
may  be  brown.  They  are  sharply  denned,  neither  raised  nor  de- 
pressed, and  vary  in  size.  Such  pigmented  spots  are  seen  after  glos- 
sitis and  in  Addison's  disease.  In  the  latter  affection  other  pigmented 
areas  are  found.  Blood-stains  are  observed  in  purpura.  Bright  red 
spots  the  size  of  a  split  pea  or  larger,  patches,  known  as  ecchymoses, 
are  of  frequent  occurrence.  They  are  not  removed  by  pressure. 
Hemorrhagic  infarcts  are  sometimes  seen  on  the  tip  of  the  tongue. 

Black  Tongue.  This  rare  condition  is  of  parasitic  origin.  It  has 
recently  been  described  anew  by  Cohen.     It  is  also  known  as  nigrities. 

The  affected  portion  is  of  a  brownish-black  or  black  color,  varying 
in  size  and  usually  situated  in  the  middle  of  the  dorsum  of  the  tongue. 
It  looks  like  an  iron-stain,  and  in  some  instances  the  surface  is  rough- 
ened. The  papilla?  are  abnormally  enlarged.  It  usually  begins  as  a 
small  spot,  and  extends  slowly,  so  that  at  the  end  of  a  month  the 
dorsum  is  covered.  The  centre  is  blacker  than  the  circumference. 
After  the  entire  dorsum  is  covered  the  spot  begins  to  disappear  from 
the  circumference  toward  the  centre,  and  is  followed  by  desquamation. 
This  series  of  phenomena  is  repeated  and  the  entire  affection  subsides 
slowly.  Desquamation  may  last  from  a  few  days  to  two  months.  The 
papillae  of  the  affected  surface,  too,  look  like  "  a  field  of  corn  laid  by 
the  wind  and  rain."  The  sensations  of  taste  and  touch  are  not  altered, 
but  a  feeling  of  dryness  is  marked.  It  must  be  remembered  that 
a  black  tongue  is  sometimes  the  result  of  deliberate  deception. 

Inflammation  of  the  Tongue.  Acute  glossitis  is  a  rare  affection, 
more  common  in  adults  than  in  children,  and  more  frequent  in  men  than 
in  women.  It  occurs  more  frequently  in  the  summer.  The  onset  is  rapid. 
After  a  short  period  of  tenderness  on  mastication  the  movements  of  the 
tongue  are  stiff  and  painful,  or  there  are  pains  in  the  muscles  of  the  neck 
and  submaxillary  region.  In  a  few  hours  the  tongue  swells.  It  rapidly 
increases,  and  at  the  end  of  fifteen  to  twenty  hours  is  three  times  its 
natural  size,  protrudes  from  the  mouth,  is  indented  by  the  teeth,  and 
is  almost  immovable,  feeling  heavy,  painful,  and  tender.  It  is  coated 
with  a  thick  fur  on  the  dorsum.  Salivation  accompanies  these  symp- 
toms, speech  is  impossible,  dysphagia  extreme,  and  dyspnoea  not  un- 
usual. The  glands  underneath  the  jaw  are  swollen.  The  temperature 
rises  to  101°,  rarely  above  it,  even  if  the  case  is  severe.  Death  may 
occur  in  a  few  hours  from  suffocation,  or  after  a  longer  interval  from 
diffuse  suppuration,  gangrene,  exhausting  septic  fever,  or  pneumonia. 
Gangrene  is  more  frequent  than  spontaneous  resolution.  If  resolution 
is  to  be  established,  the  swelling  begins  to  subside  in  three  or  four 
days.  Small  ulcers  form  on  the  surface  of  the  tongue,  and  by  the  end 
of  a  week  its  normal  appearance  is  regained.  The  fever  and  distress- 
ing symptoms  subside  with  the  local  swelling.  It  is  said  to  be  due  to 
colds,  to  bites  and  stings  of  animals,  to  mercury,  and  to  corrosive  and 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,    (ESOPHAGUS.     697 

acrid  substances.  It  may  occur  in  fevers.  The  diagnosis  is  easy.  It 
must  be  distinguished  from  acute  oedeniatous  swelling  due  to  salivary 
calculus  or  affections  of  the  floor  of  the  mouth.  Acute  ranula  some- 
times causes  considerable  swelling  of  the  tongue,  simulating  acute 
glossitis.  JSemiglossitis  sometimes  occurs.  The  local  symptoms  are 
not  so  great,  because  only  half  of  the  mouth  is  occluded.  I  saw  a  case 
in  which  the  inflammation  was  limited  to  half  the  side  of  the  tongue 
on  the  posterior  surface.  It  went  on  to  suppuration,  but  was  not 
attended  by  serious  symptoms,  except  discomfort  in  eating.  It  was 
preceded  by  a  definite  nodule  in  the  substance  of  the  inflamed  part. 
Glossitis  from  mercurial  poisoning  has  been  described  in  connection 
with  stomatitis. 

Chronic  superficial  inflammation  of  the  tongue  may  also  occur.  The 
surface  is  smooth  and  deprived  of  papilla?  over  the  affected  area,  which 
is  redder  than  natural.  The  margin  of  the  raw  patch  is  sharply  de- 
fined, but  the  area  has  no  depth.  The  epidermis  alone  is  removed. 
When  associated  with  dyspepsia  it  covers  a  considerable  area  of  the 
surface  of  the  tongue.  The  tongue  may  be  deprived  of  papilla?  on  the 
anterior  part  of  the  dorsum  while  the  fungiform  papilla?  remain.  The 
tongue  is  enlarged  and  the  borders  marked  by  the  teeth.  The  surface 
looks  glossy.  The  tongue  feels  stiff  and  uncomfortable.  Movement  is 
irksome,  irritating  foods  are  painful.  Spirits  and  tobacco  cause  dis- 
tress. Indiscretions  in  diet  and  slight  traumatism  quickly  produce 
fresh  inflammation.  One  observer,  Hack,  has  described  a  form  of 
glossitis  hereditary  and  peculiar  to  women.  He  observed  a  row  of  long, 
oval  areas,  caused  by  previous  inflammation.  They  commenced  in  early 
childhood.  The  tongue  was  smooth  over  remaining  large  areas,  with 
red  excoriations  here  and  there.     There  was  no  syphilis. 

Sequelce  of  glossitis.  Indentations  occur  when  the  tongue  is  swollen, 
as  in  mercurial  and  other  forms  of  glossitis.  The  borders  of  the  tongue 
are  indented  by  the  pressure  of  the  teeth.  But  in  states  of  debility 
a  flabby  tongue  with  indented  borders  is  often  seen.  Sometimes  the 
swelling  is  so  great  that  the  pressure  of  the  teeth  causes  ulceration. 

Furrows,  or  grooves  and  wrinkles,  are  seen  on  the  dorsal  aspect 
of  the  tongue.  They  are  not  necessarily  tokens  of  disease  ;  hi  many 
persons  they  are  of  constant  occurrence.  Furrows  vary  from  a  few 
lines  to  an  inch  or  more  in  length.  In  many  this  is  most  striking  in 
the  middle  line  of  the  tongue.  The  median  furrow  is  liable  to  become 
ulcerated  on  slight  provocation.  The  edges  of  the  fissures  are  smooth 
and  without  papilla?  or  fur.  Other  furrows  are  directed  horizontally 
and  vary  in  depth.  They  may  be  curved  and  forked.  They  are  more 
frequent  in  older  persons,  especially  if  the  tongue  is  too  large  to  lie 
within  the  circle  of  the  teeth.  They  are  an  evidence  of  past  inflamma- 
tion, or  rarely  of  hypertrophy.  They  resemble  the  median  furrows  as 
regards  smoothness  and  absence  of  fur.  Inflammatory  furrows  occur 
in  chronic  superficial  inflammation,  but  more  commonly  after  chronic 
inflammation  which  has  left  the  tongue  enlarged.  The  furrows  are 
sometimes  so  abundant  that  the  surface  of  the  tongue  looks  like  the 
eyelid.  The  raised  areas  become  sore,  due  to  irritation  of  a  foreign 
body  (food)  or  a  tooth.     They  are  an  indirect  result  of  inflammation. 


698  SPECIAL  DIAGNOSIS. 

True  inflammatory  furrows,  described  as  dissecting  glossitis  by  Wun- 
derlich,  occur.  Dissecting  glossitis  is  only  a  more  aggravated  form  of 
superficial  glossitis.  Furrows  of  this  character  may  be  due  to  syph- 
ilis, and  dissecting  glossitis  sometimes  has  a  syphilitic  origin.  Fissures 
and  clefts  are  frequently  caused  by  the  rubbing  and  deep  indentation 
of  a  rough  and  jagged  tooth.  The  area  around  the  fissure  is  inflamed 
and  its  base  indurated.  The  sides  and  bottom  are  ulcerated.  It  is 
recognized  by  its  relation  with  the  offending  tooth.  It  may  be  mis- 
taken for  syphilis,  another  common  cause  of  fissures. 

Syphilitic  Lesions.  It  must  be  remembered  that  the  tongue  is 
always  predisposed  to  inflame  and  ulcerate  in  syphilis.  In  secondary 
syphilis  fissures  are  always  found  on  the  borders  of  the  tongue  ;  they 
are  almost  certain  to  occur  if  the  teeth  irritate  the  border.  They  may 
be  due  to  the  ulceration  of  a  mucous  tubercle  which  is  developed  upon 
the  border  of  the  tongue.  The  ulcer  is  stellate,  and  gradually  deepens 
until  it  becomes  a  foul  fissure.  Two  processes  cause  the  ulceration — 
the  specific  infection  and  the  irritation  of  the  teeth.  Syphilitic  ulcers 
are  not  very  angry,  as  are  non-syphilitic  sores  and  fissures  which  may 
occur  in  persons  in  poor  health.  They  may  be  sensitive,  however,  on 
account  of  the  involvement  of  the  tongue.  The  absence  of  active  in- 
flammation, the  large  number  of  sores  and  fissures,  and  the  associa- 
tion with  other  lesions  of  the  disease  upon  the  tongue,  cheeks,  and  lips 
point  to  their  syphilitic  origin.  Tertiary  syphilitic  ulcers  are  more 
pronounced  and  deeper  than  other  forms.  They  may  be  as  long  as 
two  or  three  inches  ;  they  are  sinuous  and  branched.  Gummata  may 
occur  on  the  tongue  at  the  same  time.  The  gummata  may  be  circum- 
scribed or  linear,  and  may  break  down  and  ulcerate.  Sclerosis  of  the 
tongue,  as  described  by  Fournier,  follows  the  healing  of  these  ulcers. 
It  is  curious  to  note  that  the  lymphatic  glands  are  seldom  enlarged  in 
association  with  syphilitic  fissures.  The  fissures  must  be  distinguished 
from  carcinoma  and  tuberculosis.  In  carcinoma  there  is  a  distinct 
tumor,  which  may  become  fissured.  Tuberculous  ulceration  is  a  sign 
of  the  presence  of  tubercle  in  other  organs.  The  tuberculous  fissures 
are  small,  at  first  single  ;  tubercle,  however,  rarely  begins  as  a  fissure, 
but  as  tuberculous  ulcers  on  the  tip  or  borders  of  the  tongue.  They 
are  stellate  or  irregularly  branched.  They  are  shallow  at  first,  and 
deepen  later,  but  do  not  widen  in  a  corresponding  manner.  The 
lymphatic  glands  are  always  involved.     (See  Tuberculous  Ulcer.) 

Ulcers  of  the  Tongue.  They  may  be  simple,  aphthous,  or  trau- 
matic. Simple  ulcers  follow  long-standing  superficial  glossitis.  They 
form  in  the  centre  of  vthe  tongue,  or  of  the  inflammatory  area. 
They  are  due  to  sloughing,  or  simple  melting  away  of  epithelium. 
The  ulcer  is  smooth,  red,  glazed  on  the  surface.  The  edges  are  callous 
and  inactive,  and  the  shape  irregular.  It  is  sensitive,  and  may  be  pain- 
ful. The  signs  of  chronic  glossitis  continue  with  it.  Dyspeptic  or 
catarrhal  ulcers  occur  on  the  tip,  or  on  the  dorsum  near  the  tip.  The 
dorsum  of  the  tongue,  from  the  tip  backward,  is  very  red,  and  filiform 
papillae  are  absent.  The  ulcers  are  small  and  superficial  without  defi- 
nite shape  or  character,  except  that  they  are  red  and  irritable.  Dys- 
peptic ulcers  may  occur  from  the  breaking  down  of  vesicles  on  the 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,  CESOPHAGUS.     699 

tongue.  They  are  small,  circular,  well-defined  ulcers,  with  sharp-cut 
edges,  in  size  from  a  pin's  head  to  a  split  pea,  and  are  the  source  of 
considerable  pain  and  much  annoyance.  They  are  recurrent.  Saliva- 
tion may  attend  them.  Aphthous  ulcers  are  seen  in  children  and  adults, 
and  when  multiple  are  attended  with  the  same  symptoms  as  aphthous 
ulcers  of  the  mouth,  with  slight  fever.  Foetor  is  characteristic.  When 
single  they  occur  with  indigestion,  or  in  women  at  the  menstrual  period. 
The  tendency  to  their  formation  is  inherited.  Traumatic  ulcers  from 
sharp  teeth  may  persist  a  long  time  if  the  general  health  is  bad.  When 
indolent  they  may  be  mistaken  for  syphilitic,  tuberculous,  or  cancer- 
ous ulcers.  The  rapidity  of  formation,  the  location  opposite  a  rough 
tooth,  and  the  absence  of  other  signs  of  syphilis  point  to  the  true 
nature  of  the  ulcer.  Chancre  can  be  excluded  by  the  greater  hard- 
ness and  circumscription  of  the  lesion,  its  seat  near  the  tip,  and  its 
association  with  enlargement  of  the  lymphatic  glands.  The  latter  is 
not  present  in  traumatic  ulcer,  unless  it  is  acute  and  angry.  Traumatic 
ulcer  is  distinguished  from  tuberculous  ulcers  by  the  absence  of  signs 
of  tubercle  in  other  organs  and  by  the  result  of  an  examination  of  the 
scrapings  of  the  ulcer  ;  from  cancer  by  the  age.  In  cancer  all  the 
glands  become  affected  later. 

Excoriations  on  the  surface  of  the  tongue,  or  rawness,  arise  from 
injury,  and  may  also  be  seen  in  dyspepsia. 

Tubeeculous  Ulceb.  The  tuberculous  ulcer  presents  an  uneven, 
pale,  flabby  surface,  covered  with  a  yellowish-gray  viscid  or  coagulated 
mucus.  The  edges  are  sometimes  sharp-cut,  sometimes  bevelled, 
seldom  elevated.  They  are  not  usually  very  red.  There  is  but  little 
surrounding  inflammation,  and  the  adjacent  portions  of  the  tongue  are 
but  slightly  swollen.  The  borders  of  the  ulcer  may  be  sinuous,  and 
the  shape  oval  or  ovoid,  or  elongated.  In  the  neighborhood  of  an 
ulcer  a  number  of  tiny  yellowish  gray  points  may  be  observed.  The 
ulcer  is  painful,  and  attended  by  salivation.  I  saw  in  the  Philadelphia 
Hospital  a  case  of  tuberculous  ulcer  of  the  tongue,  in  a  young  man 
twenty-five  years  of  age,  with  pulmonary  and  intestinal  tuberculosis. 
The  dorsum  of  the  tongue  was  covered  with  a  dozen  ulcers,  with  sharp- 
cut  edges  and  pale,  flabby  granulations,  without  induration  or  inflam- 
mation around  them.  They  were  yellowish-gray,  and  tubercle  bacilli 
were  found  in  the  scrapings.  Tuberculous  ulceration  must  always  be 
carefully  distinguished  from  syphilitic  and  cancerous.  The  associate 
symptoms  are  often  most  reliable.  Ulcers  due  to  lupus  are  also  seen 
upon  the  tongue. 

Patches  and  Plaques.  Space  forbids  further  consideration  than 
the  naming  of  the  plaques  which  are  seen  on  the  tongue.  First,  there 
is  the  smoker's  patch,  on  the  middle  of  the  dorsum  about  the  point 
where  the  tobacco-pipe  rests,  or  where  the  stream  of  smoke  from  the 
pipe  or  cigar  strikes  the  tongue.  This  is  a  slightly  raised  area  of  oval 
shape.  It  is  not  ulcerated,  but  is  smooth  and  red,  or  livid.  Some- 
times it  is  bluish-white  or  pearly  in  appearance.  The  smoothness  is 
characteristic.  White  and  bluish-white  patches  or  plaques  are  seen  in 
leucoma,  leucoplakia,  ichthyosis,  keratosis,  and  are  also  known  as  opaline 
plaques.     The  smoker's  patch  belongs  to  the  same  class,  and  is  proba- 


700  SPECIAL  DIAGNOSIS. 

bly  an  early  stage  of  these  affections.  It  is  a  whiteness,  or  white 
opacity  of  the  surface  of  the  tongue,  usually  on  the  dorsum.  It  is 
almost  always  the  result  of  the  direct  action  of  irritants.  These  patches 
are  unknown  under  twenty  years  of  age,  do  not  commence  after  sixty, 
and  very  rarely  attack  women.  They  are  not  attended  by  subjective 
symptoms  usually.  There  may  be  a  sensation  of  induration  and  dry- 
ness.    The  course  is  always  chronic. 

Wandering  Rash.  Ringworm,  or  circular  exfoliations — the  geo- 
graphical tongue — occurs  most  frequently  in  children.  One  or  more 
patches  on  the  dorsum  of  the  tongue  are  observed,  smooth  and  red, 
but  not  depressed  or  elevated.  The  filiform  papillae  have  been  shed. 
The  patch  spreads  and  becomes  a  ring,  circular  or  oval.  The  border 
is  faintly  or  decidedly  yellow,  and  usually  slightly  raised  and  sharply 
defined.  The  circles  may  widen  and  contract  from  time  to  time.  No 
subjective  symptoms  are  noted  except  itching  in  a  few  cases.  The 
cause  is  not  known.  The  diagnosis  is  easy.  It  may  continue  for 
months  or  years. 

Mucous  patches  are  multiple  lesions  of  syphilis  in  the  mucous 
membrane.  They  have  been  referred  to  in  the  section  on  Diseases  of 
the  Mouth. 

Eruptions.  Eruptions  of  variola,  measles/  and  erysipelas  are  seen 
on  the  tongue.  Herpes  and  aphthous  ulcers,  preceded  by  vesicles,  are 
met  with  on  the  surface  of  the  tongue. 

Nodes.     Nodules  in  the  tongue  are  always  tuberculous  or  syphilitic. 

Atrophy.  Atrophy  of  the  tongue  is  very  unusual.  Hemiatrophy 
may  occur  as  the  effect  of  central  or  peripheral  causes,  as  softening, 
hemorrhage,  or  tumors  of  the  region  of  the  hypoglossal  nucleus.  Other 
centres  near  the  nucleus  are  affected,  hence  other  forms  of  paralysis  are 
seen,  due  to  the  lesions  of  the  medulla.  These  are  seen  in  progressive 
muscular  atrophy  and  bulbar  paralysis,  and  in  cases  of  hemiplegia. 
It  is  not  difficult  to  recognize  it  on  inspection.  The  functions  of  the 
tongue  are  not  affected. 

Hypertrophy.  Enlargement  of  the  tongue,  or  macroglossia,  is  gen- 
erally congenital,  but  may  occur  late  in  life.  The  tongue  enlarges,  and 
is  accompanied  by  pressure  symptoms  due  to  such  enlargement. 
Hypertrophy  of  the  tongue  is  sometimes  seen  in  idiots  and  cretins. 
The  hypertrophy  is  more  frequently  the  result  of  lymphatic  obstruc- 
tion, on  account  of  which  there  is  lymph-stasis.  The  diagnosis  is  easy. 
Inflammatory  hypertrophy  occurs  in  stomatitis,-  and  syphilitic  hyper- 
trophy occurs  with  gummata. 

Cysts.  Various  cysts  occur  in  the  tongue.  Mucous  cysts  and 
blood-cysts  are  the  most  common.  The  cysticercus  cellulosse  and  the 
echinococcus  occur  rarely.  Ranula  is  a  cyst  underneath  the  tongue 
that  causes  suffering  from  mechanical  obstruction.  It  is  easy  of  recog- 
nition. 

Parasitic  Disease.  Thrush  is  the  most  common.  Other  infections 
of  the  mouth  extend  to  the  tongue  in  most  instances. 

The  Tongue  in  General  and  Remote  Disease.  The  Coating. 
With  a  view  to  estimate  the  condition  of  the  system  in  general  by 
the  appearances  of   the  tongue,   excluding   all  local   conditions,  the 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,  (ESOPHAGUS.     701 

following  characteristics  are  observed  :  First,  the  color ;  second, 
the  fur  ;  third,  the  degree  of  moisture  ;  and,  fourth,  the  movements. 
The  student  should  bear  in  mind  that  changes  in  the  condition  of 
the  tongue  are  frequently  of  local  origin ;  that  dryness,  for  in- 
stance, may  be  due  to  the  open  mouth,  or  that  a  coating  may  be 
unusually  marked  because  the  tongue  had  not  been  used  in  mastica- 
tion. Often  coating  is  seen  on  one  side  of  the  tongue.  This  has  been 
referred  to  as  due  to  disease  of  the  nerves  of  one  side.  It  is  just  as 
likely  to  be  due  to  an  absence  of  mastication  on  that  side,  of  the  mouth, 
the  bolus  of  food  being  kept  on  the  other  side  because  of  pain,  diseased 
teeth,  or  other  local  cause. 

Clinical  experience  has  shown  that  certain  conditions  in  the  tongue 
are  associated  with  certain  general  conditions  which  render  the  appear- 
ance somewhat  diagnostic.  The  term  diagnostic  must  be  qualified, 
because  the  changes  are  so  often  local,  or  are  modified  by  conditions 
independent  of  the  general  system.  For  convenience,  the  classification 
of  Dickinson  as  to  the  appearance  of  the  tongue  in  disease  may  be 
utilized.  In  the  Lumleian  lectures  this  eminent  authority  described 
the  average  healthy  tongue  based  on  extensive  observations.  Depart- 
ures from  the  normal  were  arranged  and  afterward  classified.  It  re- 
sulted in  the  formation  of  eleven  classes  : 

1.  The  Stippled  or  Dotted  Tongue.  The  tongue  is  moist  and 
dotted  with  little  white  points,  due  to  an  excess  of  white  epithelium 
on  the  papillae.  It  is  usually  seen  in  persons  in  poor  health  without 
fever.  It  is  not,  therefore,  a  febrile  tongue,  nor  one  indicative  of 
grave  constitutional  disease.  It  is  seen  in  cases  of  chronic  disease, 
usually  one  in  which  there  are  no  grave  symptoms. 

2.  The  Dry  Stippled  Tongue.  This  is  found  in  mildly  acute  dis- 
eases, or  in  cases  in  which  the  constitutional  disturbance  is  more  marked. 

3.  The  Stippled  and  Coated  Tongue.  The  patients  in  whom 
this  is  found  are  very  frequently  the  subjects  of  acute  and  constitu- 
tional affections.  Fever  is  more  frequently  present  with  this  variety 
of  fur. 

4.  The  Coated  Tongue.  There  is  excess  of  white  epithelium  on 
the  papillae,  and  the  coat  is  continuous.  The  intervals  between  the 
papilla?  are  more  commonly  filled  up  with  epithelium  and  accidental 
matters  than  in  the  preceding  types.  It  is  seen  in  acute  and  febrile 
diseases,  and  whether  moist  or  dry,  in  pneumonia,  pleurisy,  and  typhoid 
fever.  It  is  associated  with  a  far  greater  degree  of  prostration  and 
pyrexia,  while  the  saliva  is  absent  in  the  larger  proportion  of  cases. 

5.  The  Strawberry-tongue.  The  tongue  is  coated  and  injected  ; 
the  fungiform  papillae  shine  through  the  coat,  particularly  at  the  tip 
and  edges.  It  is  the  tongue  of  scarlet  fever,  but  may  often  be  seen  in 
any  acute  febrile  disorder.  In  scarlet  fever,  however,  it  appears  by 
the  second  or  third  day — most  marked  after  the  second.  Pyrexia  is 
more  common  in  this  class  than  in  the  preceding. 

6.  The  Plaster-tongue.  A  thick,  uniform  coat,  edges  abrupt 
and  striking,  covers  the  tongue.  The  papillae  are  elongated  and  the 
intervals  crowded  with  accumulations,  among  which  are  bacteria  ;  it 
is  the  tongue  of  acute  febrile  disease.     Fever  was  marked  in  a  number 


702  SPECIAL  DIAGNOSIS. 

of  cases  Dickinson  studied,  and  prostration  was  a  common  attendant. 
Saliva  was  deficient. 

It  is  thus  seen  that,  beginning  with  the  healthy  tongue,  Dickinson 
described  a  series  of  groups,  in  each  succeeding  one  the  coating  becom- 
ing more  marked,  with  or  without  moisture.  The  clinical  association 
that  he  found  is  a  common  experience.  Each  successive  group  was 
attended  by  more  fever,  greater  exhaustion,  and  less  saliva  than  the 
preceding  group,  and  in  each  the  tongue  became  more  and  more  furred. 

7.  The  Furred  or  Shaggy  Tongue.  When  moist  the  papilla? 
are  greatly  elongated,  composed  mostly  of  horny  epithelium.  It  has 
the  same  appearance  as  if  the  tongue  were  dry.  The  moist,  furred 
tongue  is  not  so  common  as  the  other.  It  is  most  commonly  seen  in 
old  age  and  in  constipation.  The  dry,  furred,  or  shaggy  tongue  may 
succeed  the  dotted  tongue  or  the  coated  tongue  in  the  course  of  ad- 
vancing disease.  It  is  the  result  of  disease  and  want  of  moisture. 
The  saliva  is  deficient ;  it  indicates  that  there  has  been  fever,  and  that 
possibly  but  little  food  was  taken. 

8.  The  Incrusted,  Dry  Brown  Tongue.  Over  the  surface  of 
the  tongue  there  is  a  dry,  thick,  felted  coat,  which  is  continuous  and 
dips  down  between  the  papilla?.  The  coat  is  largely  made  up  of  para- 
sitic material.  In  the  course  of  fevers  it  is  the  outcome  of  a  preceding 
condition,  the  coated  tongue,  and  is  indicative  of  the  typhoid  state.  It 
occurs  in  the  fevers  with  high  temperature,  but  may  be  seen  in  condi- 
tions of  low  temperature,  as  from  cancer,  phthisis,  albuminuria,  chronic 
nervous  diseases.  There  is  much  depression  or  prostration  associated 
with  it,  and  there  is  absence  of  saliva.  If  the  patients  with  a  dry 
brown  tongue  recover,  it  retrogresses  to  the  furred  or  incrusted  tongue, 
which  in  turn  becomes  bare  gradually,  at  first  in  small  layers  ;  the  latter 
is  thin,  usually  dry,  but  is  more  moist  than  the  dry  brown  tongue. 
As  the  incrustation  disappears  it  may  become  bare,  red,  and  dry. 

9.  The  red  dry  tongue  indicates  a  more  serious  condition  usually 
than  the  dry  and  brown.  It  is  the  tongue  of  chronic  wasting  diseases. 
It  occurs  in  phthisis  in  the  later  stages,  and,  as  the  raw-beef  tongue,  is 
associated  with  dysentery  and  also  with  liver  abscess.  There  may  be 
fever  associated  with  the  cases.  It  is  in  a  measure  the  tongue  of 
chronic  diarrhoea.  The  tongue  is  shrunken,  red,  polished,  and  smooth. 
The  papilla?  have  disappeared  and  the  epithelium  is  stripped  off  in 
patches.  It  may  be  associated  with  aphtha?.  If  the  patient  is  to  im- 
prove, the  redness  fades,  the  papillae  become  softer,  and  the  moisture 
returns. 

10.  Red  and  Membranous  ;  otherwise  as  (9)  the  red  denuded 
tongue. 

11.  Cyanosis,  or  Venous  Congestion  of  the  Tongue.  The 
tongue  is  of  a  bluish  or  purplish  color,  the  surface  is  smooth  and  wet, 
and  the  papilla?  are  almost  indistinguishable.  It  is  not  confined  to 
organic  heart  disease  or  cyanosis.  It  is  of  quite  frequent  occurrence 
in  albuminuria.  With  the  venous  congestion  in  the  albuminuric  cases 
there  is  always  a  superabundance  of  deep  epithelium.  When  the  sur- 
afce  is  examined  it  looks  as  if  the  papilla?  were  fused  together  and 
overlaid  by  a  moderate  coat. 


DISEASES  OF  MO  UTH,  FA  UOES,  PHAR  YNX,  (ESOPHA  G  US.     703 


Classification  op  Tongues. 


To  the  naked  eye. 
1.  Healthy,  moist. 

Microscopically. 

White  epithelium  in  small  amount  on  papilla?,  not 
continuous  or  superabundant. 

2.  Stippled,  moist,   dotted   with 
white. 

2  (D).1  Stippled,  dry. 

Excess  of  white  epithelium  on  papilla?,  not  extend- 
ing between  them. 
Ditto. 

3.   Stippled  +  coated  ;    moist. 
Coat  continuous  in  parts. 

White  epithelium  on  papilla?  in  excess,  with  partial 
filling  of  intervals. 

4.  Coated   white ;    moist.     Coat 
continuous. 

4  (D).  Coated  white,  dry.     Coat 
continuous. 

Excess  of  white  epithelium  in  papilla?.  Intervals 
more  or  less  filled  up  with  epithelium  and  acci- 
dental matter. 

Ditto. 

5.   Strawberry,  coated  4-  injected, 
especially  showing  in  fungi- 
form papillae. 

Like  the  coated  or  plastered,  but  with  more  injec- 
tion. 

6.   White,  plastered,  thick,  uni- 
form coat ;  edges  abrupt  and 
striking. 

More   elongation    of    papilla?    than   with    coated 
tongue,  more  filling  of  intervals  with  superficial 
accumulation. 

7.  Furred   or   shaggy,    moist. 

Greatly  elongated  papilla?. 

7(D).  Furred  or  shaggy,  dry. 

Extravagantly  long:  papillse,  mostly  of  horny  epi- 
thelium. 
Ditto. 

8.   Incrusted,  dry,  brown;  thick, 
felted  dry  coat  over  papilla?. 

Continuous  crust  on  and  between  papilla?,  largely 
of  parasitic  matters. 

9.  Furred   or  incrusted,  becom- 
ing bare.     Generally  dry. 

Crust  breaking  away,  together  with  more  or  less  of 
normal  surface. 

10.  Bed,    denuded.      Absence  of 
normal  covering. 

General  absence  of  all  epithelium  excepting  the 
Malpighian  layer ;  sometimes  of  that  also. 

11.  Red,  smooth, dry,  membranous 
covering. 

Level  membrane  replacing  epithelial  processes. 

12.  Cyanosed. 

Injected ;  hypernucleated ;  excess  of  deep  epithe- 
lium. 

Moisture  of  the  Tongue.  The  moisture  is  due  to  the  saliva, 
any  deficiency  of  which  causes  dryness  of  the  tongue.  It  is  natural, 
therefore,  to  conclude  that  any  changes  in  the  moisture  of  the  tongue 
are  due  to  altered  secretion  of  the  salivary  glands.  This  is  almost 
always  deficient  when  fever  is  present,  and  hence  the  tongue  is  dry. 

1  The  letter  D  is  used  to  imply  dryness.  Thus,  to  Class  2  a  certain  description  is 
attached.     Class  2D  presents  the  same  characteristics  with  the  addition  of  dryness. 


704  SPECIAL  DIAGNOSIS. 

At  the  same  time,  it  must  be  remembered  that  this  failure  of  secretion 
of  the  salivary  glands  does  not  depend  upon  gastro-intestinal  disturb- 
ance. 

Deyxess  of  the  tongue,  it  must  not  be  forgotten,  may  be  due  to  hir 
crease  of  evaporation  from  keeping  the  mouth  open,  as  well  as  to 
diminution  of  the  salivary  secretion.  All  states,  therefore,  in  which 
the  mouth  is  open  will  lead  to  dryness  of  the  tongue.  Again,  in 
chronic  fever,  dryness  of  the  tongue  is  a  constant  characteristic. 
Dryness  is  due  to  the  effects  of  the  temperature  upon  the  secretions 
in  general,  but  it  is  not  the  effect  of  high  temperature,  curiously, 
but  rather  a  temperature  which  has  persisted  for  a  considerable 
length  of  time.  Thus,  in  pneumonia,  with  a  temperature  of  105°, 
the  tongue  may  be  moist ;  whereas,  in  typhoid  fever,  with  a  tem- 
perature of  103°,  the  tongue  is  dry.  General  dehydration  of  the 
body  causes  dryness  of  the  tongue,  even  without  local  diminution  of 
secretion.  This  dehydration  is  seen  in  diarrhoea,  in  which  disease 
simple  or  uncomplicated  dryness  of  the  tongue  is  the  common  symp- 
tom. It  is  curious  to  observe  that  in  cholera  the  tongue  remains  moist 
even  until  death  ;  whereas,  if  the  patient  is  about  to  improve  and  the 
discharges  cease,  reaction  and  fever  setting  in,  the  tongue  begins  to  dry 
and  becomes  quite  brown.  Local  causes  may  explain  this.  The  watery 
vomit  may  keep  the  tongue  moist,  and  the  temperature  of  the  body 
may  contribute  to  the  change.  Xext  after  diarrhoea  we  have  excessive 
discharge  of  urine  as  a  frequent  cause  of  dryness.  Hence,  in  diabetes 
in  all  forms  extreme  dryness  of  the  tongue  is  seen.  The  osmotic  action 
of  the  sugar  in  the  blood  is  the  cause  of  a  reaction  in  diabetes  mellitus, 
just  as  it  is  in  cases  of  dehydration  of  the  lens  in  cataract.  The  final 
cause  of  dryness  of  the  tongue  is  prostration.  Asthenia  in  all  forms 
continuing  over  a  moderate  period  of  time,  as  a  week  or  ten  days, 
causes  lingual  dryness. 

The  Effects  of  Food.  These  must  be  studied  before  deciding 
upon  the  clinical  significance  of  changes  in  the  tongue.  The  immedi- 
ate results  of  taking  of  food  influence  the  coating  and  the  degree  of 
moisture.  The  act  of  eating  cleanses  the  tongue.  In  disease,  there- 
fore, in  which  this  act  is  not  performed,  it  is  natural  that  we  observe 
more  fur  on  the  surface,  and  in  conditions  in  which  diet  is  limited  to 
fluids  the  effect  is  marked.  In  cases  of  liquid  diet  the  tongue  is  likely 
to  remain  furred.  It  is  particularly  seen  in  patients  who  are  kept 
upon  a  milk-diet  exclusively. 

The  Tongue  in  Relation  to  Diseases  of  the  Alimentary  Canal. 
So  much  lias  been  written  on  this  subject  that  it  is  Avell  to  give  the 
experience  of  Dickinson  briefly.  He  has  not  been  able  to  discern 
any  relationship  between  any  state  of  the  tongue  and  dyspepsia,  or 
ulcer  of  the  stomach,  apart  from  that  which  might  occur  from  loss  of 
appetite  or  restriction  in  the  amount  of  food.  With  regard  to  the 
bowels,  some  forms  of  constipation  are  often  connected  with  changes 
in  the  tongue,  but  such  connection  is  not  constant.  The  author  rather 
tl links  it  to  have  been  a  coincidence,  and  cannot  even  point  to  the 
diagnostic  significance  of  the  tongue  in  obstruction.  The  state  of  the 
tongue   in  the  latter  condition  is  dependent   not  upon  the  intestinal 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,  ESOPHAGUS.     705 

lesion  but  upon  the  constitutional  disturbance.  A  dry  tongue  is  well 
known  to  occur  in  acute  obstruction,  due  to  deficiency  of  salivary 
secretion.  In  chronic  obstruction,  unless,  however,  there  is  consti- 
tutional disturbance,  the  tongue  will  not  change.  In  diarrhoea  all  con- 
ditions of  dryness,  furring,  and  incrustation  are  observed.  The 
absence  of  saliva,  dehydration,  and  pyrexia  help  the  desiccation.  In 
diarrhoea  and  dysentery,  therefore,  the  change  in  the  appearance  of 
the  tongue  is  more  marked  than  in  any  other  disease. 

Other  Diseases.  As  regards  the  relation  of  the  tongue  to  other 
individual  diseases  but  little  can  be  said.  Of  more  direct  association, 
we  have  the  cyanotic  tongue  in  heart  disease ;  the  dry  tongue  in 
chronic  albuminuria  and  diabetes  inellitus ;  the  strawberry-tongue  of 
scarlet  fever ;  and  the  dry  brown  tongue  of  typhoid  fever.  Of  course, 
the  so-called  typhoid  tongue  represents  but  one  stage  of  typhoid  fever. 
Throughout  the  disease  it  may  present  all  varieties  in  direct  succes- 
sion, from  the  stippled,  the  coated,  the  plastered,  the  furred,  to  the 
incrusted.  In  lobar  pneumonia  the  same  changes  occur  as  the  disease 
advances.  In  bronchitis  the  lower  degrees  of  coating  are  presented, 
while  in  rheumatism  the  variety  is  considerable.  In  conclusion,  it 
may  be  stated  that  the  tongue  seldom  points  to  solitary  organs  or  iso- 
lated disorders,  but  is  a  gauge  of  the  effects  of  disease  upon  the  system. 

The  Tongue  in  Prognosis  and  Treatment.  Clinical  observers 
agree  with  Dickinson,  that  the  condition  of  the  tongue  is  due  very 
largely  to  the  four  states  with  which  he  has  associated  it — dehydra- 
tion, exhaustion,  pyrexia,  and  local  conditions  about  the  mouth.  As 
these  conditions  modify  the  state  of  the  tongue,  it  is  evident  that  the 
first  sign  of  improvement,  as  return  of  moisture,  denotes  a  diminution 
in  temperature.  Its  appearance  is,  therefore,  of  good  prognostic  omen. 
The  degree  of  fever,  the  state  of  the  nervous  system,  the  maintenance 
or  abeyance  of  secretions,  and  the  failure  of  vitality,  are  indicated  by  the 
condition  of  the  tongue.  The  return  of  moisture,  the  removal  of  fur,  the 
subsidence  of  tremor,  at  once  indicate  that  the  patient  is  getting  better. 
The  persistence  and  increase  of  these  signs  show  that  the  disease  is  get- 
ting the  better  of  the  patient.  As  to  indications  for  treatment,  the  dry- 
ness, furring,  and  incrustation  are  connected  with  the  want  of  saliva. 
The  processes  by  which  this  want  is  brought  about  differ.  They  have 
previously  been  referred  to,  and  the  indications  for  treatment  are  obvious. 
One  can  infer  from  the  state  of  the  saliva  the  condition  of  the  intesti- 
nal canal,  a  matter  of  the  highest  importance  practically.  There  is  no 
doubt  that,  except  possibly  in  diabetes,  when  there  is  diminished 
saliva,  there  is  also  diminished  gastro-intestinal  secretion.  Such 
diminution  is  followed  by  loss  of  appetite  and  impairment  of  digestion. 
The  indication  is  at  once  to  administer  material  that  is  digested  with 
the  least  difficulty.  Hence,  liquid  food  and  stimulants  are  to  be  used. 
The  dry  and  bare  tongue  is  of  serious  prognostic  omen  in  all  conditions. 
While  it  may  be  due  to  want  of  saliva  alone,  it  also  occurs  as  a  part 
of  the  failure  of  nutrition  in  hectic  fever,  suppuration,  and  other  condi- 
tions. It  is  an  indication  for  the  use  of  tonics,  stimulants,  and  liquid 
and  highly  nutritious  food.  The  weak  pulse  docs  not  more  surely  tell 
of  an  asthenic  tendency  than  the  red,  dry,  and  polished  tongue. 

45 


706  SPECIAL  DIAGNOSIS. 

Movements  of  the  Tongue  When  the  patient  is  asked  to  put  out 
his  tongue  it  is  done  without  other  movement  than  that  required  for 
its  ejection.  Interference  with  its  motility  occurs  in  disease,  when  the 
projection  is  attended  by  abnormal  movement.  It  may  be  tremulous, 
as  in  alcoholism  or  in  simple  weakness  alone.  It  may  be  slow  or  im- 
peded in  the  various  stages  of  paralyses.  It  is  tremulous  and  the  seat 
of  fibrillar  contractions  in  general  paralysis.  It  cannot  be  projected 
at  all  in  glosso-labial  paralysis  ;  it  can  be  projected,  but  with  difficulty, 
and  may  have  to  be  aided  by  the  finger,  in  general  paralysis  and  diph- 
theritic paralysis,  progressive  muscular  atrophy,  and  hemiplegia,  be- 
cause the  paralysis  is  only  partial.  The  tongue  points  to  the  paralyzed 
side  of  the  body  in  hemiplegia  when  the  face  is  involved. 

Angina  Ludovici.  Angina  Ludovici  is  characterized  by  slight 
inflammatory  congestion  of  the  throat  out  of  proportion  to  the  symptoms 
of  the  inflammation  in  the  external  structures.  Woodeny  induration 
of  the  connective  tissue,  which  will  not  pit  on  pressure ;  spreading  of 
this  induration,  which  is  circumscribed,  so  that  it  is  bound  sharply  by 
unaffected  cellular  tissue,  is  characteristic.  The  induration  may  extend 
from  the  rami  of  the  jaws  to  the  face.  With  this  there  is  a  hard  swell- 
ing hi  the  tongue  and  along  the  lower  jaw,  causing  thickening  of  the 
floor  of  the  mouth.  This  is  observed  by  palpation  with  the  finger  in 
the  mouth.  The  glands  are  not  affected.  For  a  long  time  the  nature 
of  this  affection  was  not  known.  It  is  now  believed  to  be  due  to 
actinomyces.  (See  Parker,  Lancet,  1879,  and  Anderson,  Transactions  of 
the  Medico- Chirurgical  Society,  1891.) 

The  Fauces  and  Pharynx 

The  passageway  between  the  mouth  and  the  respiratory  passages  is 
lined  with  mucous  membrane,  which  is  subject  to  diseases  to  which 
they  are  liable.  The  symptoms  thereof  are  similar  to  the  symptoms 
of  mucous  membrane  inflammation  elsewhere.  The  large  muscles  of 
the  pharynx  which  aid  in  deglutition  are  subject  to  affections  which 
belong  to  muscular  tissue  generally,  hence  rheumatic  inflammation  and 
loss  of  power  of  muscle,  or  paralysis  occurs.  Paralysis  of  the  pharynx 
has  not  the  same  practical  importance  in  diagnosis  of  central  lesions  as 
paralysis  of  other  structures,  such  as  parts  of  the  larynx.  This  is  due  to 
the  fact  that  the  nerve-supply  of  the  pharynx  is  derived  from  a  nerve 
(glosso-pharyngeal)  which  supplies  other  structures,  paralysis  of  which 
is  more  evident  than  pharyngeal  paralysis,  more  readily  ascertained, 
and  which  causes  more  pronounced  symptoms.  (See  Cerebral  Nerves.) 
From  its  exposed  situation  the  pharynx  is  particularly  liable  to  infec- 
tion from  micro-organisms.  The  infection  may  extend  from  the  mouth, 
or  from  the  nares  above,  or  the  micro-organisms  may  affect  it  primarily. 

The  fauces  and  pharynx  may  be  the  seat  of  morbid  processes  which 
occur  secondarily  to  diseases  in  other  portions  of  the  body  with  a  mod- 
erate degree  of  frequency.  Inflammations  of  the  mucous  membrane 
of  the  pharynx  are  of  rheumatic  or  gouty  origin  in  a  large  number 
of  cases.  Indeed,  gouty  inflammation  of  the  pharynx  seems  to  be 
more  common  than  gouty  inflammations  of  mucous  membranes  in  other 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,  OESOPHAGUS.     707 

situations.  The  large  majority  of  subacute  or  chronic  pharyngeal  in- 
flammations are  secondary  to  dyspepsia.  They  also  occur  from  exten- 
sion of  the  disease  from  cavities  related  to  the  pharynx. 

Affections  of  the  tonsils  are  usually  more  common  in  rheumatic 
states,  and  bear  some  relationship  to  the  rheumatic  diathesis.  Inflam- 
mation of  the  tonsils  may  follow  acute  rheumatism  or  may  alternate 
with  it.  A  patient  who  is  predisposed  to  rheumatism  may  at  one 
season  have  tonsillar  inflammation,  at  another  rheumatism.  The 
writer  has  seen  tonsillitis  immediately  followed  by  rheumatism,  and 
then  the  latter  replaced  by  the  former. 

Apart  from  what  has  just  been  said,  diseases  of  the  pharynx  bear 
but  little,  if  any,  diagnostic  relationship  to  disease  elsewhere.  While 
there  may  be  cyanosis  of  the  mucous  membrane,  or  tuberculous  ulcer- 
ation, or  other  changes  which  we  have  noted,  the  signs  of  the  primary 
disease  are  so  much  more  marked  that  we  need  not  rely  upon  the 
appearance  of  the  pharynx  or  symptoms  of  pharyngeal  disease  for 
diagnostic  purposes.  The  only  general  affection  which  may  be  diag- 
nosticated from  the  appearance  of  the  pharynx  alone  is  measles.  In 
obscure  cases  of  sudden  fever,  with  nasal  catarrh,  the  appearance  of 
the  eruption  in  the  situation  just  indicated  may  lead  to  the  recogni- 
tion of  measles  Avhen  the  external  eruption  is  not  apparent.  For 
the  purposes  of  the  therapeutist  it  should  be  borne  in  mind  that  symp- 
toms referable  to  the  pharynx  are  very  frequently  due  to  disease  in 
the  nares,  particularly  in  that  portion  of  the  pharynx  which  is  not 
open  to  direct  hispection — the  nasopharynx. 

The  general  symptoms  of  pharyngeal  disease  are  not  marked,  except 
in  diphtheria,  in  erysipelas,  in  retropharyngeal  abscess,  and  in  affec- 
tions of  the  tonsils.  In  the  latter  the  general  symptoms  appear  to  be  out 
of  proportion  to  the  local  process.  The  high  fever,  the  intense  head- 
ache and  backache,  and  rapid  pulse,  seem  to  point  to  a  process  which  in 
extent  and  severity  should  far  surpass  that  which  occurs  in  the  tonsils. 

As  a  passageway  or  channel,  affections  of  the  pharynx  are  liable  to 
obstruct  it,  causing  symptoms  of  occlusion.  As  a  channel  for  the  pas- 
sage of  air,  obstruction  in  the  pharynx  will  lead  to  dyspnoea.  In  addi- 
tion to  its  function  as  a  simple  channel,  the  pharynx  is  concerned  in 
the  act  of  deglutition.  When,  therefore,  there  is  obstruction  of  the 
pharynx,  deglutition  is  made  difficult,  or  may  even  become  impossible. 

Attention  cannot  be  too  strongly  directed  to  the  investigation  of  the 
nasopharynx  in  children  who  are  poorly  developed  physically  and  men- 
tally, and  who  present  appearances  that,  to  the  practised  eye,  are  most 
familiar.  The  experienced  observer  will  at  once  judge,  and  judge  cor- 
rectly, that  this  combination  of  symptoms  is  due  to  disease  in  the  naso- 
pharynx. Eeference  must  be  made  to  the  remarks  on  adenoid  vegeta- 
tions of  the  nasopharynx,  but  it  is  proper  to  state  here  the  relationship 
and  the  importance  of  investigating  the  structures  in  the  class  of  cases 
just  indicated. 

The  Data  Obtained  by  Inquiry. 

Pain.  In  affections  of  the  fauces  and  pharynx  pain  is  one  of  the 
most  common  subjective  symptoms.     It  is  due  to  the  fact  that  the 


708  SPECIAL  DIAGNOSIS. 

functional  acts  of  the  pharynx  require  movement  of  all  the  struc- 
tures. When  they  are  the  seat  of  inflammation,  or  ulceration,  the 
movement  excites  pain.  It  is,  therefore,  a  symptom  of  great  severity 
in  inflammation  of  the  tonsils  and  pharynx,  of  rheumatism  of 
the  muscular  structure  of  the  pharynx,  and  of  tuberculous  and  can- 
cerous ulceration.  Pain  in  the  pharynx  is  a  frequent  accompaniment 
of  post-nasal  inflammations,  although  the  pharynx  itself  is  not 
affected. 

Dryness.  Dryness  of  the  fauces,  with  a  tickling  sensation  and  a 
more  or  less  constant  desire  to  hawk,  occurs  in  pharyngitis.  Hawk- 
ing, however,  is  not  a  symptom  of  disease  of  the  pharynx  alone.  It 
may  also  be  due  to  disease  in  the  posterior  nares. 

The  Odor  of  the  Breath.  In  follicular  tonsillitis  the  breath  has 
a  peculiar  odor.  This  is  more  marked  in  the  milder  forms  of  inflam- 
mation, with  retention  of  the  secretion  of  the  glands.  The  odor  is  in- 
tense and  foetid.  In  cancer  and  syphilis  there  is  also  fcetor  of  the 
breath.  The  foetor  may  be  of  diagnostic  significance  in  distinguishing 
cancer  from  tuberculosis. 

Dysphagia.  The  symptom  varies  in  degree  from  slight  difficulty 
in  swallowing  to  complete  prevention  of  the  act.  Any  disease  which 
occludes  the  passageway  causes  dysphagia ;  pain  is  also  a  cause.  It 
is,  therefore,  present  in  all  painful  affections  of  the  pharynx.  Dysp- 
noea is  seen  in  tumors,  in  inflammation  of  the  tonsils,  in  the  rare  form 
of  erysipelas  of  the  pharynx,  and  in  retropharyngeal  abscess.  It 
occurs  from  occlusion  of  the  passages,  and  is  more  marked  in  retro- 
pharyngeal abscess  and  erysipelas  than  in  other  conditions.  In  cer- 
tain forms  of  abscess  of  the  tonsils  it  may  be  very  extreme. 

Spasm  of  the  pharynx  is  a  subjective  symptom  complained  of  in  some 
cases  of  pharyngitis.  The  degree  of  spasm  or  the  amount  of  choking 
sensation  is  largely  dependent  upon  the  neurotic  constitution  of  the 
individual.  It  may  be  extreme  when  only  a  moderate  amount  of  inflam- 
mation is  present.    It  is  seen  in  the  most  aggravated  form  in  hydrophobia . 

The  Data  Obtained  by  Observation. 

Examination  of  the  Fauces.  Method.  For  this  purpose  examin- 
ation is  made  by  the  unaided  eye,  illuminating  the  throat  as  in  the  ex- 
amination of  the  larynx.  The  difficulties  of  examination  arise  from  the 
tongue  and  the  uvula.  The  mouth  should  be  opened  as  wide  as  is  con- 
sistent with  comfort  and  in  an  unrestrained  manner.  The  tongue  is 
pressed  out  of  the  way  by  the  use  of  a  tongue-depressor.  In  many  cases, 
however,  even  with  the  tongue-depressor,  the  tongue  muscles  will  con- 
tract and  the  organ  bunch  up  in  the  mouth.  Moderate,  quiet,  full 
breathing,  gently  opening  the  mouth  as  the  deeper  inspirations  are  made, 
causes  the  tongue  to  relax  and  lie  in  the  bottom  of  the  mouth,  and  at 
the  same  time  elevates  the  uvula.  At  the  time  of  a  full  breath  the 
part  may  be  inspected  throughout.  Sometimes  the  fauces  can  be  ex- 
amined if  the  tongue  is  protruded  and  held  with  a  soft  napkin  between 
the  finger  and  thumb  by  the  patient.  In  the  fauces  the  tonsils  and 
uvula  are  to  be  observed,  following  out  the  routine  method  of  ascer- 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,  GESOPHAGUS.     709 

taming  all  facts.  Attention  is  then  paid  to  the  posterior  Avail  of  the 
pharynx,  with  the  same  object  in  view. 

Inspection.  In  examining  the  fauces  and  pharynx  observation  is 
made  of  the  color  of  the  parts,  the  appearance  of  the  mucous  mem- 
brane and  its  glands,  the  appearance  and  position  of  the  uvula,  the 
size  of  the  tonsils,  the  character  of  the  secretions  on  the  pharynx,  and 
the  presence  or  absence  of  swellings  and  abnormal  exudations. 

Color.  The  color  of  the  mucous  membrane  is  generally  dark  red. 
In  the  acute  forms  of  pharyngitis  the  color  is  bright  red.  In  cases  of 
heart  disease,  when  there  is  cyanosis,  the  veins  are  congested  and  the 
surface  dusky.  In  obstruction  of  the  superior  vena  cava  by  tumor  there 
is  a  cyanotic  hue  of  the  surface  of  the  pharynx. 

Appearance  of  Surface.  The  capillary  vessels  may  pulsate  in  aortic 
regurgitation.  Bleeding-points  may  be  seen  over  the  surface  of  the 
pharynx,  the  discharges  of  blood  from  which  may  simulate  pulmonary 
hemorrhage.  The  blood  may  be  swallowed  and  then  vomited,  and 
hence  gastric  hemorrhage  is  simulated.  When  the  hemorrhage  occurs 
at  night  it  is  seen  on  the  pillow  as  yellowish  stains.  It  is  often  due 
to  adenoid  vegetations  in  the  nasopharynx.  In  chronic  pharyngitis  the 
membrane  is  dry,  the  glands  are  prominent,  and  the  secretion  viscid. 

On  examination  of  the  posterior  wall  of  the  healthy  pharynx  little 
elevations  due  to  glands  are  seen  upon  its  surface,  and  moderate-sized 
vessels  are  seen  coursing  through  the  mucous  membrane. 

Eruptions.  Eruptions  may  be  observed  in  the  pharynx  in  some  of 
the  specific  fevers.  Thus,  in  measles,  the  appearance  of  the  rash  on 
the  pharynx  and  on  the  soft  palate  may  be  observed  before  the  devel- 
opment of  the  rash  on  the  skin.  The  eruption  of  scarlatina  is  also  seen 
in  the  pharynx,  and  the  papules  and  pustules  of  variola  are  frequently 
observed  in  that  situation. 

Ulceration.  Follicular  Ulceration.  Small  superficial  ulcers  cor- 
responding to  the  follicles  may  be  seen  over  the  posterior  wall  of 
the  pharynx.  They  occur  in  chronic  catarrh,  and  are  due  to  in- 
flammation of  the  follicles.  In  addition,  ulcers  secondary  to  infectious 
processes  are  sometimes  seen,  as  in  typhoid  fever.  In  syphilis,  in  the 
secondary  stage,  small,  shallow  ulcers  are  seen  on  the  posterior  wall  of 
the  pharynx.  They  do  not  cause  pain.  Mucous  patches  are  observed 
at  the  same  time,  not  only  on  the  pharynx,  but  also  in  the  mouth. 
In  the  tertiary  stage  deep  ulcers,  followed  by  scars,  are  seen  on  the 
posterior  wall  of  the  pharynx.  Although  the  absence  of  pain  renders 
it  probable  that  they  are  of  syphilitic  origin,  nevertheless  the  history 
of  infection  and  of  the  primary  lesion,  and  the  evidence  of  the  disease 
in  other  structures,  ought  to  be  secured  before  a  diagnosis  is  fully  estab- 
lished. In  the  tertiary  forms  it  may  be  necessary  to  resort  to  the 
therapeutic  test.     (See  The  Infections — Syphilis.) 

Tuberculous  ulcers  are  irregular  in  shape,  and  the  floor  grayish. 
They  are  seen  in  tuberculosis  in  its  later  stages.  They  are  the  source 
of  extreme  pain.  There  is  usually  ulceration  in  the  larynx  at  the  same 
time,  and,  in  extremely  rare  cases,  tuberculous  ulceration  of  the  tonsils. 
In  tuberculous  ulceration,  after  the  application  of  cocaine,  a  portion 
may  be  scraped  off  and  examined  microscopically  for  tubercle  bacilli. 


710  SPECIAL  DIAGNOSIS. 

Cancer  of  the  pharynx  is  rare,  and  is  usually  secondary,  the  dis- 
ease having  spread  from  other  situations. 

Exudations.  On  the  pharynx  the  exudation  may  be  due  to 
diphtheria,  to  pseudodiphtheria,  or  to  thrush.  The  method  of  dis- 
tinguishing the  various  forms  will  be  considered  in  the  articles  on  the 
respective  affections.  In  diphtheria  the  membrane  is  made  up  of 
fibrin  arranged  in  a  network,  in  the  meshes  of  which  epithelium, 
blood-corpuscles  and  pus-corpuscles  and  micro-organisms  are  found. 
When  removed,  hemorrhagic  abrasions  and  raw  purulent  inflammatory 
areas  remain.  Two  forms  of  bacilli  are  found  in  the  membrane — the 
pseudodiphtheritic  bacillus  and  the  true,  or  Klebs-Loffler  bacillus. 
(See  Bacteriology.)  The  Loffler  bacillus  is  best  detected  by  cultiva- 
tions. After  the  membrane  is  removed  and  washed  in  a  2  per  cent, 
solution  of  boric  acid,  it  is  cultivated  in  blood-serum.  The  pseudo- 
diphtheritic  bacillus  likewise  grows,  but  its  appearances  are  different. 

Anaesthesia.  Some  of  the  results  of  inspection  may  be  confirmed 
by  means  of  the  probe,  and  alterations  in  the  sensibility  of  the  phar- 
ynx may  be  detected.  Sensations  may  be  absent  in  the  whole  poste- 
rior wall  of  the  pharynx.  Loss  of  sensation  may  occur  in  hysteria,  in 
bulbar  paralysis,  and  in  diphtheritic  paralysis.  On  the  other  hand, 
there  may  be  an  apparent  hyperesthesia.  In  some  individuals  the 
pharynx  is  particularly  sensitive  to  the  presence  of  foreign  bodies,  such 
as  inflammatory  exudates,  and  may  resent  their  presence  by  sudden 
coughing  and  retching.  Inflammations  increase  the  hyperesthesia  of 
the  pharynx.     The  condition  is  sometimes  observed  in  hysteria. 

The  Uvula.  In  health  it  hangs  midway  from  the  palate.  It  varies 
in  shape  from  congenital  causes,  and  may  be  elongated,  on  account  of 
disease.  This  takes  place  particularly  if  there  has  been  hawking  or 
coughing,  on  account  of  chronic  nasal  catarrh.  When  elongated  it  is 
pointed  and  may  extend  almost  to  the  base  of  the  tongue.  The  uvula 
may  be  swollen  and  oedematous.  The  oedema  is  usually  associated 
with  subcutaneous  oedema  in  acute  Bright' s  disease.  It  may  occur 
in  debility.  In  both  conditions  it  may  become  so  enlarged  as  to 
interfere  with  swallowing  and  breathing.  In  some  cases  of  pharyn- 
gitis the  uvula  is  the  seat  of  intense  inflammation  and  great  oedema. 
In  addition  to  the  constant  cough  which  it  causes  there  may  be  dysp- 
noea and  repeated  attacks  of  choking. 

Hemorrhagic  infarcts  may  take  place  in  the  uvula.  In  two  in- 
stances under  the  writer's  care  the  intense  infarction  led  to  sloughing, 
and  in  one  the  uvula  was  swallowed. 

The  Cervical  Glands.  The  pharynx  is  in  such  intimate  rela- 
tion with  the  large  lymphatic  glands  in  the  neck  that  diseases  of  the 
former  are  frequently  attended  by  enlargement  of  the  latter.  The 
glands  at  the  angle  of  the  jaw  are  increased  in  size.  The  glands  ex- 
tending along  the  vessels  of  the  neck  may  also  be  enlarged.  In  cases, 
therefore,  of  enlargement  of  the  glands  in  this  situation,  it  is  absolutely 
essential  to  examine  the  fauces  and  pharynx. 

The  Tonsils.  The  tonsils  are  situated  at  the  sides  of  the  pharynx, 
between  the  anterior  and  posterior  folds  of  the  palate.  They  are 
small  bodies,  not  larger  than  a  filbert   in   the  adult.      Their  entire 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,   OESOPHAGUS.     71 1 

surface  can  be  seen  by  ordinary  inspection.  If  enlarged,  the  posterior 
surface  cannot  be  seen,  although  a  larger  view  may  be  obtained  by 
causing  the  patient  to  gag  or  retch,  during  which  they  are  brought 
forward  to  the  light.  They  are  pathologically  of  much  importance. 
They  are  made  up  of  glandular  structure  arranged  in  follicles  and  held 
together  by  connective  tissue.  The  crypts  of  the  follicles  open  on 
the  surface,  and  in  disease  are  visible.  The  diseases  of  the  tonsils 
have  nothing  to  do  with  their  function  as  far  as  known.  The  tissue 
and  gland  follicles  are  liable  to  inflammations,  which  may  be  bacterial 
or  may  be  the  result  of  rheumatism.  The  tonsils  become  enlarged  ; 
the  swelling  takes  place  rapidly  in  the  acute  forms.  They  may  be 
simply  enlarged  and  the  covering  membrane  intensely  red.  In  other 
forms  of  inflammation  the  surface  may  be  dotted  over  with  white 
points,  due  to  exudation  from  the  follicles  ;  these  may  be  covered  with 
a  white  or  grayish  membrane,  which  is  removed  with  difficulty,  leaving 
an  abraded  surface  beneath.  Repeated  attacks  of  inflammation  cause 
chronic  enlargement  of  the  tonsils.  They  are  enlarged  sometimes  to 
a  great  degree,  filling  almost  entirely  the  lumen  of  the  fauces.  The 
surface  is  irregular,  and  may  be  scarred.  The  mouths  of  the  follicles 
may  be  dilated.  By  virtue  of  their  position,  enlarged  tonsils  from  any 
cause  are  a  source  of  dyspnoea  and  dysphagia.  The  tonsils  may  be 
the  seat  of  sarcoma  and  tuberculosis. 

Ulcers.  Tuberculous  ulceration  is  rare.  In  a  patient,  a  lad  of 
sixteen  years,  under  the  writer's  care,  the  large  tonsils  were  of  a  honey- 
combed appearance,  on  account  of  the  grayish,  irregular  ulceration. 
Deglutition  was  absolutely  impossible,  on  account  of  pain,  and  the 
young  man  died  of  starvation. 

Exudations  on  the  tonsils  are  due  to  inflammation  of  the  follicles, 
to  diphtheria,  to  the  pseudodiphtheritic  inflammation  which  attends 
scarlatina,  or  which  arises  secondarily  to  other  infectious  debilitating 
diseases,  and  to  thrush. 

Leptothrix  of  the  Tonsils.  In  healthy  persons  the  plugs 
which  block  the  tonsillar  crypts  are  found  to  be  made  up  of  cells  and 
segmented  fungi.  The  latter  stain  bluish-red  with  iodo-potassic  iodide 
solution.  Sometimes  the  micro-organisms  extend  beyond  the  follicles, 
covering  the  surface  of  the  tonsils  with  patches  of  various  size.  They 
are  thus  seen  in  follicular  tonsillitis. 

Tonsillitis.  Acute  inflammation  of  the  tonsils  may  affect  the  folli- 
cles, to  which  form  the  term  follicular  tonsillitis  is  applied,  or  it  may 
be  limited  to  the  mucous  membrane,  when  it  is  known  as  catarrhal 
or  erythematous  tonsillitis.  If  with  the  catarrhal  inflammations  vesi- 
cles appear  on  the  surface  of  the  mucous  membrane,  the  term  herpetic 
tonsillitis  is  used.  When  the  inflammation  extends  to  the  stroma  of 
the  glands  it  goes  on  to  suppuration.  It  is  characteristic  of  all  forms 
of  acute  tonsillitis  to  recur  frequently  in  the  same  subject.  The  rela- 
tionship to  rheumatism  has  been  spoken  of.  This  relationship  applies 
to  both  the  acute  and  the  suppurative  forms.  The  various  forms  of 
tonsillitis  occur  at  any  age,  although  it  is  least  common  under  ten 
years  of  age  ;  the  suppurative  form  occurs  most  frequently  in  adoles- 
cence.    Tonsillitis  occurs  in  both  sexes.     It  may  follow  exposure  to 


7 1 2  SPECIAL  DIA  GNOSIS. 

wet  and  cold,  although  patients  who  are  subject  to  the  attacks  bear 
exposure,  unless  they  are  at  the  same  time  unduly  fatigued.  The  fol- 
licular form  of  tonsillitis  is  apparently  associated  with  bad  drainage 
or  other  unhygienic  conditions,  which  makes  it  possible  that  noxious 
emanations  act  as  an  exciting  cause.  Several  persons  of  the  same 
family  may  be  affected  at  one  time,  so  that  it  is  often  difficult  to  dis- 
tinguish the  cases  from  diphtheria.  The  disease,  however,  is  not  con- 
tagious. Persons  brought  in  contact  with  the  family,  but  who  do  not 
reside  in  the  same  house,  escape  the  disease.  This  applies  as  well  to 
children,  who  would,  if  the  cases  were  diphtheritic,  be  most  liable  to 
become  infected.  The  disease  occurs  more  commonly  in  the  spring 
than  in  any  other  season  of  the  year,  more  especially  in  cold  and  wet 
seasons. 

Symptoms.  In  follicular  tonsillitis,  with  or  without  a  rigor,  but 
always  with  chilly  sensations,  the  temperature  rises  rapidly  to  a  great 
height.  The  subjective  sensation  of  fever  is  very  quickly  noticeable 
to  the  patient,  and  is  generally  more  pronounced  than  in  other  affec- 
tions. With  the  chill  and  during  the  rise  of  temperature  there  are 
some  frontal  headache  and  severe  pain  in  the  back  and  limbs.  The 
pain  in  the  back  is  most  excruciating.  In  a  short  time  the  patient 
complains  of  pain  in  the  throat.  Swallowing  is  difficult,  and  there  is 
a  sense  of  fulness.  The  throat  is  dry  and  burning.  On  examination 
the  tonsils  are  found  to  be  swollen,  and  a  yellowish-white  exudation  is 
seen  on  the  crypts.  In  twenty-four  hours  the  points  may  coalesce  to 
form  a  patch.  The  glands  expand  slightly,  and  may  extend  only 
slightly  beyond  the  arches,  or,  in  younger  subjects,  one-quarter  of  the 
way  into  the  lumen  of  the  fauces.  Sometimes  one  gland  is  affected 
before  the  other.  The  difficulty  in  deglutition  increases  and  the  voice 
becomes  nasal.  There  is  usually  some  enlargement  of  the  cervical 
glands.  The  general  symptoms  continue  for  forty-eight  hours,  the 
temperature  remains  at  105°,  and  the  pulse  is  very  rapid.  After  the 
first  twenty-four  hours  the  pain  in  the  back  lessens.  The  tongue  is 
coated  and  the  breath  heavy.  The  urine  is  loaded  with  urates.  At 
the  end  of  the  fifth  day  the  fever,  which  subsides  gradually,  has  disap- 
peared. The  local  symptoms,  however,  may  remain  longer  ;  that  is, 
the  tonsils  are  still  enlarged  and  the  exudation  disappears  slowly. 
Sometimes  the  prostration  and  general  symptoms  are  very  severe,  so 
that  after  the  fever  has  subsided  convalescence  may  be  very  slow. 

Albuminuria,  due  in  all  probability  to  the  fever,  frequently  occurs  ; 
in  some  cases,  undoubtedly,  acute  nephritis  attends  the  attack  and 
retards  the  convalescence.  In  a  case  under  the  writer's  care  the 
patient  first  had  acute  rheumatism  ;  this  was  replaced  by  a  severe  attack 
of  tonsillitis,  during  which  albumin,  blood,  and  granular  casts  were 
found  in  the  urine.  The  swelling  of  the  tonsils  subsided  in  due  course, 
but  the  Bright's  disease  continued  for  a  long  period,  finally  ending, 
however,  in  complete  recovery. 

In  herpetic  tonsillitis  the  severe  pain  and  intense  general  symptoms 
are  out  of  proportion  to  the  local  lesion. 

In  suppurative  tonsillitis  the  constitutional  disturbance  is  also  very 
great.     The  temperature  rises  high,  104°  to  105°,  and  the  pulse  is 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,  (ESOPHAGUS.     713 

very  rapid,  from  110  to  130  in  the  adult.  The  inflammation  usually 
begins  in  one  tonsil,  and  the  other  may  be  involved  later.  The 
tonsils  at  first  are  enlarged  and  firm  and  very  red.  There  is  swelling 
of  the  surrounding  tissues.  In  twenty-four  hours  deglutition  becomes 
almost  impossible,  and  there  is  salivation.  At  the  end  of  forty-eight 
hours  the  patient  presents  a  striking  appearance.  The  glands  of  the 
neck  are  enlarged,  the  patient  is  unable  to  open  his  mouth,  the  voice 
is  nasal  or  almost  suppressed  ;  there  is  dribbling  of  saliva  from  the 
mouth.  The  face  may  have  a  dusky  hue  in  spite  of  the  capillary  con- 
gestion due  to  the  fever.  There  is  constant  desire  to  discharge  saliva 
and  accumulated  secretions  from  the  back  part  of  the  mouth.  The 
patient  cannot  lie  down.  The  pain  is  extreme,  and  is  aggravated  by 
swallowing.  It  is  sometimes  of  a  throbbing  character,  and  often  shoots 
to  the  ears.  Indeed,  earache  may  be  the  chief  complaint.  The  patient 
does  not  take  food,  and  exhaustion  soon  ensues.  During  the  twenty- 
four  hours  before  rupture  takes  place  the  previously  reddened  face 
becomes  blanched  from  exhaustion.  The  fever  is  continuous  during 
this  time,  with  great  rapidity  of  the  pulse.  The  patient  may  be  delirious. 
Sometimes  the  delirium  is  marked  and  the  patient  resists  efforts  to  keep 
him  in  bed. 

The  suffering  is  out  of  proportion  to  the  danger  of  the  case.  About 
the  fourth  or  fifth  day  suppuration  is  over,  and  if  the  finger  can  be 
inserted  into  the  mouth  between  the  almost  closed  teeth,  fluctuation 
is  detected.  In  cases  in  which  the  mouth  is  opened  a  little  more 
freely,  in  addition  to  the  swelling  of  the  tonsils  below  the  arches, 
marked  swelling  and  projection  forward  of  the  half-arches  may  be 
seen.  The  fluctuation  may  be  detected  through  the  anterior  fold  of 
the  palate,  and,  if  lancing  is  to  be  performed,  the  pus  can  only  be 
reached  through  this  structure.  In  short,  a  peritonsillitis  takes  place. 
After  spontaneous  rupture,  which  usually  takes  place  into  the  mouth, 
instant  relief  is  experienced.  Rupture  may  take  place  into  the  pharynx 
and  cause  suffocation  from  entrance  of  pus  into  the  larynx.  In  rare 
cases  it  has  opened  into  the  carotid  artery,  causing  instant  death  from 
hemorrhage. 

Diagnosis.  The  diagnostic  features  of  acute  tonsillitis  are  the 
sudden  high  fever,  severe  backache  and  headache,  pain  in  the  throat, 
and  albuminuria.  The  characteristic  appearance  of  the  face,  the  sali- 
vation and  pain,  with  suppressed  voice  and  difficult  deglutition,  should 
distinguish  it  from  trismus  or  tetanus.  In  both  the  jaws  are  closed. 
It  must  not  be  confounded  with  smallpox,  which  it  resembles  during 
the  first  twenty-four  hours. 

Cases  of  follicular  tonsillitis  are  frequently  mistaken  for  diphtheria. 
The  follicular  inflammation  in  tonsillitis  is  limited  to  the  gland,  on 
which  patches  of  a  yellowish-gray  color,  easily  removed  without  leaving 
bleeding  surfaces,  are  seen.  In  diphtheria  the  membrane  is  of  an  ashy- 
gray  color,  not  in  points  or  small  patches,  or  separated  by  red  tonsillar 
tissue  ;  it  extends  to  the  pillars  of  the  fauces,  and  may  appear  on  the 
uvula.  There  are,  nevertheless,  many  cases  which  are  doubtful,  when  a 
bacteriological  diagnosis  must  be  resorted  to.  (See  Bacteriological  Ex- 
amination.)    A  history  of  exposure  sometimes  helps  us  to  arrive  at  a 


714  SPECIAL  DIAGNOSIS. 

conclusion.  The  cases  that  particularly  increase  our  anxiety  are  those 
of  adults  who  are  subject  to  attacks  of  follicular  tonsillitis.  In  the 
grave  and  extensive  forms  of  diphtheria  with  asthenic  symptoms  (sep- 
ticaemia) the  diagnosis  is  not  difficult. 

Enlargement  of  the  Tonsils.  Chronic  Tonsillitis.  The  ton- 
sils may  be  enlarged,  on  account  of  repeated  attacks  of  acute  inflamma- 
tion or  from  chronic  inflammation.  They  do  not  appear  to  cause 
serious  symptoms  unless  associated  with  adenoid  vegetations  in  the 
nasopharynx.  They  may  interfere  with  hearing,  however,  and  with 
breathing,  and  cause  snoring  at  night.  Foetor  of  the  breath  may  be  noted, 
particularly  if  the  secretion  lodges  in  the  crypts.  The  latter  may  be 
recognized  by  its  characteristic  yellowish  color  and  by  its  odor  on 
removal.     The  enlarged  tonsils  are  irregular  in  contour. 

Foreign  bodies  in  the  tonsils  are  not  of  common  occurrence.  They 
give  rise  to  local  symptoms,  as  the  sensation  of  the  presence  of  a  mass 
causing  repeated  efforts  at  swallowing.  If  calculi  are  present  the 
patient  may  complain  of  a  rough  sensation.  The  calculi  follow  frequent 
attacks  of  quinsy.     Hydatids  are  sometimes  located  in  the  tonsils. 

Adenoid  Vegetations  of  the  Nasopharynx.  Adenoid  vegetations 
cause  more  or  less  obstruction  in  the  nasopharynx.  The  symptoms 
may  be  classed  as  primary  and  secondary.  The  former  are  local,  and 
due  to  the  foreign  substance,  per  se ;  the  latter  are  local  and  general. 
The  former  are  catarrhal ;  the  latter  the  result  of  stenosis. 

Local  Symptoms.  In  a  large  number  of  cases  there  is  discharge 
from  the  nose.  This  may  be  mucopurulent,  or  be  associated  with 
crusts.  If  the  discharge  is  not  constant,  the  child  is  subject  to  coryza, 
with  its  customary  discharge,  on  the  slightest  provocation.  With  or 
without  the  chronic  purulent  nasal  discharge  mucus  and  blood  may 
be  passed  at  night  and  found  on  the  pillow  in  the  morning. 

The  hearing  is  frequently  impaired.  There  may  be  simply  dulness 
of  hearing,  or  it  may  amount  to  marked  deafness,  either  because  of 
pressure  of  the  adenoid  vegetations,  or  extension  of  secondary  inflam- 
mation to  the  Eustachian  tubes.  The  senses  of  taste  and  smell  are  often 
much  impaired.  There  is  increase  in  the  secretion  of  pharyngeal 
mucus,  which  in  older  persons  causes  difficult  expectoration. 

Rhinoscopic  Examination.  The  roof  of  the  pharynx  is  covered 
with  rounded  or  villous  projections,  often  concealing  the  posterior 
nares.  Rarely  the  villi  may  be  seen  projecting  below  the  soft  palate. 
In  children  the  examination  is  difficult,  and  hence  digital  exploration 
must  be  used  under  an  anaesthetic.  The  finger  readily  detects  the 
masses,  which  sometimes  are  soft,  at  other  times  tough  and  of  fibrous 
or  cartilaginous  consistency. 

The  Appearance.  The  expression  of  the  face  is  characteristic. 
It  is  dull  and  stupid,  and  may  be  drawn.  (Fig.  187.)  The  mouth  is 
kept  open  in  breathing.  The  lips  are  dry,  and  may  be  cracked.  They 
are  thickened.     The  palatal  arch  is  high  and  narrowed. 

The  nostrils  are  flattened  laterally.  Rarely  they  may  be  depressed. 
In  one  instance,  which  the  writer  saw  with  Dr.  Harrison  Allen,  the 
exterior  of  the  nose  suggested  inherited  syphilis,  all  the  more  because 


DISEASES  OF  MOUTH,   FAUCES,  PHARYNX,   CESOPHAGUS.     715 


Fig.  187. 


of  our  knowledge  of  the  possible  presence  of  the  disease.  There  were 
no  other  evidences  of  hereditary  syphilis  in  the  child  or  in  any  mem- 
ber of  the  family. 

The  Voice.     It  is  thick  and  muffled,  becoming  indistinct  upon  the 
occurrence  of  slight  cold. 

The  Chest  While  there  is  a  general  lack  of  physical  development, 
the  appearance  of  the  chest  is  most  striking.  The  cases  have  been 
frequently  mistaken  for  rickets,  however ;  in  this  country  adenoid  veg- 
etations are  a  common  cause  of  chest- 
deformity,  whereas  in  England  and  on 
the  continent  rickets  is  the  most  frequent 
cause.  The  ribs  are  prominent  in  front, 
the  sternum  is  angulatecl  forward  at  the 
manubrio-gladiolar  j  unction  and  grooved 
at  the  gladiolar-xiphoid  junction.  A 
saucer-shaped  depression  is  found  at 
the  lower  costal  cartilages.  The  ribs 
behind  are  closely  compressed,  so  that 
the  intercostal  spaces  at  the  lower  part 
of  the  chest  are  obliterated.  The  chicken- 
breast  appearance  is  most  striking,  with 
the  depression  in  the  lower  portions  of 
the  chest.  The  diaphragm  may  be 
drawn  in  during  inspiration  in  the 
middle  and  lateral  thoracic  regions. 

In  addition  to  the  "  chicken "  or 
"  pigeon-breast "  the  more  advanced 
deformity  known  as  the  "funnel-breast" 
or  trichterbrust  is  seen.  In  children 
who  suffer  from  asthma  and  bronchitis, 
the  chest  becomes  emphysematous. 

Mental  and  Neevous  Symptoms. 
Headache,  listlessness,  and  indisposition 
for  mental  exertion  are  marked.  The 
patients  are  usually  backward  in  their 
studies  and  are  unable  to  fix  their  at- 
tention for  any  length  of  time  upon  any 
subject.  The  child  is  forgetful  and  can- 
not study  without  effort.  Aprosexia  is 
the  term  applied  to  this  condition. 

Choreiform  spasm  of  the  face  occurs 
in  connection  with  it.  Enuresis  is  a 
frequent  associate  symptom.  The  child 
is  subject  to  frequent  attacks  of  indiges- 
tion. I  have  seen  the  following  occur  in  many  cases  :  Prior  to  opera- 
tion the  child  had  an  abnormally  poor  appetite  and  was  subject  to  fre- 
quent attacks  of  indigestion,  characterized  by  vomiting,  with  fever. 
After  the  operation  the  appetite  improved  and  continued  good,  and 
the  attacks  of  indigestion  disappeared  entirely.  The  cases  had  been 
under  observation  before  and  after  the  operation  for  a  number  of  years. 


Appearance  in  adenoid  disease. 
(Dawson-Williams.) 


716  SPECIAL  DIAGNOSIS. 

The  indigestion  seems  to  have  been  due  to  the  fact  that,  owing  to  the 
obstruction,  the  child  would  have  to  eat  rapidly,  in  order  to  keep  the 
lumen  of  the  mouth  free  for  breathing  puq:>oses.  The  rapid  eating, 
of  course,  prevented  proper  mouth-digestion,  and  hence  the  occurrence 
of  gastric  catarrh. 

Symptoms  from  Embarrassed  Eespiratiox.  In  addition  to 
mouth-breathing,  the  patient  snores  at  night,  and  sleep  is  always  dis- 
turbed. The  respirations  are  irregular,  with  a  pause  between,  fol- 
lowed by  noisy  'inspirations.  The  difficulty  of  breathing  is  the  cause 
of  restlessness,  and  the  child  will  often  wake  up  in  the  night  with 
dyspnoea.  Night-restlessness,  with  dyspnoea  and  irregular  respirations, 
should  point,  therefore,  to  obstruction  in  the  nasopharynx. 

Diagnosis  is  based  upon  the  facies,  which  is  very  characteristic,  and 
the  physical  examination.  In  children,  digital  examination  is  neces- 
sary. The  finger  can  readily  detect  small,  flat  bodies  or  grape-like 
masses  in  the  nasopharynx. 

The  student  cannot  become  too  familiar  with  the  symptoms  and 
signs  of  adenoid  disease  of  the  nasopharynx.  There  is  no  doubt  that 
in  our  large  cities  this  local  affection  is  of  more  common  occurrence 
and  more  disastrous  in  its  results  than  any  other  that  we  have  to  deal 
with  in  children.  It  may  be  said  that  in  children  in  poor  health, 
ansemic,  with  impaired  digestion,  and  lack  of  muscular  and  physical 
development,  if  the  causes  are  not  due  to  impure  air  and  improper 
diet,  or  to  improper  sanitation  generally,  it  is  almost  certain  that  there 
is  disease  of  the  nasopharynx.  The  writer  has  seen  a  very  large  num- 
ber of  cases  in  recent  years  in  his  practice,  and  has  had  the  satisfac- 
tion of  seeing  the  entire  picture  of  the  child  change  after  proper  opera- 
tions. It  may  be  said  in  passing  that  this  change  does  not  take  place 
at  once,  but  after  three  to  twelve  months  the  child  will  be  fully 
restored  in  physique,  if  during  that  time  attention  is  paid  to  proper 
exercise  and  the  development  of  the  chest.  ^Notwithstanding  all  this, 
however,  the  natural  shape  of  the  chest  and  appearance  of  the  face  are 
only  resumed  gradually. 

Inflammations  of  the  Pharynx.  Inflammation  of  the  pharynx, 
acute  pharyngitis,  or  sore-throat,  follows  cold  or  exposure,  particularly 
after  the  patients  have  been  physically  depressed.  The  acute  inflam- 
mation may  be  associated  with  rheumatism  or  gout.  The  inflammation 
often  involves  the  tonsils  as  well  as  the  pharynx.  The  symptoms  are 
pain  on  swallowing,  with  dryness  and  a  constant  desire  to  hawk  and 
cough,  on  account  of  the  tickling  sensation.  There  may  be  slight 
laryngitis  and  inflammation  of  the  Eustachian  tubes,  with  deafness. 
Stiffness  of  the  neck  and  enlargement  of  the  cervical  glands  attend  the 
local  inflammation.  The  general  symptoms  are  not  marked.  The 
attack  is  ushered  in  by  chilliness  and  slight  fever.  On  examination 
the  mucous  membrane  is  seen  to  be  congested,  dry,  and  fflistenino-, 
and  covered  m  spots  with  sticky  secretions.  The  uvula  may  be  very 
much  swollen.  AVhen  the  submucous  tissues  are  involved  the  parts 
are  more  swollen  and  there  is  greater  dyspnoea.  The  dysphagia  is 
more  marked,  although  the  pain  is  not  any  greater.  The  fever  is 
higher.     The  larynx  is  always  involved,  causing  aphonia. 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,   OESOPHAGUS.     717 

Phlegmonous  Inflammation.  A  diffused  inflammation  of  this 
character  occurs.  The  writer  saw  one  case  with  dyspnoea,  nervous 
symptoms,  and  high  temperature,  simulating  severe  pneumonia. 
Pneumonia  was  thought  to  be  present  because  there  were  congestion 
and  oedema  of  the  lungs.  It  occurred  during  the  prevalence  of  the 
recent  epidemic  of  influenza.  The  disease  began  in  the  pharynx  ;  the 
tissues  were  swollen  and  infiltrated.  The  early  symptoms  were  phar- 
yngeal. The  dysphagia  was  extreme,  and  there  was  an  abundant 
mucopurulent  expectoration,  which  did  not  contain  pneumococci. 
Death  took  place  on  the  ninth  day  from  exhaustion.  The  autopsy 
showed  a  high  degree  of  congestion  of  the  lungs,  and  phlegmonous 
inflammation  of  the  pharynx,  larynx,  and  trachea.  While,  therefore, 
the  recognition  of  an  acute  phlegmonous  inflammation  is  not  difficult, 
it  must  not  be  forgotten  that  it  is  a  grave  disease,  which  may  present 
such  marked  pulmonary  and  systemic  symptoms  as  to  lead  to  the  sus- 
picion of  pneumonia. 

Angina  Ludovici  is  an  inflammation  of  the  cellular  tissue  of  the 
floor  of  the  mouth  and  neck.  It  is  probably  a  form  of  actinomycosis. 
The  swelling  is  most  marked  below  the  jaw  of  one  side.  The  symp- 
toms are  very  intense  and  both  local  and  general.  There  are  general 
septic  symptoms  from  the  outset.  With  the  swelling  there  are  oedema 
and  board-like  induration.  Redness  and  the  rapid  formation  of  an 
abscess  occur  rarely.  The  throat  is  not  affected.  Death  takes  place 
from  reflex  suffocation  or  in  coma.     (See  The  Mouth.) 

Rheumatic  pharyngitis  is  of  short  duration,  without  objective 
symptoms.  Pain  is  intense,  deglutition  difficult.  The  usual  concomi- 
tants of  rheumatism  are  present.  It  frequently  gives  place  to  torti- 
collis, lumbago,  or  rheumatism  in  some  other  situation. 

Chronic  pharyngitis  follows  acute  attacks,  and  is  a  frequent 
accompaniment  of  nasal  catarrh.  It  is  common  in  smokers  and'  alco- 
holic subjects  ;  the  use  of  the  voice  in  loud  tones,  as  bv  clergymen, 
auctioneers,  etc.,  is  also  a  cause.  It  is  a  frequent  attendant  upon  in- 
digestion, due  probably  to  the  eructations.  The  objective  signs  are 
relaxation  of  the  mucous  membrane,  with  dilatation  of  the  veins.  The 
membrane  is  covered  with  a  thick  secretion,  which  is  dry  and  glisten- 
ing. In  the  granular  form  the  Avail  of  the  pharynx  is  covered  with 
millet-seed  projections  and  is  congested.  Tough  mucus  is  seen  in 
small  areas. 

Retropharyngeal  Abscess.  The  inflammation  may  begin  in 
the  submucous  connective  tissue,  and  a  retropharyngeal  abscess  form. 
There  are  high  fever  and  dysphagia,  with  stiffness  of  the  neck  and 
enlarged  glands.  On  examination  a  projection  into  the  pharynx  can 
be  seen  or  distinctly  felt  on  the  posterior  wall.  The  disease*  may  be 
difficult  of  recognition  in  infants,  in  whom  it  is  not  possible  to  gei  a 
good  view  of  the  pharynx.  On  the  other  hand,  it  may  be  simulated 
by  disease  of  the  cervical  vertebra?,  in  which  there  may  be  stiffness. 
difficulty  in  deglutition,  and  possibly  a  tumor.  It  must  not  be  for- 
gotten that  retropharyngeal  abscess  may  result  from  caries  of  the  cer- 
vical vertebra?.  In  children  the  abscess  is  attended  with  dyspnoea  and 
alteration  in  the  voice,  so  that  laryngeal  disease  may  be  suspected.     I 


718  SPECIAL  DIAGNOSIS. 

recall  a  case  of  retropharyngeal  abscess  in  which  the  dyspnoea  was  so 
severe  as  to  suggest  croup  ;  in  fact,  preparations  for  tracheotomy  were 
made,  when  sudden  rupture  of  the  abscess  revealed  the  nature  of  the 
disease.  Fortunately  the  child  had  been  kept  in  the  upright  position, 
so  that  pus  was  discharged  into  the  mouth,  or  suffocation  would  have 
ensued. 

Inflammation  of  the  Parotid  Gland.  First,  specific  inflammation 
or  parotitis  (see  Mumps) ;  second,  symptomatic  parotitis  occurs  in 
tvphoid  fever,  pneumonia,  pyaemia,  and  septicaemia.  The  process  is 
intense,  characterized  by  swelling,  redness,  and  heat  over  the  parotid 
gland.  There  are  pain  and  difficulty  of  mastication  ;  suppuration 
rapidly  ensues  in  the  septic  form.  It  is  thought  to  be  an  unfavor- 
able symptom,  but  I  have  seen  two  cases  in  typhoid  fever  get  well. 
In  a  case  of  septicaemia  it  did  not  advance  to  suppuration.  Stephen 
Paget  has  described  a  symptomatic  inflammation  in  disease  of  the 
abdomen  and  pelvis.  He  collected  101  cases,  50  of  which  were  due 
to  injury,  disease,  or  temporary  derangement  of  the  genital  organs, 
as  by  slight  blows,  or  in  females  to  the  introduction  of  a  pessary.  It 
may  occur  before  the  menstrual  period  or  during  pregnancy.  Septi- 
caemia or  pyaemia  does  not  attend  the  process — indeed,  many  of  the 
cases  are  afebrile.  In  78  cases,  45  suppurated  and  33  resolved  with- 
out suppuration. 

Gowers  describes  a  case  of  parotitis  which  occurred  in  the  course  of 
fatal  peripheral  neuritis. 

The  (Esophagus. 

The  oesophagus  is  open  to  all  affections  which  arise  in  mucous  mem- 
branes, although  its  histological  structure,  its  position,  and  its  func- 
tions largely  protect  it  from  involvement  in  disease.  Should  morbid 
processes  arise,  the  symptoms  expressive  of  these  processes  are  the 
common  symptoms  of  disease  of  the  mucous  membrane.  But  the  oesoph- 
agus is  a  closed  tube,  the  function  of  which  is  to  convey  food  from 
the  pharynx  to  the  stomach.  It  is  subject  to  all  the  affections  common 
to  channels.  Any  disease  of  the  tube  interferes  with  its  function, 
made  evident  by  the  symptom  common  to  all  disorders  of  the  oesoph- 
agus— dysphagia.  As  this  symptom  occupies  a  position  of  such  promi- 
nence in  the  symptomatology  of  disease  of  this  tube,  it  is  evident  that 
the  diagnosis  of  disease  resolves  itself  into  the  differentiation  of  all 
forms  of  difficulty  of  deglutition. 

Before  beginning  the  discussion  along  the  lines  indicated,  the  sub- 
jective and  objective  symptoms  of  disease  of  the  oesophagus  must  be 
considered. 

The  Subjective  Symptoms.  Pain  is  a  common  symptom  of  dis- 
ease of  the  oesophagus.  In  acute  inflammation  it  is  extreme,  and  is 
complained  of  in  the  neck,  between  the  shoulders,  and  along  the  verte- 
brae for  a  short  distance.  Its  character  depends  upon  the  cause.  Severe 
burning  pain,  often  agonizing,  is  due  to  inflammation  caused  by  hot 
or  caustic  fluids.  Absence  of  pain  after  the  ingestion  of  such  sub- 
stances, or  its  disappearance  in  a  short  time,  points  to  extreme  corro- 
sive action  and  gangrene.     Pain  attends  and  is  a  part  of  the  symptom 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,   OESOPHAGUS.     719 

— dysphagia  (q.  v.).  Cough  attends  such  diseases  of  the  oesophagus  as 
exert  pressure  upon  the  bronchus,  as  carcinoma. 

The  Objective  Symptoms.  Stiffness  of  the  neck  is  seen  in  acute 
inflammation  of  the  oesophagus  and  in  peri-cesophageal  abscess  ;  it 
may  also  occur  in  traumatism.  The  expectoration  in  diseases  of  the 
oesophagus  is  characteristic.  It  is  usually  a  glairy  mucus,  often  frothy 
or  viscid.  It  is  not  coughed  up,  but  after  welling  into  the  pharynx 
is  hawked  up.  It  is  abundant  in  acute  and  chronic  inflammation  and 
in  cancer. 

Hemorrhage  from  the  (Esophagus.  Hemorrhage  from  the 
oesophagus  occurs  from  varicosity  of  the  veins  at  the  lower  portion  of 
the  gullet.  It  may  occur  in  old  people,  from  senile  disease  of  the 
liver,  kidney,  and  spleen,  or  at  any  age  in  cirrhosis  of  the  liver.  In 
hemorrhage  from  the  oesophagus  the  blood  is  usually  bright  in  color, 
has  not  been  acted  on  by  an  acid,  as  in  hsematemesis,  and  is,  therefore, 
alkaline  in  reaction,  and  is  not  discharged  by  vomiting,  although  vom- 
iting may  occur  after  the  blood  is  poured  out.  In  a  grave  case  of 
purpura  under  the  care  of  the  writer  hemorrhage  took  place  from  the 
lower  end  of  the  oesophagus.  Small  bleedings  from  the  oesophagus  are 
usually  indicative  of  cancer,  especially  if,  in  addition  to  the  hemor- 
rhage, there  are  present  the  symptoms  of  occlusion.  Hemorrhage  is 
also  seen  in  foreign  bodies  :  (1)  from  trauma ;  (2)  from  ulceration. 
Emaciation  is  the  most  characteristic  general  symptom  of  oesophageal 
disease.  It  is,  of  course,  more  striking  in  cancer,  but  occurs  to  a  mod- 
erate degree  in  all  forms  of  stricture.  Foetor  of  the  breath  attends 
dilatation  of  the  oesophagus. 

Emphysema  of  the  subcutaneous  connective  tissue  should  always  lead 
to  investigation  of  the  oesophagus.  Usually  it  is  found  to  have  been 
preceded  by  pronounced  symptoms  of  disease  of  the  oesophagus.  In 
rare  cases  ulceration  of  the  oesophagus  may  progress  without  symp- 
toms, and  extend  into  the  air-passages.  The  passage  of  air  through 
the  fistulous  communication  causes  subcutaneous  emphysema.  It  is  of 
frequent  occurrence  when  foreign  bodies  lodge  in  the  gullet. 

Physical  Examination.  Examination  of  the  oesophagus  is  made 
by  inspection  and  auscultation,  and  by  means  of  palpation  with  or 
without  a  bougie. 

Inspection  can  be  made  only  with  an  endoscope. 

Auscultation  of  the  oesophagus,  while  the  patient  is  swallowing 
fluids,  sometimes  confirms  the  results  obtained  by  instrumental  palpa- 
tion as  to  the  seat  of  an  obstruction.  A  gurgling  sound  is  audible  to 
the  left  of  the  spine  as  the  fluid  passes  the  obstruction. 

Palpation.  The  oesophagus  behind  the  trachea  in  the  neck  may  be 
palpated  when  it  is  enlarged,  as  in  abscess.  Palpation  yields  the 
most  positive  results. 

It  must  not  be  forgotten  that  the  normal  constriction  of  the  oesoph- 
agus is  situated  nearly  opposite  the  fourth  dorsal  vertebra,  ten  inches 
from  the  teeth.  The  bougie  is  used  to  determine  the  cause  of  diffi- 
culty in  swallowing.  If  the  cause  is  due  to  paralysis  or  to  spasm  of 
the  oesophagus  the  bougie  can  usually  be  passed  with  ease.  If,  on 
the  other  hand,  it   is   due   to   organic  disease,  an  obstruction  will  be 


720  SPECIAL  DIAGNOSIS. 

found.  In  organic  disease  this  is  generally  in  the  upper  half  of  the 
oesophagus.  If  near  the  pharynx,  the  obstruction  is  due  to  cicatricial 
stricture.  If  the  obstruction  is  encountered  nine  inches  from  the  teeth 
or  about  the  position  of  the  bronchus,  it  is  usually  due  to  cancer. 
The  bougie  should  not  under  any  circumstances  be  passed  if  there  are 
grounds  for  believing  there  is  an  aneurism.  Fatal  rupture  has  fol- 
lowed its  passage  under  such  circumstances. 

Method.  The  patient  should  be  seated  with  the  head  thrown  back 
sufficiently  far  to  make  the  passage  from  the  pharynx  to  the  oesopha- 
gus almost  continuous.  The  operator  may  stand  behind  or  in  front  of 
the  patient.  The  bougie,  held  like  a  pen,  should  be  passed  through 
the  pharynx,  guided  by  the  fingers,  close  to  its  posterior  wall.  But 
little  force  should  be  used.  It  should  be  passed  slowly,  when  the 
gagging  will  soon  be  overcome.  The  bougie  should  be  warmed  and 
oiled  before  it  is  introduced.  The  handles  should  be  flexible,  the  bulb 
olive-shaped. 

Obstruction  of  the  (Esophagus.  Dysphagia  is  a  symptom  com- 
mon to  all  diseases  of  the  oesophagus.  It  may  vary  from  simple  pain- 
dvsphagia  to  complete  obstruction  of  the  tube.  Dysphagia  from  ob- 
struction of  the  oesophagus  is  due  (1)  to  disease  outside  of  the  canal 
(external  pressure),  (2)  to  disease  of  the  canal  itself,  and  (3)  to  the  pres- 
ence of  a  foreign  body  in  the  canal.  In  the  consideration  of  this  symp- 
tom, therefore,  these  conditions  must  be  studied. 

1.  External  Pressure.  The  oesophagus  at  different  parts  of  its 
course  is  in  intimate  relationship  with  the  trachea,  the  thyroid  gland, 
the  carotid  artery,  the  left  bronchus,  the  bronchial  glands,  the  arch  of 
the  aorta,  and  the  descending  aorta.  Disease  of  these  structures  at- 
tended by  enlargement  may,  therefore,  cause  difficulty  in  swallowing. 
It  is  not  likely  that  difficulty  of  deglutition  from  disease  of  the  trachea, 
thyroid  gland,  or  carotid  arteries  will  be  overlooked.  If  the  trachea 
is  affected,  dyspnoea  will  be  a  prominent  symptom  ;  if  the  thyroid 
gland,  dyspnoea  will  be  associated  with  dysphagia,  and  the  enlarged 
gland  will  be  visible  from  the  outside.  Disease  of  the  vertebra?  is 
not  likely  to  cause  obstruction  of  the  oesophagus,  for  it  would  not  press 
that  organ  against  any  other  solid  structure.  Disease  of  other  struc- 
tures, however,"  may  cause  difficulty  of  deglutition  by  pressing  the 
oesophagus  against  the  vertebrae.  Within  the  thorax,  disease  of  the 
mediastinal  glands,  aneurism  of  the  arch,  or  descending  portion  of  the 
aorta,  an  enlarged  left  auricle,  a  pericardial  effusion  or  disease  of  the 
left  bronchus  might  cause  constriction  of  the  oesophagus.  The  medi- 
astinal glands  are  enlarged  from  tuberculosis,  carcinoma,  sarcoma,  or 
syphilitic  disease.  The  occurrence  of  physical  signs  of  a  mediastinal 
tumor,  with  a  history  of  syphilis  or  the  general  symptoms  of  tuber- 
culosis, sarcoma,  or  carcinoma,  would  point  to  the  presence  of  these 
affections.  In  aneurism  of  the  aorta,  in  its  arch  or  transverse  portion, 
the  physical  signs  and  subjective  symptoms  of  aneurism — with  accent- 
uation of  the  aortic  second  sound  and  the  presence  of  atheroma — 
would  lend  color  to  the  view  that  the  obstruction  was  of  this  nature.  In 
both  instances  just  mentioned  the  obstruction  rarely  goes  to  the  extent 
of  preventing  the  passage  of  liquids.     In  enlargement  of  the  left  auri- 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,   CESOPHAGUS.     721 

cle  and  in  pericardial  effusion  the  degree  of  difficulty  may  amount 
simply  to  a  temporary  sense  of  obstruction  or  pain  about  the  point 
where  food  passes  these  structures.  If  the  early  physical  signs  are 
associated  with  an  enlarged  auricle,  with  mitral  stenosis,  or  with  peri- 
cardial effusion,  the  diagnosis  of  the  causal  condition  is  easy.  It  is 
particularly  important,  in  considering  difficulty  of  deglutition  from 
external  pressure,  to  remember  that  the  oesophagus  is  in  close  relation 
with  the  bronchus  on  the  left  side,  at  about  the  fourth  dorsal  vertebra 
—ten  inches  from  the  teeth — in  case  it  is  desirable  to  investigate  the 
obstruction  with  a  probe.  Obstruction  from  aneurism  of  the  descend- 
ing portion  of  the  arch  of  the  aorta  is  also  located  at  the  upper  portion 
of  the  oesophagus,  nine  inches  from  the  incisor  teeth. 

2.  Organic  Disease.  Difficulty  of  deglutition,  due  to  disease  of 
the  oesophagus  itself,  occurs  in  acute  inflammation,  in  chronic  inflam- 
mation, and  in  stricture,  which  is  always  the  result  of  traumatic  in- 
flammation, syphilis,  or  cancer. 

Acute  inflammation  is  recognized  by  severe  pain  on  swallowing.  It 
is  associated  with  the  sensation  of  a  foreign  body  in  the  lower  portion 
of  the  throat.  There  may  be  tenderness  on  pressure  along  the  course 
of  the  pharynx.  The  pain  is  aggravated  by  speaking.  The  pain  may 
extend  along  the  vertebral  column  to  the  cardiac  end  of  the  stomach, 
and  is  usually  of  a  burning  or  raw  character.  When  the  inflammation 
is  due  to  traumatism,  as  the  swallowing  of  acids  or  other  caustics,  the 
mouth  and  pharynx  show  the  effects  of  the  inflammation,  and,  in  addi- 
tion, there  is  agonizing,  burning  pain  at  the  root  of  the  neck  and  be- 
tween the  shoulders.  The  inflammation  is  usually  attended  by  erosion 
of  the  mucous  membrane,  and  hence  not  only  frothy  mucus  of  a  glairy 
character  is  expectorated,  but  also  blood  and  shreds  of  membrane. 
The  effect  of  the  corrosive  poisoning  on  the  general  system  is  marked. 
There  is  great  prostration.  Because  of  the  accompanying  gastritis 
there  is  intense  thirst.  Acute  inflammation  of  the  oesophagus  may 
end  in  ulceration  or  in  resolution.  The  traumatic  inflammation  is 
followed  by  chronic  inflammation,  which  ultimately  results  in  stricture. 

Chronic  inflammation  is  attended  by  pain  in  the  act  of  swallowing  ; 
liquids  are  swallowed  readily,  but  solids  with  great  difficulty.  Viscid 
mucus  is  expectorated,  usually  in  large  amounts. 

Abscess  of  the  Oesophagus.  The  acute  inflammation  may  terminate 
in  abscess.  The  abscess  usually  develops  slowly,  with  pain  on  swal- 
lowing and  on  movements  of  the  neck.  When  the  abscess  is  high 
up  in  the  gullet  it  may  present  on  the  exterior  of  the  neck.  If  it  is 
situated  outside  of  the  oesophagus,  and  is  secondary  to  disease  of  the 
vertebrce,  it  is  slow  and  chronic  in  its  course  ;  fever  and  rigors  attend 
its  development. 

Stricture  of  the  oesophagus  due  to  the  healing  of  ulcers,  following 
traumatic  inflammation,  is  recognized,  first,  by  the  gradual  development 
of  the  symptoms,  by  the  painless  nature  of  the  obstruction  in  the  large 
majority  of  cases,  and  by  its  seat.  It  is  readily  found  by  the  use  of  a 
bougie ;  the  patient  can  sometimes  localize  the  area  in  the  upper  por- 
tion of  the  oesophagus.  The  difficulty  of  deglutition  continues  over 
such  a  long  period  of  time  that  the  nutrition  is  but  slowly  interfered 

46 


722  SPECIAL  DIAGNOSIS. 

with,  but  gradual  emaciatiou  with  coincident  anamiia  develops  eventu- 
ally. 

Carcinoma  of  the  (Esophagus.  In  cancer  of  the  oesophagus  dys- 
phagia is  the  most  prominent  symptom.  It  comes  on  gradually.  The 
patient  expectorates  a  considerable  quantity  of  frothy  mucus,  often 
containing  blood,  and  revealing,  on  careful  examination,  cancerous 
tissue  at  times.  Pain  is  not  generally  very  severe.  Cough  is  usually 
present,  due  to  pressure  of  the  cancerous  mass  on  the  recurrent  laryn- 
geal or  pneumogastric  nerve.  Sometimes  the  cancer  develops  in  the 
anterior  wall,  and  ulcerates  into  the  trachea  or  bronchus.  When  this 
complication  takes  place  the  cough  is  violent.  Dyspnoea  from  pressure 
is  likely  to  occur.  Perforation  of  the  oesophagus  into  the  air-passages 
is  followed  by  pulmonary  abscess  or  gangrene,  or  the  sudden  appear- 
ance of  dyspnoea,  and  shortly  the  onset  of  aspiration  pneumonia. 
"When  ulceration  causes  a  pulmonary  oesophageal  fistula  the  condition 
may  simulate  that  of  phthisis. 

The  difficultv  of  deglutition  due  to  cancer  must  be  distinguished 
from  that  of  traumatic  or  syphilitic  stricture  and  from  spasmodic  stric- 
ture and  paralysis  of  the  oesophagus.  The  history  of  the  case  aids  in 
the  recognition  of  traumatic  or  syphilitic  stricture,  while  the  ready 
passage  of  a  bougie  indicates  that  the  difficulty  is  spasm  or  paralysis. 
Cancer  usually  occurs  late  in  life  and  is  attended  with  rapid  emacia- 
tion. Its  complications,  more  common  than  in  other  obstructions,  are 
attended  with  fever  and  rapid  prostration.  Cancer  may  be  distin- 
guished from  disease  outside  of  the  oesophagus  by  the  condition  of  the 
stomach  beyond  the  point  of  stricture.  If  there  is  cancer,  atrophy  is 
more  likely  to  take  place,  the  change  in  size  being  recognized  by  a 
tube  or  by  inflating  the  stomach  with  air  or  fluids. 

Sarcoma  of  the  oesophagus  is  very  rare.  It  occurs  most  frequently 
in  males  and  presents  symptoms  like  those  of  carcinoma. 

3.  Foreign  Body.  Stricture  or  difficulty  of  deglutition  from  the 
presence  of  foreign  bodies  is  usually  recognized  with  ease.  The  diffi- 
culty of  deglutition  is  due  both  to  the  foreign  body  and  to  the  spasm 
excited  by  the  mass.  In  consecmence  of  the  latter  regurgitation  of 
food  takes  place.  In  the  first  place,  there  is  a  history  of  the  swal- 
lowing of  a  foreign  material.  Sudden  pain  succeeds  the  act,  while 
there  are  great  anxiety  and  distress,  particularly  if  the  body  is  a  large, 
hard  mass.  Xot  only  is  there  difficulty  in  deglutition,  but  also  dysp- 
noea. The  latter  is  due  to  pressure,  but  is  aggravated  by  the  nervous 
state.  "When  the  foreign  body  is  small  the  dysphagia  is  moderate  in 
degree  and  the  reflex  irritation  slight,  although  nausea  and  vomiting 
may  be  common.  If  it  cannot  be  removed,  ulceration  and  abscess 
result,  the  further  course  of  which  depends  upon  the  seat  of  the  ob- 
structing material.  Pain,  hemorrhage,  subcutaneous  emphysema,  and 
the  emission  of  air  are  symptoms  which  follow.  The  exact  location 
of  the  foreign  body  may  be  ascertained  by  the  use  of  the  Eontgen  rays, 
as  in  the  remarkable  case  of  "White's. 

Harrison  Allen1,  in  his  exhaustive  essay,  calls  attention  to  several 

1   "Foreign  Bodies  in  the  (Esophagus."    Allen  :  New  York  Medical  Journal,  August 
17,   1895. 


DISEASES  OF  MOUTH,  FAUCES,  PHARYNX,   CESOPHAGUS.     723 

features.  Many  of  the  symptoms  are  primary  and  some  are  secondary. 
The  former  are  due  to  the  trauma  and  the  presence  of  the  foreign  body  ; 
the  latter  to  the  secondary  ulceration.  This  softening  and  ulceration 
of  the  walls  may  take  place  rapidly.  Allen  does  not  think  that  pain 
or  the  occurrence  of  convulsions  is  of  much  significance,  but  that  em- 
physema, the  excessive  secretion  of  mucus,  and  the  emission  of  air  are 
important  signs.  Anxiety  he  considers  of  very  common  occurrence 
and  very  suggestive.  The  excessive  secretion  of  ropy  mucus,  saliva- 
tion included,  is,  in  Allen's  judgment,  pathognomonic  of  disease  in 
the  pharyngo-larynx  or  in  the  oesophagus,  at  or  above  the  level  of  the 
left  bronchus.  Tins  secretion  may  be  an  early  indication  of  cancer  of 
the  oesophagus.     It  may  occur  in  aneurism. 

Dilatation  of  the  (Esophagus.  Primary  dilatation  of  the  oesopha- 
gus is  an  extremely  rare  affection.  The  chief  symptom  is  the  regurgi- 
tation of  food,  which  is  neutral  or  alkaline,  and  may  be  returned  some 
time  after  the  act  of  swallowing.  The  patient  sometimes  complains  of 
a  sensation  of  distention  along  the  course  of  the  oesophagus,  with  heat 
and  burning.  The  odor  of  the  breath  is  foetid.  If  the  oesophagus  is 
not  deflected,  a  bougie  can  be  passed  through  its  course. 

If  the  dilatation  is  secondary,  the  amount  of  dysphagia  depends 
upon  the  obstruction.  Food,  however,  is  not  returned  immediately. 
After  remaining  an  indefinite  time,  not  longer  than  two  hours,  it  is 
regurgitated  unchanged.  Bougies,  of  course,  do  not  pass.  In  saccu- 
lated dilatation,  which  usually  takes  place  in  the  posterior  wall  near 
the  pharynx,  a  bougie  may  sometimes  pass,  and  at  other  times  may  be 
caught  in  the  sac.  The  sac  may  be  enlarged,  so  as  to  retain  a  consid- 
erable amount  of  food,  which  is  regurgitated  some  time  after  it  is  swal- 
lowed. A  sacculated  diverticulum,  from  traction  on  the  outside  of 
the  oesophagus,  may  occur  when  there  is  glandular  disease  of  the  neck, 
with  adhesions  to  the  oesophagus. 

Functional  Affections  of  the  (Esophagus.  The  functional  affec- 
tions are  quite  as  common  as  organic  disease.  They  are  of  longer 
duration,  but  are  unattended  by  the  same  grave  effects  upon  the  gen- 
eral system.  Spasm  is  one  of  the  most  frequent  affections.  It  may 
be  so  intense  as  to  lead  to  temporary  stricture.  It  usually  occurs  in 
women.  The  attack  comes  on  suddenly  during  the  act  of  swallowing 
food.  The  food  is  at  once  regurgitated.  After  the  subsidence  of  the 
perturbation,  swallowing  can  be  accomplished,  if  it  is  done  slowly. 
It  usually  occurs  in  hysteria.  The  patient  may  have  had  some  slight 
accident  in  the  performance  of  the  ordinary  act  of  deglutition,  out  of 
which  grew  the  idea  that  swallowing  cannot  be  accomplished.  In 
consequence,  the  further  acts  are  performed  with  trepidation,  and  slight 
emotional  disturbance  at  the  table  may  cause  a  recurrence  of  the  sud- 
den spasm. 

Unfortunately  calling  attention  to  the  act  of  swallowing  always  has 
the  effect  of  embarrassing  the  patient,  and  the  taking  of  a  meal  under 
unusual  circumstances  is  sure  to  be  attended  by  complete  dysphagia. 
Sometimes  the  idea  is  conceived  that  certain  forms  of  food  alone  <"in- 
not  be  swallowed.  It  is  usually  thought  that  solid  food  gives  the 
distress.     Mitchell  says  that  the  dysphagia  occurs  early  in  cases  of 


724  SPECIAL  DIAGNOSIS. 

hysteria  ;  unless  relieved,  the  hysterical  symptoms  are  likely  to  be 
transferred  to  the  stomach.  I  saw  a  female  patient  who,  after  an 
ordinary  choking  attack,  for  several  years  could  not  swallow  food  in 
the  presence  of  strangers,  or  after  the  slightest  emotional  disturbance, 
or  if  hurried.     The  spasm  disappeared  after  treatment  with  bougies. 

In  paralysis  difficulty  of  deglutition  is  the  main  symptom.  The 
course  of  oesophageal  paralysis  depends  upon  its  cause.  The  larynx  is 
usually  affected  at  the  same  time,  so  that  laryngeal  symptoms  are 
present.  Paralysis  generally  comes  on  very  gradually.  It  may  be 
due  to  cerebral  hemorrhage,  tumor,  bulbar  paralysis,  or  to  general 
paralysis  of  the  insane.  The  bougie  passes  easily,  and  does  not  cause 
irritation.     In  paralysis  there  is  no  regurgitation  of  food. 


PLATE    XXXV. 


w, 


■Quadrants  of  the  Abdomen.     Position  of  the  Viscera. 

Liver  and   colon— red  lines.    Stomach,  kidneys  and  bladder— solid  green  lines. 
Pancreas— dotted  green  lines. 


CHAPTER    V. 

DISEASES   OF  THE  STOMACH,  INTESTINES,  AND   PERITONEUM. 

The  abdomen  is  divided  arbitrarily  into  regions,  to  enable  us  to 
locate  the  various  organs  in  health  and  in  disease.  Simplicity  is  essen- 
tial, and  a  method  of  delimitation  that  is  commonly  used  in  the  subdi- 
vision of  other  regions  should  be  adopted,  for  the  sake  of  uniformity  of 
description  and  to  assist  the  memory  of  the  learner.  For  these  reasons 
Ballance's  method  of  dividing  the  surface  is  the  best.  This  author 
includes  the  abdomen  within  a  circle  which  has  the  umbilicus  as  its 
centre.  The  circle  is  divided  into  quadrants  by  diameters  drawn  at 
right  angles,  corresponding  to  the  median  and  transverse  umbilical 
lines.  The  portions  to  the  right  of  the  middle  lines  are  the  right 
upper  and  lower  quadrants,  respectively  ;  the  portion  to  the  left,  the 
left  upper  and  lower  quadrants.     (See  Plate  XXXV.) 

With  the  abdomen  thus  divided,  the  umbilicus  and  fixed  bony  struc- 
tures in  the  periphery  of  the  circle  serve  as  points  from  which  meas- 
urements are  made  to  indicate  the  exact  position  of  the  structure.  The 
circle  may  be  further  divided  by  other  radii.  To  locate  a  tumor  in 
the  right  lower  quadrant,  for  instance,  the  umbilicus,  pubic  bone,  and 
anterior  spine  of  the  ilium  may  be  used  as  points  from  which  to  meas- 
ure the  distance.  Measurements  may  also  be  made  along  the  radii 
extending  from  the  umbilicus  to  fixed  points.  The  following  illus- 
trates a  useful  method  :  A  tumor  is  situated  in  the  right  lower  quad- 
rant ;  the  centre  of  the  tumor  is  two  inches  below  a  point  on  the  transverse 
umbilical  line,  three  inches  from  the  centre  ;  it  is  also  three  inches 
to  the  right  of  a  point  on  the  median  line,  two  inches  from  the  umbili- 
cus. The  size  of  the  tumor  can  be  defined  by  measurements  from  its 
own  centre.  Organs  bisected  by  the  median  line,  as  the  bladder  and 
uterus,  can  be  described  as  situated  in  the  median  line,  so  many  inches 
to  the  right  and  left,  as  the  case  may  be,  and  so  many  inches  from  the 
pubis. 

The  right  upper  quadrant  includes  the  right  lobe  of  the  liver,  the 
gall-bladder,  the  hepatic  flexure  of  the  colon,  and  part  of  the  trans- 
verse colon,  a  portion  of  the  pancreas,  the  pyloric  orifice  near  the  me- 
dian line,  and,  deeper,  the  upper  half  of  the  kidney ;  the  left  upper 
quadrant,  the  left  lobe  of  the  liver,  the  stomach,  part  of  the  transverse 
colon  and  the  splenic  flexure,  the  pancreas,  the  upper  portion  of  the 
kidney  and  the  spleen  ;  the  right  lower  quadrant,  the  caecum,  the  ascend- 
ing colon,  appendix  vermiformis,  right  tube  and  ovary,  a  portion  of 
the  bladder  and  uterus,  and,  above,  the  lower  part  of  the  kidney  at  the 
end  of  full  inspiration  ;  the  left  lower  quadrant,  the  corresponding  tube, 
ovary,  and  portions  of  the  bladder  and  uterus,  the  descending  colon, 
and  the  sigmoid  flexure,  but  not  likely  the  lower  part  of  the  kidney, 
as  it  is  one-half  inch  or  more  higher  than  the  right  (Holden).     About 


726  SPECIAL  DIAGNOSIS. 

the  centre  and  extending  to  the  periphery  on  all  sides  are  the  small  and 
large  intestines. 

The   Data  Obtained   by  Inquiry.     The  Subjective   Symptoms 
of  Abdominal  Disease. 

This  class  of  symptoms  will  be  discussed  in  the  articles  devoted  to 
affections  of  the  particular  organs  of  the  abdomen,  because  the  symp- 
toms are  usually  directly  referred  by  the  patient  to  the  affected  organs. 
They  are  local  sensations  of  heat,  fulness,  or  distention,  of  burning, 
of  pain,  of  weight,  or  of  undue  motion.  Local  sensations  of  weight, 
fulness,  or  distention  are  due  to  enlargements  or  to  displacements  of. 
organs  (liver,  kidneys),  or  to  tumors.  Heat  or  burning  is  described 
in  inflammatory  tumors,  as  pyosalpinx.  It  is  often  difficult  for  the 
sufferer  to  define  the  location  of  pain  in  the  abdomen  and  describe  its 
features.  Moreover,  the  pain  is  frequently  due  to  disease  of  the  walls 
of  the  abdomen,  which  may  increase  the  confusion.  Pain  must  be  in- 
vestigated by  an  examination  of  each  structure  in  close  proximity  to 
the  part  complained  of.  The  state  of  the  function  of  each  organ  must 
also  be  inquired  into. 

Paix  Confixed  to  the  Abdominal  Walls.  The  skin,  the 
nerves,  the  muscles  and  fascia,  the  connective  tissue,  may  be  the  seat 
of  pain.  If  the  skin  is  affected,  the  pain  is  usually  localized  and  of 
moderate  degree  of  severity.  There  is  superficial  tenderness.  There 
are  evidences  of  inflammation,  as  erythema  or  ulcers.  Pain  due  to 
affections  of  the  nerves  is  seen  in  simple  neuralgia  and  herpes  zoster. 
Herpes  zoster  is  recognized  by  the  localized  neuralgic  character  of  the 
pain  in  the  distribution  of  superficial  nerves  and  the  peculiar  eruption 
which  follows.  Xeuralgias  are  recognized  by  the  well-known  points 
of  tenderness,  the  intermittent  character  of  the  pain,  and  the  association 
with  ansemia ;  neuritis  may  be  present,  with  the  usual  objective  signs. 

Rheumatism,  The  muscles  and  fascia  may  be  the  seat  of  rheuma- 
tism, causing  severe  pain.  The  muscles  are  tender.  Movement  always 
increases  the  pain,  and  sighing,  laughing,  or  coughing  aggravates  it. 
The  pain  may  be  diffuse  and  severe,  causing  it  to  be  confounded  with 
peritonitis.  The  presence  of  rheumatism  in  other  muscles,  of  moderate 
fever  without  gastro-intestinal  disturbance,  of  uric  acid  and  urates  in 
excess,  due  to  the  rheumatic  diathesis,  point  to  the  true  condition. 

Referred  Paix.  A  common  cause  of  pain  in  the  abdomen  is  dis- 
ease of  the  vertebra?,  with  pressure  upon  the  peripheral  nerves  at  their 
emergence  from  the  spinal  column.  The  pain  is  situated  in  the  median 
line,  either  below  the  ensiform  cartilage  or  around  the  navel ;  it  is  an 
intermittent  pain.  Aneurism  of  the  abdominal  aorta,  with  pressure 
upon  and  erosion  of  the  vertebrae,  causes  the  same  kind  of  pain. 

Paix  withix  the  Abdomex.  The  seat  of  the  pain,  if  general  or 
local,  will  be  considered  in  discussing  the  special  organs  and  their 
diseases.  In  general,  it  may  be  said  that  the  seat  of  the  pain  is  a  fair 
index  of  disease  of  some  structure  in  the  part  indicated.  When  the 
pain  is  general  it  points  to  rheumatism  or  to  peritonitis. 

Charade-  of  Pair).  Attacks  of  severe  pain  in  the  abdomen  may  be 
sudden  in  onset,  or  the  culmination  of  slight  sensations  of  discomfort 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     727 

progressively  increasing  in  severity.  The  pain  may  be  of  brief  dura- 
tion or  may  continue  over  a  long  period  of  time.  Sudden  acute  pain 
points  to  inflammation,  to  perforation  of  some  one  of  the  hollow  viscera, 
to  gastralgia,  to  enteralgia,  flatulent  distention  of  the  stomach  or  of 
the  intestines,  or  to  occlusion  of  channels,  of  which  the  abdomen 
contains  so  many.  Attacks  of  sudden  pain  are  spoken  of  as  colic ; 
the  onset  is  sudden  ;  the  pain  is  paroxysmal ;  each  spasm  of  pain  may 
be  attended  by  vomiting,  rapid  pulse,  cold  extremities,  cold  sweat,  and 
more  or  less  collapse,  except  in  lead-colic.  Such  pain  is  seen  in  intes- 
tinal colic,  hepatic  colic,  renal  colic,  and  in  uterine  and  vesical  colic. 
Sudden  acute  pain  occurs  in  'perforation  of  some  one  of  the  hollow 
viscera,  indicated  by  the  history  and  location  of  the  disease  of  the  part 
affected  and  the  character  of  the  symptoms  attending  the  pain.  Thus, 
in  a  case  of  gastric  ulcer,  sudden  pain  indicates  possible  perforation, 
which  may  take  place  in  the  course  of  the  disease.  Chronic  pain  points 
to  ulcer,  to  chronic  processes,  or  to  gastric  or  intestinal  neurosis. 

The  Data  Obtained  by  Observation. 

The  Objective  Symptoms.  It  must  be  remembered  that  objective 
symptoms  of  abdominal  change  are  not  alone  due  to  disease  of  the  ab- 
dominal contents,  but  also  to  disease  elsewhere.  Thus  the  abdomen 
may  be  enlarged  from  the  ascites  of  cardiac  or  renal  disease,  contracted 
in  tuberculous  meningitis. 

Disease  or  paralysis  of  the  diaphragm  alters  the  appearance  of  the 
upper  half  of  the  abdomen  and  its  movements  in  respiration.  Fluctu- 
ating changes  in  size  occur  in  hysteria  and  gastric  neurasthenia,  and 
permanent  change  in  tuberculous  meningitis. 

Inspection.  We  note  the  appearance  of  the  abdominal  walls,  the 
movements  of  the  abdomen,  its  general  shape  and  size,local  enlargements. 

The  Abdominal  Walls.  A  glance  suffices  to  tell  of  the  thick- 
ness of  the  abdominal  walls.  Thin  walls  are  due  to  absence  of  adipose 
tissue  and  of  muscular  structure  associated  with  general  atrophy  (see 
Emaciation),  on  the  one  hand,  or  sometimes  in  consequence  of  intra- 
abdominal pressure.  Frequent  pregnancies,  previous  ascites  or  ante- 
cedent growths  (ovarian  tumor)  lead  to  atrophy  of  the  muscles  ;  the 
recti  separate  and  hernia-like  protrusion  of  abdominal  contents  results. 
Furthermore,  a  conical  projection  of  the  lower  median  portion  of  the 
abdomen  is  brought  about,  especially  if  ascites  is  present.  Such  pro- 
jections are  often  confusing  when  tapping  is  to  be  resorted  to.  Thick 
walls  are  due  to  oedema  or  to  increase  in  fat. 

The  Color.  The  abdomen,  in  general,  partakes  of  the  hue  of  the 
skin.  It  is  darker  around  the  umbilicus.  In  Addison's  disease  a  dis- 
tinct areola  often  forms.  The  median  line,  from  the  umbilicus  to  the 
pubis,  darkens  in  pregnancy — the  "  brown  line."  It  is  sometimes 
seen  in  men.  The  skin  of  the  abdomen  is  the  seat  of  specific  erup- 
tions, as  in  typhoid  fever,  and  of  sudamina.  The  Avails  may  be  pale 
and  glistening  in  oedema. 

Markings.  In  first  pregnancies  and  great  ascites,  less  frequently  in 
obesity  and  tumors,  strice  arc  produced  in  the  parts  of  the  skin  where 


728  SPECIAL  DIAGNOSIS. 

the  tension  has  been  greatest.  In  pregnancy  they  form  sinuous  lines 
upon  the  lower  lateral  portions  of  the  abdominal  wall  and  upon  the 
upper  inner  portions  of  the  thighs.  When  first  developed  they  are  red- 
dish, but  subsequently  become,  by  a  process  of  fading,  more  glistening 
and  white  than  the  rest  of  the  skin.  They  are  also  known  as  "  water 
lines,"  and  linece  albicantes.    Rarely  they  are  seen  after  typhoid  fever. 

The  umbilicus  may  project  from  hernia  or  may  be  prominent  in 
ascites.  The  veins  about  the  umbilicus  are  often  enlarged  in  cirrhosis 
even  to  such  an  extent  as  to  produce  a  large  soft  tumor,  the  caput 
Medusae.  Not  infrequently  the  walls  around  the  umbilicus  are  infil- 
trated with  carcinoma,  occurring  secondarily  to  gastric  carcinoma. 
In  tuberculous  peritonitis,  as  pointed  out  by  Henry,  this  infiltration, 
more  inflammatory,  however,  is  seen.  Removal  of  such  nodules  for 
microscopical  study  often  establishes  a  correct  diagnosis  of  the  internal 
disease. 

Glands.  Sometimes  isolated  lymphatic  glands  are  seen  in  the  ab- 
dominal wall.  They  may  be  utilized  by  a  microscopical  examination 
to  confirm  any  suspicion  of  malignant  disease. 

The  Veins.  Enlargement  of  the  superficial  veins  is  a  common 
accompaniment  of  cirrhosis  of  the  liver,  adhesive  pyelophlebitis,  and 
of  any  cause  which  obstructs  the  free  circulation  in  the  inferior  vena 
cava.  In  order  to  complete  the  collateral  circulation  they  may  anasto- 
mose with  the  mammary  veins  above  or  the  epigastric  veins  below. 
The  caput  Medusce  has  already  been  described. 

The  Movements.  (See  the  Lungs — Dyspnoea.)  The  movements  of 
the  abdomen  are  of  respiratory,  vascular,  gastric,  and  intestinal  origin. 
Much  is  learned  by  carefully  observing  them. 

Respiratory  Movements.  The  upper  half  of  the  abdomen  swells  or 
rises  synchronously  with  inspiration.  In  enlargement  of  the  abdomen 
and  in  tumors  within  the  upper  half  the  movement  is  restricted.  In 
paralysis  of  the  diaphragm  it  falls  in  with  inspiration,  reversing  the 
normal  movement.  If  such  paralysis  is  limited  to  one  side,  as  in  large 
pleural  effusions,  the  inspiratory  collapse  is  unilateral.  In  laryngeal 
and  tracheal  obstruction,  inspiratory  retraction  is  noteworthy  and  its 
extent  significant  of  the  amount  of  obstruction.  Respiratory  move- 
ment causes  the  liver  to  rise  and  fall.  In  persons  with  thin  walls,  its 
shadow  can  be  seen  to  descend  with  inspiration,  the  extent  indicating 
the  degree  of  respiratory  expansion,  the  size  and  position  of  the  liver. 
Such  information  is  of  great  value.  A  tumor  connected  with  the  liver 
and  an  enlarged  gall-bladder  will  move  synchronously  with  respira- 
tion. Other  growths  are  fixed,  unless  adherent  to  the  liver.  Rarely 
an  exception  is  seen  in  movable  right  kidney. 

Vascular  Movements.  They  are  noted  in  the  median  line  and  usually 
in  the  upper  half  of  the  abdomen.  In  moderately  thin  subjects  the 
aorta  may  be  the  cause  of  such  pulsation.  (See  Epigastric  Pulsation.) 
If  the  pulsation  is  wide  and  extends  to  the  right  or  left  of  the  median 
line,  an  aneurism  may  be  suspected,  or  the  impulse  may  be  trans- 
mitted to  a  growth  overlying  the  aorta,  as  a  carcinoma  of  the  stomach. 
Aneurism  of  the  coeliac  axis  will  give  rise  to  a  movement  near  the 
umbilicus  and  to  the  right  or  left  of  the  median  line.     Pulsation  of  the 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     729 

liver,  of  vascular  origin,  and  hence  rhythmical  with  cardiac  pulsation 
is  seen  in  the  hepatic  area  in  right-sided  dilatation  of  the  heart, 

Gastric  and  Intestinal  Movements.  Peristaltic  movement,  either  of  the 
stomach,  the  large  or  the  small  intestine,  may  be  seen  through  the 
abdominal  walls.  In  gastric  dilatation  and  gastroptosis  the  waves  may 
be  seen  in  rhythmical  succession,  from  left  to  right,  in  the  centre  of 
the  abdomen.  Their  general  course  may  be  from  the  left  upper  to  the 
lower  right  quadrant.  If  of  the  large  intestine,  the  waves  are  confined 
to  the  course  of  this  canal ;  if  in  the  small  intestine,  to  the  region  around 
the  umbilicus.  It  is  due  to  obstruction  of  the  pylorus,  if  gastric,  or 
of  the  lumen  of  the  bowels  if  intestinal.  The  application  of  a  cold 
napkin  will  excite  the  movements. 

The  Shape.  In  general  enlargement  the  shape  is  uniform.  In 
large  accumulations  of  fat,  in  women  with  relaxed  abdominal  walls, 
the  abdomen  may  be  pendulous.  In  ascites  the  tissue  over  the  umbil- 
icus may  protrude,  changing  the  uniform  appearance.  Abdominal 
enlargements  due  to  ascites,  in  women  whose  abdominal  walls  have 
previously  been  relaxed,  sometimes  assume  a  peculiar  cone-shape  ;  the 
base  corresponding  to  the  plane  of  the  abdomen,  the  apex  rising  below 
the  umbilicus.  This  is  particularly  the  case  if  the  patient  has  had  to 
assume  the  semi-erect  position  for  some  time.  It  is  often  difficult  to 
decide  where  to  tap  in  such  cases.  In  local  enlargements  the  surface 
is  often  irregular,  the  prominences  corresponding  to  the  seat  of  the 
enlargement.  The  shape  changes  in  hysterical  distention.  In  enlarge- 
ment due  to  wasting  disease  of  the  viscera,  as  cancer  of  the  retroperi- 
toneal glands,  the  abdomen  retracts  in  the  later  stage  of  the  disease, 
causing  undue  prominence  of  the  viscera  affected. 

Gexeral  Exlargemext  of  the  Abdomex.  The  abdomen 
differs  very  much  in  size  in  different  persons,  depending  not  only  upon 
the  thickness  of  the  fat  in  the  abdominal  walls  and  omentum,  but 
upon  the  calibre  of  the  intestines  themselves,  which  are  apt  to  be  much 
distended  in  those  accustomed  to  eat  large  meals.  In  general,  the 
belly  is  more  protuberant  in  infants  and  children  than  in  adults. 
Enlargement  occurs  in  obesity,  and  it  is  often  difficult  to  tell  whether 
the  excessive  deposit  of  fat  in  the  abdominal  walls  and  omentum 
accounts  for  the  whole  enlargement  or  only  serves  to  mask  the  presence 
of  a  tumor.  Enlargement  of  the  belly  is  only  a  part,  though  fre- 
quently the  most  pronounced  evidence  of  obesity  ;  whereas,  in  enlarge- 
ments of  the  abdomen  from  tumors  and  ascites,  there  is  usually  a 
marked  contrast  between  the  size  of  the  abdomen  and  that  of  the  rest 
of  the  body. 

Ascites. 

In  enlargement  from  ascites,  when  the  patient  is  lying  upon  his  back, 
the  front  of  the  abdomen  is  flattened,  while  the  flanks  bulge.  If  he 
turns  upon  his  side,  the  flank  which  is  uppermost  becomes  hollowed 
out  and  the  front  of  the  belly  is  prominent.  This  is  the  appearance  in 
moderately  large  effusions  which  have  existed  long  enough  to  stretch 
the  lateral  abdominal  muscles.  When  the  effusion  is  enormous  all 
parts  of  the  belly  are  distended,  and  the  abdomen  is  barrel-shaped  ; 
no  change  of  shape  occurs  upon  change  of  posture. 


730  SPECIAL  DIAGNOSIS. 

Ascites  is  the  accumulation  of  fluid  in  the  peritoneal  cavity.  The 
causes  may  be  local  or  general.  Its  local  origin  may  be,  first,  simple, 
cancerous,  or  tuberculous  inflammation  of  the  peritoneum  ;  second, 
portal  obstruction  from  disease  of  the  liver,  as  cirrhosis,  or  disease  of  the 
portal  veins,  either  from  compression  or  inflammation.  Tumors  of  the 
abdomen  are  often  attended  by  ascites,  particularly  solid  tumors  of  the 
ovary.    The  general  causes  of  ascites  are  those  which  give  rise  to  dropsy. 

Physical  Signs.  (Plate  XXXVI.)  Inspection.  The  abdomen  is 
uniformily  enlarged.  The  surface  is  usually  smooth.  The  skin  is 
tense  if  the  effusion  is  large,  and  linece  albicantes  may  be  seen.  The 
navel  may  project.  If  the  ascites  is  due  to  liver  disease  or  disease  of 
the  portal  vein,  the  superficial  veins  enlarge,  although  the  enlargement 
is  sometimes  seen  when  any  effusion  continues  a  long  period  of  time. 

Palpation.  On  palpation  fluctuation  can  usually  be  detected.  Care 
must  be  taken  not  to  confound  the  wave  of  the  abdominal  walls, 
produced  by  percussion,  with  the  wave  of  true  fluctuation  ;  the  former 
must  be  cut  off  by  the  hand  of  an  assistant  placed  vertically  in  the 
median  line.  The  left  hand  should  be  applied  firmly  against  one  side 
of  the  abdomen,  while  with  the  right  percussion  or  tapping  is  gently 
performed  at  the  opposite  point.  The  points  selected  should  be  at 
about  the  level  of  the  fluid.  At  first  the  hand  should  be  placed  on  the 
flank,  and  if  the  fluctuation  is  not  revealed,  then  with  each  successive 
percussion  it  should  be  brought  forward  toward  the  median  line. 
Sometimes  light  percussion  will  yield  the  sign,  at  others  more  firm  per- 
cussion must  be  employed.  The  faintest  tap  may  be  sufficient.  In 
order  to  ascertain  the  position  of  solid  organs  in  ascites,  dipping  is  em- 
ployed. This  consists  in  suddenly  pressing  the  tips  of  the  fingers  over 
the  organ  sought  for.  The  fluid  is  thus  displaced  and  the  edge  or 
surface  of  the  organ  readily  felt. 

When  the  abdomen  is  percussed  in  the  usual  manner  there  is  dulness 
over  the  fluid.  As  the  fluid  gravitates  to  dependent  portions  the  dul- 
ness is  found  in  these  parts.  Sometimes  the  colon  gives  rise  to  tym- 
pany in  the  flanks,  as  pointed  out  by  Tyson.  When  the  patient  is 
lying  down,  it  is  in  the  flanks,  and  may  extend  arouud  the  lower  por- 
tion of  the  abdomen.  If  the  patient  stands  up,  the  dulness  may  reach 
to  the  umbilicus  in  the  median  line  and  to  the  same  level  in  the  mid- 
clavicular .  line. 

Aspiration  In  ascites  it  is  important  to  ascertain  the  nature  of  the 
fluid.  This  can  only  be  clone  by  aspiration.  If  the  fluid  is  serous,  it 
has  the  characteristics  belonging  to  that  fluid.  Hemorrhagic  effusions 
usually  occur  in  cancer  and1  tuberculosis,  although  both  of  these  dis- 
eases may  occur  with  clear  serum.  In  ruptured  tubal  pregnancy  the 
effusion  is  hemorrhagic.  In  rare  cases  a  chylous,  milky  fluid  is  found 
in  disease  of  the  lymphatics.  In  one  instance  this  occurred  from  per- 
foration of  the  thoracic  duct.  Chylous  ascites  may,  however,  be  due 
to  an  excessive  milk-diet.  In  other  instances  it  is  due  to  filaria.  The 
patient  on  a  mik-diet  is  often  lipsemic,  in  consequence  of  which  effu- 
sions are  made  turbid. 

The  sub/erf  ire  symptoms  are  those  due  to  the  cause  of  the  ascites  and 
to  mechanical  pressure. 


PLATE    XXXVI. 


Ascites. 


Blue  shading  shows  level  of  dulness  in  recumbent  posture.     Dotted  lines 
indicate  change  of  level  of  fluid   in  other  postures. 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     731 

Ascites  must  be  distinguished  from  enlargement  of  the  abdomen  due 
to  ovarian  tumor,  enlargement  due  to  pregnancy,  and  enlargement  due 
to  an  overdistended  bladder.     In  ovarian  tumor  the  development  at 

Fig.  188. 


Ascites.    Upper  limits  of  duluess  indicated  by  the  dotted  line.    Umbilicus  prominent. 

first  takes  place  to  the  right  or  left  of  the  median  line.  When  large 
the  signs  may  be  in  the  central  region  of  the  abdomen.  The  flanks, 
however,  are    always    tympanitic    on    percussion.      On   vaginal   ex- 

FlG.  189. 


Ascites  from  sarcoma  of  ovary.    Dislocation  of  liver  and  spleen.    X  is  apex  beat,  not  lifted 
because  of  fallen  abdominal  organs. 

animation  the  local  disease  may  be  ascertained.  A  distended  bladder 
should  always  be  thought  of,  and  catheterization  performed  in  doubt- 
ful cases.     Cysts  of  the  pancreas  may  be  mistaken  for  ascites,  and 


732 


SPECIAL  DIAGNOSIS. 


large  hydatid  cysts  connected  with  the  liver  may  simulate  an  accumu- 
lation of  fluid  in  the  peritoneal  cavity.  The  history  and  the  appear- 
ance of  the  fluid  on  aspiration  point  to  the  diagnosis. 

Enlargement  from  accumulation  of  gas  within  the  bowels  is  gen- 
eral, and  may  attain  a  very  high  degree,  giving  the  abdomen  a  uni- 
form arched  appearance  resembling  a  barrel.  The  diaphragm  may  be 
pressed  upward  so  far  as  to  interfere  seriously  with  respiration  and 
heart-action.  In  debilitated  children  the  enlargement  due  to  flatulency 
is  associated  with  flaccid  abdominal  walls,  causing  lateral  and  central 
enlargement.  Moderate  degrees  of  distention  from  gas  in  the  intes- 
tines may  be  the  result  of  eating  certain  articles  of  food,  such  as  tur- 
nips or  beans.  Excessive  accumulations  are  met  with  in  typhoid 
fever  ;  peritonitis,  operative  and  non-operative  ;  and  in  stenosis  of  the 
colon  or  rectum  from  any  cause.     They  are  also  common  in  hysteria. 

In  the  last  month  or  two  of  pregnancy  enlargement  of  the  abdomen 
is  general,  especially  in  a  woman  who  has  previously  borne  children. 

General  enlargement  of  the  abdomen  may  be  due  also  to  fecal  accu- 
mulation, cancer  of  the  peritoneum,  to  hydatid  cyst,  and  to  cancer  of  the 
bowel. 

It  has  been  observed  in  children  in  dilatation  of  the  colon.  The  dila- 
tation may  take  place  temporarily  in  constipation  with  obstruction.  In 
rare  cases  it  may  become  permanent.  In  such  the  distention  of  the 
abdomen  is  enormous.  It  often  begins  in  childhood  and  continues 
through  adult  life.  Congenital  obstruction,  the  eating  of  oatmeal  and 
similar  food,  with  attendant  constipation  are  causes.  The  bowels  are 
constipated.  The  constipation  may  continue  for  several  weeks,  during 
which  period  there  is  increasing  dulness  in  the  tract  of  the  colon,  with 

Fig.  190. 


Case  of  dilatation  of  colon.    (Griffith  ) 


fecal  tumors  distinguished  by  palpation.  This  condition  is  relieved 
by  diarrhoea,  which  may  continue  for  two  or  three  days,  during  which 
enormous  amounts  of  feces  are  passed.  It  may  be  preceded  by  vomit- 
ing\>f  a  fecal  character.  After  the  bowels  are  open  the  distention 
continues,  the  dulness  being  replaced  by  tympany.     The  abdomen  was 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     733 

uniformly  enlarged  in  Hughes'  and  Osier's  cases.  Coils  of  the  intes- 
tine, with  waves  of  peristalsis,  were  seen  through  the  thin  abdominal 
walls.  Formad's  patient  was  an  adult.  It  must  be  remembered,  as 
described  on  page  729,  intestinal  peristalsis  is  observed  in  constriction 
of  the  bowels.  The  motion  of  the  intestine  above  the  seat  of  stricture 
is  wave-like  or  worm-like,  and  the  bowel  itself  dilated. 

From  a  consideration  of  the  recorded  cases  of  so-called  idiopathic 
dilatation  of  the  colon,  Treves  believes  that,  although  enormous  dilata- 
tion of  the  large  intestine  may  undoubtedly  occur  in  adults  indepen- 
dently of  mechanical  obstruction,  in  children  it  is  probably  due  to 
congenital  defects  in  the  terminal  part  of  the  bowel. 

Enlargement  of  the  abdomen  simulating  ascites  may  be  due  to  retro- 
peritoneal and  peritoneal  lipomata.  Fluctuation  even  may  be  detected, 
but  repeated  puncture  fails  to  secure  fluid ;  the  negative  aspiration 
should  always  suggest  lipoma.  This  is  all  the  more  likely  if  the  en- 
larged abdomen  is  due  to  a  slowly  growing  tumor,  which  is  probably 
more  visible  on  one  side  than  the  other,  but  which  causes  little  if  any 
general  disturbance  except  progressive  emaciation,  dyspnoea,  and  some- 
times oedema  of  the  legs.  The  tumor  is  usually  crossed  by  a  portion 
of  the  intestine. 

Other  causes  of  abdominal  enlargement  are  diseases  of  the  liver  and 
gall-  bladder.  When  these  are  enlarged  a  local  swelling  may  be  de- 
tected in  the  right  upper  quadrant ;  but  when  they  attain  very  large 
dimensions,  as  happens  not  infrequently  in  cancer,  amyloid  disease, 
and  hydatid  liver,  inspection  may  be  able  to  detect  only  general  en- 
largement, with  small  prominences  corresponding  with  cancerous  nod- 
ules or  small  cysts. 

Splenic  enlargements,  which  attain  the  greatest  size,  are  from  leu- 
kaemia or  chronic  malarial  poisoning,  and  are  usually  visible  only  as 
general  enlargements  of  the  belly.  There  may,  however,  be  greater 
prominence  over  the  lower  left  ribs  and  in  the  left  upper  quadrant 
posteriorly. 

In  diseases  of  the  kidney  producing  great  enlargement  there  is  usu- 
ally visible  a  prominence  in  the  lateral  and  lumbar  region  of  the  side 
corresponding  with  the  kidney  involved,  unless  there  is  considerable 
emaciation  ;  anteriorly  the  enlargement,  if  any  be  visible,  usually 
appears  to  be  general. 

Enlargements  of  the  abdomen  which  begin  in  the  lower  quadrants 
are  usually  of  pelvic  origin.  The  most  common  are  those  due  to  preg- 
nancy, retroperitoneal  sarcoma,  cysts  of  the  ovary  or  parovarium,  fibroids 
and  fibro-cysts  of  the  uterus,  and  abscesses  or  effusions  (chronic  perito- 
nitis). A  greatly  distended  bladder  may  cause  confusion  ;  it  is  a  good 
rule  to  be  sure  that  the  bladder  is  empty,  by  having  a  catheter  passed 
before  proceeding  further  with  the  examination. 

Local  Enlargement  or  Tumors  of  the  Abdomen.  In  the 
space  below  the  xiphoid  cartilage  and  between  the  ribs  (epigastrium) 
local  enlargements  may  be  due  to  a  distended  or  dilated  stomach  or  to 
a  tumor  of  the  pylorus,  which  is  almost  always  cancerous.  Promi- 
nence in  this  region  is  seen  in  large  eaters.  But  enlargement  in  this 
region  is  sometimes  due  to  cysts,  sclerosis  or  cancer  of  the  pancreas, 


734  SPECIAL  DIAGNOSIS. 

to  aneurisms,  to  cancer  of  the  large  intestine  or  tumor  of  the  left  lobe 
of  the  liver.  It  is  in  this  region  or  to  the  left  of  the  median  line  and 
nearer  the  umbilicus  that  the  effusions  into  the  lesser  peritoneal  cavity 
are  found. 

A  rigid  rectus  muscle  is  capable  of  simulating  a  tumor.  Likewise, 
in  hysterical  subjects,  rigid  abdominal  muscles,  with  tympanites,  give 
rise  to  a  swelling  known  as  "  phantom  tumor."  Such  swellings  are 
less  constant  in  shape  and  character  than  genuine  tumors,  and  although 
dull  on  percussion  appear  more  superficial ;  they  sometimes  disappear 
under  friction  with  the  hand,  and  certainly  under  full  anaesthesia  ;  the 
stigmata  of  hysteria  are  present. 

Enlargements  in  the  right  upper  quadrant  (right  hypochondrium) 
are  most  frequently  due  to  diseases  of  the  liver  {q.  v.)  and  to  affections 
of  the  gall-bladder.  Less  frequently,  a  much  enlarged  kidney  or  a 
hydronephrosis  causes  swelling  in  this  region.  The  differential  diag- 
nosis is  made  by  the  history  of  the  case  and  by  noting  the  direction  in 
which  the  tumor  has  grown,  by  examination  of  the  urine,  and  by  the 
relation  which  the  ascending  colon  bears  to  the  tumor  ;  kidney  tumors 
carry  it  in  front  of  them  as  they  grow  ;  hence,  their  dulness  is  obscured 
by  the  superficial  tympany  of  the  colon. 

Primary  malignant  disease  of  the  suprarenal  bodies — a  rare  affec- 
tion— is  often  attended  by  a  tumor  in  the  upper  abdomen  (Ptolleston 
and  Marks,  American  Journal  of  the  Medical  Sciences,  1898.)  The 
clinical  picture  is  not  one  of  Addison's  disease  even  when  both  the 
organs  are  invaded.  Some  of  the  symptoms  occur  partially,  as  pig- 
mentation, vomiting,  asthenia,  pain  in  the  back.  The  growth  extends 
forward,  and  resembles  in  many  respects  renal  tumor.  It  also,  how- 
ever, may  resemble  tumors  of  the  liver,  enlarged  gall-bladder,  or  pan- 
creatic cyst. 

Enlargement  in  the  right  hirer  quadrant  (right  iliac  region)  is  most 
frequently  due  to  affections  of  the  csecum  and  appendix,  to  tumors  of 
the  ovary,  and  to  pelvic  abscesses. 

The  diseases  of  the  ccecum  and  appendix  causing  enlargement  in  the 
right  iliac  fossa  are  fecal  accumulation,  typhlitis,  fecal  abscess,  peri- 
typhlitic  abscess,  carcinoma,  and  stricture  of  the  ileo-csecal  valve. 

The  diseases  of  the  ovaries  and  tubes  causing  enlargement  in  this 
region  are  ovarian  tumors,  cysts  of  the  broad  ligament,  pelvic  abscess 
(usually  tubal  in  origin),  and  extra-uterine  pregnancy. 

Other  affections  which  need  to  be  considered  are  tubercular  peri- 
tonitis, acute  and  chronic,  and  enlarged  or  movable  kidney. 

Enlargement  in  the  left  upper  quadrant  (left  hypochondriac  region) 
is  due  to  dilatation  or  carcinoma  of  the  stomach  ;  enlargement  of  the 
spleen,  movable  kidney,  or  tumors  of  the  kidneys,  and  effusion  in  the 
lesser  peritoneal  cavity.  Enlargement  in  the  left  lower  quadrant  (left 
iliac  region)  is  due  to  tumors  (cancerous)  of  the  sigmoid  flexure  and  to 
the  tumor  due  to  volvulus,  and  to  the  same  causes  of  enlargement  of 
the  right  side  which  are  possible  on  the  left. 

Enlargement  about  the  centre  of  the  abdomen  (umbilical  region)  may 
be  due  to  umbilical  hernia,  to  a  floating  kidney,  spleen,  or  liver,  or  to 
tubercular  disease  of  the  omentum  or  mesenteric  glands.     It  is  seen 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     735 

in  retroperitoneal  sarcoma.  It  is  seen  in  cases  of  dilatation  after  a  full 
meal.  This  region  is  frequently  enlarged,  in  conjunction  with  a  more 
prominent  swelling  extending  from  the  sternum,  in  cancer  of  the  stom- 
ach ;  and  from  the  ribs  on  the  right  in  cancer  of  the  liver  or  gall- 
bladder, or  other  diseases  of  these  viscera ;  from  the  ribs  on  the  left,  in 
effusions  into  the  lesser  peritoneal  cavity,  disease  of  the  pancreas  or 
the  spleen. 

Undue  projection  of  the  vertebrae  must  not  be  mistaken  for  tumors. 

Enlargement  above  the  pubis  (hypogastric  region)  is  due  most  fre- 
quently to  enlargement  of  the  uterus  from  pregnancy,  fibroid  tumors, 
or  fibro-cysts,  or  to  distention  of  the  bladder ;  but  it  is  also  common 
in  gastric  dilatation  and  gastroptosis ;  flattening  of  the  upper  half  is 
then  seen,  and  the  lesser  curvature  is  then  made  out. 

Enlargement  in  the  lateral  regions  and  behind  {lumbar  region)  may 
occur  in  malignant  tumors  of  the  kidney,  in  hydronephrosis  and 
pyonephrosis,  in  perinephritic  abscess,  and  in  renal  cysts  of  large  size. 
Usually  renal  enlargements  of  any  kind  are  not  observed  behind, 
however.  It  may  also,  in  the  left  side,  be  due  to  perigastric  sub- 
diaphragmatic abscess  and  to  enlargement  and  displacement  of  the 
spleen.  On  the  right  side  the  cause  may  be  enlargement  of  the  liver, 
or  a  hydatid  cyst,  or  a  retroperitoneal  sarcoma. 

Diminution  in  Size.  The  abdomen  is  diminished  in  size  in 
wasting  diseases,  or  such  as  result  in  insufficient  food  being  taken. 
This  class  comprises  cancer  of  the  oesophagus  and  stomach,  chronic 
lead-poisoning,  anorexia  nervosa,  and  chronic  diarrhoea  and  tubercu- 
losis of  childhood.  In  the  second  stage  of  tubercular  meningitis  in 
children  there  is  retraction  of  the  abdomen.  The  wasting  of  the  sub- 
cutaneous and  the  omental  fat  and  atrophy  of  the  abdominal  organs 
cause  the  abdomen  to  be  concave  or  scaphoid. 

Palpation  and  Percussion  of  the  Abdomen.  Palpation  and  per- 
cussion in  diseases  of  the  abdomen  may  be  discussed  together. 

Position  of  Patient.  Generally  the  best  position  is  the  recumbent 
one,  because  it  admits  of  examination  without  too  great  exposure,  and 
because  in  that  position  the  abdominal  muscles  are  partly  relaxed. 
When  the  muscles  need  to  be  still  further  relaxed  the  patient  should 
lie  upon  the  back,  with  the  head  and  thorax  partly  elevated  and  the 
knees  drawn  up.  In  certain  obscure  tumors  much  can  be  learned  by 
having  the  patient  rest  on  the  hands  and  knees,  or  assume  a  knee- 
chest  position.  By  this  means  we  can  determine  if  the  pulsation  is 
due  to  aneurism  or  to  a  tumor.  The  latter  falls  away  from  the  vessels, 
and  hence  pulsation  is  lessened  thereby  in  the  knee-chest  position. 
A  tumor  surrounded  by  coils  of  intestine  may  thus  become  more  pal- 
pable. A  good  plan  to  secure  relaxation  for  palpation  of  the  liver 
and  spleen  is  to  have  the  patient  sit  on  a  chair  with  the  body  leaning 
forward  ;  then  flex  the  thighs,  supporting  the  feet  on  a  stool 'or  the 
rung  of  another  chair. 

Method!  The  examining  hand  should  be  warm,  as  the  application 
of  a  cold  hand  throws  the  abdominal  muscles  into  involuntary  contrac- 
tion. By  grasping  the  abdominal  walls  between  the  thumb  and  fingers 
their  thickness  and   the  relative   proportion   of  fat  can    be  estimated. 


736  SPECIAL  DIAGNOSIS. 

So,  too,  the  presence  or  absence  of  oedema  of  the  skin  can  be  readily 
detected.  This  oedema  is  general,  but  is  especially  marked  in  the 
lateral  and  posterior  portions  of  the  abdomen.  Relaxed  abdominal 
walls  occur  after  dropsy  and  pregnancy.  Redundant  skin  remains 
in  folds  when  pinched  up.  This  is  particularly  so  in  abdominal 
cancer. 

When  it  is  desired  to  explore  deeply  the  patient  should  be  instructed 
to  breathe  with  the  mouth  open,  and  the  examining  hand  pressed 
firmly  in  during  respiration,  and  held  there,  if  need  be,  during  several 
long  respirations.  The  palm  of  the  hand  should  be  laid  upon  the  sur- 
face ;  after  the  muscles  are  relaxed  the  flexed  fingers  may  be  used  to 
palpate.  The  same  procedure  is  adopted  when  we  desire  to  get  the 
percussion-note  of  a  body  lying  deep  in  the  abdomen  :  the  finger  is 
pressed  firmly  and  deeply  in,  and  then  percussed.  In  this  way  any 
superficial  resonance  due  to  overlying  intestine  is  largely  eliminated. 

When  palpating  to  determine  the  lower  edge  of  the  liver  or  spleen 
the  palmar  surface  of  the  fingers  is  pressed  into  the  abdomen  at  differ- 
ent levels  from  below  upward  until  the  edge  is  felt.  The  edge  of 
the  right  lobe  of  the  liver  in  its  normal  position  extends  to  the  margin 
of  the  ribs.  It  may  be  detected  by  pressing  the  fingers  in  as  de- 
scribed and  having  the  patient  take  a  long  breath. 

By  palpation  the  information  obtained  by  inspection  is  confirmed  ; 
the  character  of  the  abdominal  walls  and  of  swellings  is  determined  ; 
the  precise  location  of  pain  is  ascertained  ;  the  condition  at  the  hernial 
rings  and  the  movability  of  tumors  are  investigated.  The  condition 
of  the  integument  should  first  be  determined.  Passing  the  hand  gently 
over  it  is  sufficient  to  decide  whether  it  is  normal,  smooth  and  elastic, 
or  harsh  and  dry.  Any  marked  unevenness,  such  as  is  produced  by 
umbilical  and  inguinal  hernia,  by  strise,  or  by  large  tumors  of  the 
pylorus,  or  cancerous  nodules,  and  hydatid  cysts  of  the  liver,  can 
readily  be  detected.  The  degree  of  tension  of  the  abdominal  walls  is 
easily  appreciated.  It  is  increased,  of  course,  in  all  forms  of  great  en- 
largement, but  not  equally  ;  some  persons  are  so  sensitive  to  touch 
that  any  attempt  at  palpation  throws  the  abdominal  muscles  into  such 
rigid  contraction  that  examination  is  impossible.  Rigidity  of  the 
abdominal  walls  may  be  the  only  sign  of  acute  peritonitis.  It  is  com- 
mon in  local  peritonitis.  The  recti  muscles  contract  quickly  on  hurried 
palpation.  Local  contractions  point  to  inflammation  underneath.  In 
tuberculous  peritonitis  we  see  distention  with  board-like  rigidity  or 
preternatural  hardness.  The  term  carreau  is  used  by  the  French  for 
this  condition.  Peritoneal  friction  may  be  detected  most  frequently 
over  the  liver  and  in  chronic  peritonitis. 

Palpation  and  Percussion  of  the  Lower  Quadrants.  On 
the  right  side,  the  groups  of  affections  connected  with  the  csecuni  and 
appendix,  the  uterine  appendages,  and  the  peritoneum,  which  cause 
enlargement  in  this  region,  have  been  mentioned  already  under  local 
inspection  of  the  abdomen.  Palpation  and  percussion,  however,  are 
the  methods  which  afford  the  most  exact  information  of  their  physical 
characteristics,  and,  with  the  clinical  history,  enable  us  to  distinguish 
one  from  the  other. 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     737 

Diseases  of  the  Appendix  and  Ctecum.  The  information  supplied  by 
palpation  and  percussion  in  perforation  of  the  appendix  will  depend 
upon  the  rapidity  with  which  perforation  has  supervened  and  upon 
the  stage  at  which  the  examination  is  made. 

Generally  speaking,  after  the  sudden  onset  of  pain  in  the  right  iliac 
fossa,  in  a  person  previously  in  good  health,  there  is  tenderness  on 
palpation  in  that  region.  This  tenderness  is  first  localized,  but  may 
spread  with  great  rapidity  over  the  whole  abdomen.  Or  the  tender- 
ness may  at  first  be  general,  and  subsequently  become  localized  over  the 
appendix.  Subsequently,  the  tension  in  the  part  is  increased,  the  over- 
lying abdominal  muscles  are  rigid  (spasm)  and  firm,  and  the  percussion- 
resonance  impaired.  Examination  with  the  finger  in  the  rectum  may 
discover  a  tense,  swollen  appendix,  or  a  tumor  in  the  pelvis. 

But  the  disease  may  be  fulminating  in  character,  perforation  being 
followed  by  the  rapid  development  of  peritonitis,  with  collapse,  so 
that  when  the  patient  is  seen  there  will  be  no  more  tenderness  over 
one  part  of  the  abdomen  than  over  another. 

Again,  the  appendix  may  be  subject  to  repeated  attacks  of  inflam- 
mation without  perforation,  but  with  the  development  of  local  peri- 
tonitis. There  is  increased  thickness  in  the  region  of  the  crecum, 
tenderness,  diminished  resonance,  and  increased  resistance  to  the 
percussed  finger.  Sometimes  an  enlarged  and  hardened  appendix  can 
be  made  out  by  palpation,  both  during  an  attack  and  in  the  intervals. 

In  still  other  cases,  of  slower  development,  a  distinct  perityphlitic 
abscess  develops.  In  addition  to  local  pain  and  tenderness  a  swelling 
appears  above  Poupart's  ligament.  The  skin  over  it  becomes  brawny 
and  pits  on  pressure  with  the  finger-tips.  The  tumor  is  dull  on  percus- 
sion, and  on  palpation  obscure  deep-seated  fluctuation  may  be  secured. 
A  fluctuating  tumor  may  also  be  made  out  by  rectal  examination  with 
the  finger. 

In  fecal  impaction  of  the  ccecwn  a  tumor  forms,  following  the  course 
of  the  crecuni,  and  directed  upward  from  Poupart's  ligament.  It  is 
usually  oblong  and  rounded,  and  may  appear  uneven  or  lumpy  on 
closer  palpation  ;  it  is  not  tender  unless  the  csecum  itself  becomes  in- 
flamed. It  has  a  doughy  consistency.  Fecal  tumors  give  rise  to 
some  distention  of  the  abdomen.  To  distinguish  these  tumors  from 
solid  growths,  Gersuny  calls  attention  to  the  "adhesive  symptom." 
If  strong  pressure  is  slowly  made  with  the  finger  tips  on  the  tumor, 
and  then  the  pressure  be  withdrawn  gradually  and  the  hand  removed 
from  the  abdomen,  a  peculiar  sensation  due  to  the  separation  of  the 
intestinal  mucous  membrane  from  the  fecal  matter  is  transmitted  to 
the  hand.  If  the  feces  are  dry  and  hard,  the  sensation  may  not  be 
observed  until  an  oil  enema  is  used.  When  the  feces  are  soft  natur- 
ally or  artificially,  the  tissues  remain  depressed  and  only  gradually 
separate  from  the  mass  and  return  to  their  normal  position.  Slowness 
of  the  separation  of  the  abdominal  walls  from  the  tumor  is  also  charac- 
teristic of  the  fecal  accumulation.  The  diagnosis  is  made  by  the  situ- 
ation and  character  of  the  tumor,  and  the  absence  of  pain,  tenderness, 
and  constitutional  symptoms,  and  by  its  disappearance  under  the  influ- 
ence of  purgatives. 

47 


738  SPECIAL  DIAGNOSIS. 

If  the  impaction  causes  a  localized  colitis,  or  so-called  typhlitis,  the 
tumor  is  tense,  tender,  and  painful,  dull  on  percussion,  the  dulness 
being  sharply  limited  by  the  boundaries  of  the  caecum. 

Appendicitis. 

This  is  by  far  the  most  important  affection  of  the  intestinal  tract. 
It  is  of  frequent  occurrence  compared  with  intestinal  obstruction,  and, 
if  recognized,  is  amenable  to  relief  in  a  very  large  percentage  of  the 
cases  ;  whereas  intestinal  obstruction  is  more  frequently  fatal.  We 
see  twenty-five  cases,  at  least,  of  appendicitis  in  all  its  forms  to  one 
case  of  any  form  of  obstruction.  Its  importance,  therefore,  is  readily 
recognized.  Appendicitis  occurs  most  frequently  in  the  young — in 
the  large  proportion  of  cases  under  thirty.  I  have  seen  it  as  early  as 
two  years  of  age,  although  from  the  fifteenth  to  the  thirtieth  year  it 
is  more  frequent  than  at  any  other  period.  The  symptoms  vary,  but 
clinically  may  be  divided  into  those  of  appendicitis  without  perforation 
and  appendicitis  with  perforation.  Appendicitis  without  perforation 
is  characterized  by  relapses,  and  is  known  also  as  recurring  appendicitis. 

Appendicitis  without  Perforation.  Cases  of  catarrhal  appen- 
dicitis probably  occur,  although  I  am  not  prepared  to  say  that 
catarrhal  inflammation  of  the  appendix  gives  rise  to  marked  local 
symptoms,  for  in  cases  on  the  post-mortem  table  in  which  the  lesions 
of  catarrh  were  found  there  had  not  been  any  symptoms  during  life, 
due  either  to  intestinal  catarrh  or  to  any  symptoms  pointing  to  appen- 
dicitis in  any  form.  Moreover,  many  cases  in  which  the  attacks  of 
appendicitis  had  at  first  been  slight,  finally  developed  into  appendicitis 
with  perforation.  In  the  milder  cases,  if  operative  measures  are  re- 
sorted to  during  the  intervals  between  the  attacks,  the  appendix  is 
always  found  to  contain  a  fluid  loaded  with  micro-organisms  which 
are  capable  of  causing  purulent  inflammation,  as  the  staphylococcus  or 
streptococcus.  Clinically,  therefore,  all  forms  of  appendicitis  should 
be  considered  infectious,  with,  on  the  one  hand,  escape  of  the  contents 
into  the  bowel,  and  natural  relief  of  the  symptoms  ;  or,  on  the  other, 
complete  obstruction  with  perforation.  After  removal  of  the  appendix 
in  cases  of  recurring  appendicitis,  I  have  always  found  pus  or  a  muco- 
purulent material  which  was  charged  with  streptococci  or  staphylococci, 
as  well  as  the  bacillus  coli  communis,  natural  to  the  intestinal  canal 
in  this  region. 

Symptoms  of  the  Attack.  After  exposure  to  cold  rarely,  fre- 
quently after  an  indiscretion  in.  diet,  the  patient  is  seized  with  pain, 
referred  to  the  right  lower  quadrant  of  the  abdomen.  It  is  paroxysmal 
in  character,  increasing  in  intensity,  and  may  be  complained  of  as 
colicky.  The  pain  is  usually  such  as  to  require  the  patient  to  take  to 
bed  and  attempt  to  secure  relief  by  local  applications.  The  severity 
of  the  pain  may  be  so  slight  that  the  patient  pays  but  little  attention 
to  it.  He  may  even  go  about  his  business  during  the  time  and  seek 
professional  advice  at  the  office  of  a  physician.  Such  cases  as  these 
are  attributed  to  ordinary  cholera  morbus  or  intestinal  indigestion. 
The  attack  may  be  only  moderately  severe,  particularly  if  there  is 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     739 

diarrhoea.  With  the  onset  of  the  pain  vomiting  usually  occurs.  The 
bowels  may  be  open  or  they  may  be  confined.  Vomiting  may  not 
occur  if  there  is  diarrhoea.  It  is  usually  attended  by  some  nausea, 
although  this  is  not  marked.  The  vomiting  is  complete,  there  is  no 
retching.  It  occurs  at  intervals,  between  which  there  is  comparative 
comfort.  The  contents  of  the  stomach  are  ejected,  and  then  mucus. 
If  the  patients  are  to  get  well,  vomiting  does  not  return  unless  ex- 
cited by  food.  If  peritonitis  supervenes,  vomiting  returns  in  the  course 
of  two  or  three  days.  If  in  bed,  the  patient  lies  on  his  back  with 
his  right  leg  flexed. 

Even  with  a  mild  degree  of  pain  the  skin  is  hot  and  temperature 
slightly  raised.  In  the  cases  in  which  the  pain  is  more  severe  the 
general  reaction  is  greater.  The  temperature  rises  rapidly  to  102°  to 
103°.  The  skin  is  hot  and  dry,  the  face  flushed.  The  pulse  in  a 
young  adult  rises  to  90  and  95.  It  is  full  and  strong.  On  account 
of  the  pain  there  is  some  restlessness.  In  some  cases  the  patient  corn- 
plains  more  of  the  fever  than  of  the  pain  after  its  first  severity  has 
subsided.     The  tongue  is  coated  ;  appetite  is  lost. 

On  physical  examination  the  area  which  was  the  seat  of  pain  is 
found  to  be  tender.  When  examined  with  the  tip  of  the  finger  press- 
ing firmly,  a  point  of  more  marked  tenderness  can  usually  be  found 
on  a  line  midway  between  the  anterior  superior  spine  of  the  ilium  and 
the  umbilicus.  It  is  known  as  McBurney's  point,  and  is  most  charac- 
teristic. It  indicates  the  site  of  the  diseased  appendix.  The  swollen 
tender  appendix  may  occasionally  be  palpable.  On  inspection  the 
affected  area  is  slightly  or  may  be  considerably  enlarged.  Comparison 
must  be  made  with  the  opposite  side.  It  will  be  seen  that  the  usual 
depression  in  front  of  the  anterior  spine,  or  the  cavity  toward  the  loin, 
is  not  so  deep  as  on  the  opposite  side.  In  front  the  surface  may  be 
even  with  the  plane  of  the  ilium.  On  palpation,  in  addition  to  ten- 
derness and  pain  at  the  point  previously  indicated,  fulness  and  en- 
largement can  be  distinguished.  There  is  resistance  to  pressure  and 
more  or  less  rigidity  of  the  abdominal  muscles.  On  careful  measure- 
ment the  semi-circumference  will  be  found  in  most  instances  to  be 
larger  than  the  semi-circumference  of  the  opposite  side.  When 
bimanual  palpation  is  performed,  the  left  hand  being  placed  in  the 
loin  behind  and  the  right  over  the  abdominal  surface,  resistance,  in- 
duration, and  rigidity  can  more  easily  be  detected.  On  percussion 
there  is  change  in  the  note  compared  with  that  of  the  opposite  side, 
and  change  in  the  percussion-note  during  the  course  of  the  disease. 
This  is  particularly  the  case  if  the  symptoms  go  on  to  perforation. 
On  careful  deep  percussion  a  dull  tympanitic  tone  is  elicited,  or  a 
distinct  area  of  dulness  can  be  mapped  out,  but  in  some  instances  the 
distended  csecum  yields  tympany,  which  is  greater  than  on  the  opposite 
side. 

The  pain,  is  usually  referred  to  the  region  above  mentioned.  The 
pain  may  be  in  the  lower  quadrant  on  the  left  side  instead  of  the  right. 
It  is  seen  in  those  cases  in  which  the  appendix  normally  dips  into  the 
pelvis.  It  may  also  be  referred  to  the  bladder  or  genitals,  and  be 
attended  with  vesical  tenesmus  and  frequent  micturition.     The  char- 


740  SPECIAL  DIAGNOSIS. 

acter  of  the  pain  and  the  bladder  symptoms  are  such  as  to  simulate  an 
attack  of  renal  colic,  with  the  passage  of  sand.  On  account  of  the 
locality  of  the  pain  it  may  be  attributed  to  the  Fallopian  tube  or  ovary, 
and  thought  to  be  due  either  to  pain  on  account  of  disease  of  these 
organs  or  to  dysmenorrhea.  It  is  not  likely  to  be  mistaken  for  the 
pain  of  dysmenorrhea  if  the  patient  is  subject  to  pain  at  the  usual 
monthly  period.  If,  however,  the  physiological  and  the  pathological 
affection  should  take  place  at  the  same  time,  or  the  latter  occur  about 
the  time  of  the  monthly  period,  a  mistake  in  diagnosis  may  occur, 
particularly  as  increased  abdominal  pain  may  cause  a  uterine  discharge. 
The  occurrence  of  fever  would  exclude  dysmenorrhoea  in  cases  in 
which  this  symptom  was  present.  The  pain  and  leg-flexion  simulate 
hip-joint  disease. 

After  the  first  twenty-four  hours,  during  which  the  above-mentioned 
symptoms  described  take  place,  the  fever  continues.  There  is  anorexia, 
but  vomiting  occurs  only  at  long  intervals  if  at  all.  The  local  symp- 
toms continue,  although  modified  usually  by  methods  of  treatment  which 
are  applied.  Both  general  and  local  symptoms  frequently  subside  after 
a  free  movement  of  the  bowels,  which  occasionally  takes  place  sponta- 
neously. In  other  cases  constipation  continues  a  week  or  ten  days, 
and  even  over  a  longer  period. 

After  five  or  six  days  at  the  furthest  the  fever  subsides,  the  local 
distention  lessens,  the  paroxysms  of  pain  disappear,  and  convalescence 
ensues.  There  may,  however,  be  localized  tenderness  for  a  consider- 
able period  of  time,  and  diarrhoea,  or  at  least  two  or  three  evacuations 
each  day,  for  a  week  or  more.  In  rare  instances  peritonitis  supervenes 
without  the  occurrence  of  perforation.  Its  onset  under  these  circum- 
stances is  gradual,  but  the  symptoms  are  like  those  of  peritonitis 
under  other  circumstances.  Infection  takes  place  directly  through  the 
appendix. 

When  the  fever  continues,  with  mild  diarrhoea,  intestinal  pain,  and 
flatulency,  the  case  may  be  mistaken  for  typhoid  fever.  The  tempera- 
ture is,  however,  more  remittent  in  character  in  appendicitis,  and  the 
diarrhoea  is  not  characteristic  of  typhoid  fever.  The  eruption  of 
typhoid  fever  does  not  occur,  the  spleen  is  not  enlarged,  and  the  symp- 
toms of  the  typhoid  state  do  not  ensue.  The  diazo-reaction,  the 
bacteriological  examination  of  the  stools,  and  the  serum  test,  may  aid 
in  forming  a  conclusion. 

Recurrent  Appendicitis.  Frequent  attacks  of  mild  appendicitis 
occur  ;  they  may  occur  as  frequently  as  every  three  months,  or  the 
interval  may  be  as  long  as  a  year.  The  attacks  are  similar  to  the 
attacks  just  described,  although  the  duration  is  shorter.  The  local 
symptoms  in  some  instances  are  more  marked,  because  there  has  been 
a  localized  peritonitis  previously.  The  induration  is  greater,  and  dul- 
ness  more  marked.  In  some  instances  the  attacks  are  comparatively 
mild,  continuing  but  twenty -four  hours,  and  are  described  as  attacks 
of  colic.  Often  they  have  been  treated  by  the  patient  himself,  by 
household  remedies  alone.  The  patient  spends  a  night  in  agony,  with 
cramps,  but  the  next  day  follows  his  usual  habits.  It  is  possible 
that  there  has  been   no  fever  with  the  attacks,  but  in  all  cases   of 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     741 

recurrent  appendicitis  which  I  have  seen,  fever,  although  often  slight, 
has  been  a  constant  accompaniment. 

Appendicitis  with  Perforation.  Before  perforation  takes  place 
the  patient  may  have  had  symptoms  of  the  mildest  form  of  appendi- 
citis for  two  or  three  days,  or  they  may  have  extended  over  a  long 
period  of  time,  without  any  symptoms  except  colicky  pain.  As  obser- 
vations are  not  made,  the  presence  of  fever  cannot  in  such  a  case  be 
utilized  as  a  diagnostic  feature.  The  perforation  may  take  place  early 
in  the  course  of  an  acute  attack,  and  result  in  localized  peritonitis  and 
abscess,  or  in  diffuse  peritonitis.  If  the  latter,  after  the  characteristic 
symptoms  of  appendicitis  the  symptoms  of  intense  peritonitis  set  in.  The 
abdomen  rapidly  becomes  distended,  the  characteristic  vomiting  ensues, 
and  collapse  develops.  Perforation  under  these  circumstances  has 
occurred  within  the  first  twenty-four  or  at  most  within  forty-eight  hours. 
Local  inflammation  about  the  appendix  does  not  take  place,  and  the  local 
signs  of  an  inflammatory  tumor  are  not  present,  although  tenderness 
at  the  special  point  can  be  elicited. 

Abscess.  If  the  perforation  is  more  gradual,  and  there  has  been  time 
for  the  occurrence  of  local  inflammation  about  the  appendix,  by  which 
pus  is  prevented  from  infecting  the  general  peritoneum,  or  if  perforation 
takes  place  behind,  in  the  connective  tissue  which  surrounds  the  mass, 
in  which  situation  there  is  always  inflammation,  the  local  signs  of  ab- 
scess or  inflammatory  tumor  occur.  There  is  swelling  of  the  affected 
side ;  the  normal  outline  is  effaced.  The  area  is  indurated,  and  the 
early  pronounced  rigidity  gradually  gives  way  to  a  boggy  sensation, 
with  the  appearance  of  oedema  of  the  skin.  This  can  be  elicited  by 
pressure  over  parts  that  are  hard  and  resisting,  as  the  spine  of  the 

Fig.  191. 


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Acute  appendicitis,  with  perforation  and  abscess.    Female,  set  8.    Operation  on  seventh  day. 

ilium.  Fluctuation  can  often  be  detected  by  bimanual  palpation. 
Dulness  is  found,  although  in  some  instances  it  may  be  very  slight, 
there  being  scarcely  an  appreciable  change  in  pitch.  Both  light  and 
deep  percussion  must  be  performed,  and  compared  with  the  results  of 


742  SPECIAL  DIAGNOSIS. 

percussion  in  the  opposite  region.  Palpatory  percussion  may  alone 
indicate  the  departure  from  normal.  Examination  per  rectum  may 
yield  much  information.  An  induration  may  be  felt  about  the  brim 
of  the  pelvis  or  the  rectal  fossa,  which  fluctuates  and  may  eventually 
soften.  With  the  finger  in  the  rectum,  and  pressure  above,  better 
results  may  be  obtained.  If  the  symptoms  of  peritonitis  do  not  arise, 
or  rapid  infection  of  the  system  take  place,  the  signs  of  abscess  become 
more  and  more  marked.  The  surface  becomes  reddened,  and  point- 
ing may  take  place  toward  the  groin  or  opposite  the  spine  of  the 
ilium.  Sometimes  the  swelling  increases  in  the  direction  of  the  loin, 
and  the  abscess  may  point  in  that  situation. 

As  the  abscess  develops  the  general  symptoms  change.  They  now 
become  the  symptoms  of  suppuration.  The  fever  is  remitting  or  inter- 
mitting. There  may  be  chills.  Sweats  are  common,  and  there  are 
loss  of  appetite  and  diarrhoea.  Until  recently  it  was  customary  to  see 
abscess  develop  in  some  other  situation,  or  symptoms  occur  from  bur- 
rowing of  the  pus  in  various  directions.  It  may  extend  upward  along 
the  back  of  the  colon,  underneath  the  diaphragm,  and  thence  to  the 
pleura  and  lung,  and  be  expectorated.  The  abscess  may  open  into  the 
rectum  or  into  the  bladder.  If  the  local  inflammation  is  virulent, 
even  if  peritonitis  has  not  taken  place,  the  symptoms  of  septiccemia 
may  rapidly  ensue.  This  sometimes  occurs  quite  early  in  the  disease. 
There  may  be  vomiting  and  septic  diarrhoea,  and  slight  delirium  at 
night.  An  excessively  rapid  and  feeble  pulse  is  seen  ;  in  one  instance 
it  was  irregular.  Extreme  prostration  ensues,  followed  by  symptoms 
of  the  typhoid  state. 

Gangrenous  appendicitis  is  most  treacherous.  The  early  symptoms 
are  like  an  acute  attack  ;  all  symptoms  then  subside.  Unless  the 
temperature  is  taken  or  the  physical  examination  is  very  painstaking, 
the  patient  is  allowed  to  get  up.  The  course  may, be  afebrile.  In  a 
few  days  or  a  week  an  abscess  forms  about  the  slough,  and  then  the 
usual  phenomena  of  suppuration  set  in ;  or  perforation  may  occur. 

It  is  clear  that  in  cases  of  appendicitis  we  must  attempt  to  recog- 
nize :  (1)  The  inflammation  before  perforation  has  taken  place  ;  (2)  the 
occurrence  of  perforation  ;  (3)  the  occurrence  of  peritonitis  due  to 
either  of  the  two  conditions  ;  (4)  the  occurrence  of  abscess  (paratyph- 
litis and  perityphlitis)  ;  and  (5)  the  occurrence  of  septicaemia. 

Typhlitis  is  an  inflammation  of  the  caecum  due  to  accumulation  of 
fecal  or  foreign  substances.  The  inflammation  may  remain  as  a  local- 
ized enteritis,  or  may  be  followed  by  ulceration.  In  the  majority  of 
cases  the  ulceration  is  due  to  pressure  by  the  contained  foreign  mate- 
rial^ or  feces.  The  inflammation  occurs  in  early  life  usually.  The 
patients  have  been  subject  to  constipation.  The  attack  may  follow 
some  error  in  diet.  There  are  pain  in  the  right  iliac  fossa,  constipa- 
tion, and  nausea.  Moderate  fever  develops.  On  examination  there 
is  fulness  in  the  right  iliac  region,  and  the  right  thigh  may  be  flexed, 
the  crecal  region  is  tender  to  pressure,  and  a  doughy,  sausage-shaped 
tumor  may  be  outlined.  The  more  severe  symptoms  last  two  or  three 
days.  Local  tenderness  may  continue  a  week  or  even  longer.  The 
tumor  gradually  disappears.     If  ulceration  takes  place,  inflammation 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     743 

about  the  caecum  ensues.  An  abscess  forms  gradually  in  the  flank. 
Perityphlitis  is  the  term  applied  to  this  secondary  abscess,  although, 
as  the  term  has  been  confused  with  paratyphlitis,  it  had  better  not 
be  used  in  this  connection. 

Abscess  about  the  head  of  the  caecum  is  due  (1)  to  appendicitis,  of 
which  sufficient  mention  has  been  made  ;  (2)  to  perforation  of  the 
caecum,  on  account  of  typhlitis  ;  (3)  to  perforation,  on  account  of  cancer 
of  the  intestine  ;  (4)  abscess  secondary  to  kidney  disease,  perinephritic 
abscess ;  (5)  to  abscess  secondary  to  disease  of  the  vertebrae.  The 
physical  signs  are  those  of  abscess  due  to  perforation  of  the  appendix. 
The  symptoms  are  the  local  symptoms  of  abscess  and  the  general  symp- 
toms of  suppuration. 

Fecal  abscess,  arising  from  ulceration  of  the  colon,  may  be  sus- 
pected, according  to  Fenwick,  when  there  is  a  localized  abdominal 
swelling,  immovable  in  respiration  or  by  a  moderate  amount  of  pressure 
with  the  fingers,  the  size  and  shape  being  altered  when  diarrhoea 
occurs,  and  when  percussion  over  the  tumor  gives  a  tympanitic  or  a 
more  forcible  stroke,  a  dull  sound,  or  when  an  emphysematous  sensa- 
tion is  communicated  to  the  fingers. 

Pericecal  abscess  follows  the  stercoral  typhlitis  which  occurs  as  the 
result  of  cancer  in  the  course  of  the  large  intestine.  The  history  of  the 
case  points  to  the  true  nature  of  the  disease.  Abscess  may  occur 
behind  the  caecum  in  cases  of  caries  of  the  vertebrae  and  in  some  rare 
instances  of  empyema  in  which  the  pus  has  dissected  downward. 

Appendicitis  must  be  distinguished  from  perinephritic  abscess  and 
the  abscess  which  follows  perforation  of  the  intestine  or  caecum  at  this 
point.  Perinephritis  can  scarcely  be  distinguished  unless  there  has 
been  a  previous  history  of  renal  calculus  and  pronounced  evidence  of 
disease  of  that  organ  preceding  the  formation  of  the  abscess. 

Hip-joint  disease  must  be  distinguished  from  appendicitis.  The  leg 
is  flexed,  the  patient  complains  of  pain  about  the  region  of  the  hip ; 
unless  careful  observation  has  been  made  in  the  beginning  of  the 
attack,  the  early  march  of  appendicitis  may  not  be  recognized.  The 
two  are  confounded  after  abscess-formation.  The  flexed  leg  of  appen- 
dicitis can  be  extended  under  ether,  and  examination  then  shows  the 
joint  to  be  free  from  disease. 

Fenwick  says  that  acute  tubercular  peritonitis  may  be  confounded 
with  perforation  of  the  appendix.  In  both  there  may  be  pain  and 
tenderness  in  the  hypogastrium,  dulness  on  percussion,  and  fever. 
In  tubercular  peritonitis  the  onset  is  more  gradual,  the  pain  and  ten- 
derness more  general,  and  there  is  no  distinct  tumor  or  increased  tension 
in  the  hypogastrium.  If  there  is  dulness  on  percussion,  the  line  gen- 
erally varies  with  the  position  of  the  patient.  Diarrhoea  is  urgent, 
and  there  are,  in  most  cases,  some  signs  of  consolidation  of  the  lungs. 
The  absence  of  tumor  in  the  right  iliac  region  and  in  front  of  the 
rectum  is  the  chief  point  of  distinction  ;  for  when  perforation  occurs 
in  phthisical  subjects  there  is  generally  very  slight  pain,  and  severe 
diarrhoea  is  often  the  only  prominent  symptom.  The  appendicitis 
itself  may  be  of  tuberculous  origin,  as  in  several  cases  reported  by  the 
writer. 


744  SPECIAL  DIAGNOSIS. 

Returning  to  palpation  and  percussion  of  the  lower  quadrants,  we 
find  in  intussusception  a  tumor,  often  detected  in  the  right  lower  quad- 
rant or  to  the  right  of  the  navel.  It  is  generally  distinct,  of  the  shape 
of  the  bowel,  not  very  tender,  and  harder  than  the  tumor  of  appendic- 
ular inflammation.  The  diagnosis  from  the  latter  is  made  by  the 
difference  in  the  character  of  the  tumor,  by  the  pain  being  colicky  and 
recurring  hi  paroxysms,  by  vomiting  and  constipation  being  more 
marked,  and  by  the  tenesmus  and  passage  of  blood  and  mucus  from 
the  bowel.  The  last-named  symptom  and  the  tumor,  with  a  constant 
desire  to  defecate,  are  the  most  characteristic  features  of  intussuscep- 
tion. A  tumor  may  be  detected  within  the  rectum  by  digital  explora- 
tion, if  the  intussusception  is  low  down.  There  may  be  distinct 
hemorrhage,  or  the  passage  of  the  invaginated  portion  of  the  bowel  per 
rectum.  Intussusception  is  the  most  frequent  cause  of  intestinal  ob- 
struction in  infants  and  young  children.  It  occurs  nearly  twice  as 
often  in  males  as  in  females.  Stercoraceous  vomiting  is  not  so  common 
as  in  other  forms  of  acute  obstruction  of  the  bowel. 

In  pelvic  abscess  a  swelling  sometimes  makes  its  appearance  on  the 
right  side,  above  Poupart's  ligament.  It  is,  perhaps,  situated  more 
toward  the  median  line  than  perityphlitic  abscess,  and  it  is  less  defined 
than  the  tumor  of  typhlitis  ;  but  the  diagnosis  from  these  affections 
must  be  made  by  the  history,  which  is  usually  that  of  an  antecedent 
salpingitis  or  of  previous  abortion  or  miscarriage.  Vaginal  examina- 
tion discovers  that  palpation  of  the  uterus  causes  pain  ;  that  the 
uterus  is  fixed,  instead  of  being  freely  movable,  and  that  the  pelvis 
is  blocked  up  by  an  exudate  on  the  affected  side. 

In  pelvic  hematocele  a  tumor  may  form  in  the  lower  half  of  one  of 
the  lower  quadrants.  It  is  distinguished  from  appendicitis,  perityph- 
litic abscess,  and  pelvic  abscess  by  the  absence  of  fever  and  constitu- 
tional signs  of  suppuration  ;  from  perityphlitic  and  pelvic  abscess  by 
its  sudden  onset,  probably  at  a  menstrual  period  ;  by  the  less  degree 
of  tenderness,  and  by  the  anaemia  and  collapse  which  follow  its  appear- 
ance. It  is  almost  invariably  the  result  of  a  ruptured  extra-uterine 
pregnancy.  Hence,  it  may  be  preceded  by  the  passage  of  decidua  and 
the  objective  signs  of  pregnancy.  It  is  distinguished  from  pelvic 
abscess  by  its  occurrence  in  a  woman  without  antecedent  tubal  or 
uterine  disease,  and  by  the  less  degree  of  tenderness  of  the  uterus  and 
relative  absence  of  fixation. 

In  stricture  of  the  ileo-ccecal  valve  due  to  cancer  there  is  frequently  a 
tumor  in  the  right  lower  quadrant,  between  the  umbilicus  and  anterior 
superior  spinous  process  of  the  ilium,  or  between  the  latter  and  the 
ribs.  The  diagnosis  is  made  by  noting  the  fact  that  the  tumor  has 
developed  gradually,  that  the  patient  has  suffered  with  colicky  pain, 
vomiting,  and  constipation,  possibly  preceded  by  diarrhoea,  and  that 
peristaltic  movements  of  the  intestines  can  readily  be  seen  through  the 
abdominal  walls.  The  abdomen  at  the  site  of  the  tumor  is  somewhat 
distended.  The  tumor  itself  is  irregular  and  tender,  and  is  dull  on 
percussion. 

The  disease  is  very  rare,  and  is  said  by  Fenwick  to  be  more  common 
in  women  from  twenty  to  forty  years  of  age. 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     745 

In  tumors  of  the  right  ovary  there  is  at  first  a  gradual  enlargement 
in  the  right  groin,  unaccompanied  by  pain,  fever,  or  impairment  of 
health  until  the  tumor  has  attained  considerable  size.  They  are  usually 
cystic,  and  fluctuation  can  be  obtained.  The  tumor  is  dull,  and  by 
bimanual  examination,  with  the  fingers  of  one  hand  in  the  vagina,  the 
tumor  can  be  traced  into  the  broad  ligament,  and  the  displacement  of 
the  uterus  which  it  occasions  made  out.  The  cystic  ovarian  tumors 
grow  from  the  starting-point  in  the  direction  of  an  axis  diagonally 
toward  the  median  line.  There  is  dulness  in  front  of  the  abdomen 
and  a  clear  percussion-note  or  tympany  in  the  flanks.     (Fig.  192.) 

Fig.  192. 


Position  of  an  ovarian  tumor  of  the  right  side,  in  various  stages  of  enlargement.  The  shading 
indicates  the  percussion-dulness  in  ovarian  dropsy  of  moderate  extent ;  the  umbilical  region  is  dull 
from  the  presence  of  fluid,  and  the  flanks  remain  clear.  The  outer  circle  shows  a  further  extent 
which  the  dulness  may  reach  in  ovarian  dropsy.    (Bright.) 


Palpation  and  Percussion  in  the  Left  Lower  Quadrant. 
Enlargements  in  this  region  are  due  most  frequently  in  women  to 
ovarian  tumors,  pelvic  abscess,  pelvic  hcematocele,  and  fibroids  of  the 
uterus,  the  diagnostic  points  of  which  have  been  referred  to  already 
under  palpation  and  percussion  of  the  right  iliac  region.  In  addition 
to  the  affections  named,  enlargements  are  occasionally  met  with  from 
fecal  accumulations  in  the  flexure  of  the  colon,  cancer  of  the  descending 
colon,  tubercular  peritonitis,  and  enlargements  or  displacements  of  the 
spleen  and  kidney  {q.  v.).  Fecal  abscess  also  may  occur  here,  and  the 
tumor  of  intussusception  may  be  detected  on  the  left  side. 

Palpation  and  Percussion  above  the  Pubis.  Enlargements 
in  this  region  may  be  due  to  fibroid  tumors  of  the  womb.  They  occur 
most  frequently  in  sterile  women,  and  are  accompanied  usually  by 
hemorrhage.  Bimanual  examination  of  the  uterus  will  reveal  an  un- 
evenness  of  surface  of  the  womb  if  the  tumor  is  external,  and  passage  of 
the  sound  will  detect  any  growth  projecting  into  the  cavity  of  the  womb. 

The  enlargement  may  be  due  to  a  distended  bladder.  It  is  a  good 
rule  always  to  be  sure  that  this  viscus  is  empty  before  beginning  an 
examination. 

In  acute  tubercular  peritonitis  a  swelling  may  develop  in  this  region. 
It  appears  gradually,  is  diffused  and  free  from  tenderness,  but  is  pre- 


746  SPECIAL  DIAGNOSIS. 

ceded  by  pain  and  fever.  There  is  no  palpable  tumor,  but  the  percus- 
sion-note is  dull  and  the  tension  is  increased.  Moreover,  the  level  of 
dulness  is  apt  to  vary  with  change  of  posture.  The  general  health  is 
markedly  affected,  loss  of  flesh  is  rapid,  and  diarrhoea  and  sweats  are 
common.     A  focus  of  disease  may  be  discovered  in  the  lungs. 

Palpation  and  Percussion  or  the  Region  below  the  Ster- 
num. Enlargement  in  this  region  is  most  frequently  due  to  affections 
of  the  stomach  (q.  v.).  It  is  not  uncommon,  however,  to  find  here  a 
cancerous  nodule  projecting  from  the  surface  of  the  liver,  or  a  hydatid 
cyst  of  the  same  organ.  The  diagnosis  must  be  made  by  determining, 
with  the  aid  of  palpation  and  percussion,  whether  the  tumor  is  con- 
tinuous with  the  liver,  the  effect  of  respiration  upon  it,  and  its  apparent 
depth  from  the  surface,  tenderness,  fluctuation,  etc.,  and  by  a  study  of 
the  subjective  symptoms  pointing  to  disease  of  the  stomach  or  liver. 
(See  Diseases  of  the  Liver.) 

Much  more  rarely  enlargement  here  may  be  from  tumor  of  the  pan- 
creas, such  as  cyst,  abscess,  or  cancer.  According  to  the  studies  of 
Fitz,  the  former  is  marked  by  deep-seated  colicky  pain  occurring  in 
paroxysms,  by  discharges  from  the  bowels  of  matter  resembling  saliva, 
by  the  detection  of  fat  in  the  stools  and  sugar  in  the  urine,  by  saliva- 
tion, and  by  the  occurrence  of  jaundice. 

Cancer  of  the  pancreas  is  recognized  by  the  detection  of  a  painful 
tumor  in  the  epigastrium.  The  pain  is  not  aggravated  by  the  taking 
of  food,  but  is  said  to  be  increased  by  the  erect  posture.  The  bowels 
are  constipated,  and  the  stools  may  or  may  not  be  fatty.  Emaciation 
is  progressive,  as  in  all  cancerous  affections,  and  in  the  last  stages 
there  may  be  occasional  vomiting  and  persistent  jaundice. 

Palpation  and  percussion  of  the  upper  right  quadrant  is 
limited  largely  to  an  investigation  of  changes  in  the  liver  and  gall- 
bladder, and  is  discussed  in  the  section  devoted  to  them. 

Palpation  and  Percussion  of  the  Upper  Left  Quadrant. 
Enlargement  in  this  region  is  generally  due  to  disease  of  the  spleen 
(q.  v.).  It  may  be  due  to  fecal  accumulation  in  the  left  transverse  and 
descending  colon.  This  condition  is  recognized  by  the  painlessness 
and  doughy  consistence  of  the  tumor,  and  by  careful  inquiry  as  to  the 
condition  of  the  bowels.  Constipation  will,  of  course,  exist,  but  both 
patient  and  physician  may  be  misled  by  apparent  diarrhoea,  or  even 
dysentery  ;  there  will  be  fluid  or  semi-fluid  dejections  mingled  with 
scybala,  and  sometimes  mucus  and  blood. 

An  interesting  cause  of  swelling  in  this  region,  and  in  the  lumbar 
region,  is  perigastric,  or  subdiaphragmatic  abscess,  a  collection  of  pus 
walled  in  by  the  stomach,  spleen,  diaphragm,  colon  and  the  abdomi- 
nal walls. 

The  most  common  cause  is  the  irritation  of  a  gastric  ulcer  which 
has  nearly  or  quite  perforated,  and  has  formed  adhesions  with  sur- 
rounding viscera.  This  was  the  cause  in  forty-one  out  of  fifty-two 
cases  analyzed  by  Fen  wick,  while  in  six  it  was  associated  with  cancer 
and  in  four  with  abscess  commencing  externally.  Pain  in  the  epigas- 
trium or  abdomen  was  the  chief  subject  of  complaint,  and  in  most  of 
the  cases  there  was  dyspepsia,  sometimes  vomiting.     It  is  singular 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     747 

that  hsematemesis  was  mentioned  in  only  two  cases.  Fenwick  thinks 
that  in  every  case  of  perigastric  abscess,  except  in  persons  affected 
with  phthisis,  cancer,  or  some  other  chronic  exhausting  malady,  the 
first  formation  of  the  abscess  will  be  accompanied  by  either  collapse 
and  signs  of  general  peritonitis,  or  by  sudden  and  severe  pain  in  the 
epigastrium,  attended  with  indications  of  local  peritonitis. 

Fever  is  a  prominent  symptom,  but  physical  signs  are  absent.  A 
tumor,  according  to  the  same  author,  is  rarely  distinguishable  except 
when  the  cause  is  cancer.  It  is  dull,  but  afterward  tympanitic  on 
percussion,  and  not  movable  on  inspiration  or  external  pressure.  The 
tension  of  the  abdominal  muscles  prevents  successful  palpation.  There 
may  be  arching  outward  of  the  ribs.  The  displacement  of  surround- 
ing viscera  will  depend  upon  the  size  of  the  abscess  and  the  extent 
of  adhesions.  The  diaphragm  is  pushed  upward,  and  dulness  may 
extend  as  high  up  as  the  angle  of  the  scapula,  in  which  case  a  pleural 
effusion  is  simulated.  Breathing  is  embarrassed  by  the  upward  press- 
ure upon  the  lung  and  heart.  Sometimes  when  gas  is  formed  in  connec- 
tion with  the  abscess,  amphoric  sounds  on  auscultation  and  percussion 
are  heard  both  in  the  abdomen  and  over  the  thorax.  To  this  condi- 
tion the  name  pyo-pneumothorax  subphrenicus  has  been  applied.  The 
abdomen  then  becomes  tense,  tender,  prominent,  and  tympanitic  on 
percussion.  (See  p.  578.)  It  must  be  distinguished  from  left  pneu- 
mothorax. Air  in  the  pleural  cavity  pushes  the  left  wing  of  the  dia- 
phragm down,  and  hence  increases  the  area  of  percussion-dulness  and 
the  palpability  of  the  left  lobe  of  the  liver  and  spleen.  In  subdia- 
phragmatic abscess  with  gas,  the  liver  and  spleen  are  not  palpable, 
nor  can  their  area  be  limited  by  percussion.  The  heart  is  dislocated 
in  pneumothorax,  and  its  area  tympanitic  on  percussion,  while  the  im- 
pulse is  seen  in  the  epigastrium  or  to  the  right  of  the  sternum.  In 
subphrenic  pneumothorax  the  heart  is  elevated,  and  the  impulse  seen 
in  the  nipple-line.  At  the  same  time  there  is  tympany  in  the  lower 
half  of  the  cardiac  area  of  dulness.  Pyo-pneumothorax  subphrenicus 
must  not  be  mistaken  for  dilatation  of  the  stomach. 

Palpatiox  axd  Percussion  of  the  Loixs.  Enlargements  in 
these  regions  may  be  due  to  affections  of  the  kidney  (q.  v.).  They 
may,  however,  be  due  to  enlargement  or  displacement  of  the  spleen 
and  liver  (q.  v.),  or  to  tumors  of  the  retroperitoneal  glands.  On  the 
left  side  the  possibility  of  perigastric  abscess  must  be  borne  in  mind, 
as  sometimes  the  dulness  and  increased  tension  of  the  tumor  extend 
as  far  down  as  the  lumbar  region. 

Palpatiox  axd  Percussion  about  the  Cextre  of  the  Abdo- 
mex.  Umbilical  hernia,  cancers  of  the  stomach,  liver,  and  intestine, 
sarcoma  of  the  retroperitonecd  glands,  hydatid  cysts  of  the  liver,  and 
tumors  of  the  gcdl-bladder,  together  with  floating  kidney,  spleen,  and 
liver,  all  at  times  cause  tumors  which  may  be  felt  in  this  region.  They 
must  be  distinguished  from  each  other  by  methods  already  referred  to 
under  the  organs  named.  The  general  principle  upon  which  to  proceed 
is  to  endeavor,  by  palpation  and  percussion,  to  discover  the  organ  to 
winch  the  tumor  belongs.  To  this  end  careful  inquiry  should  be  made 
as  to  the  time  the  tumor  has  been  known  to  exist ;  its  effect,  if  any, 


748  SPECIAL  DIAGNOSIS. 

upon  the  general  health  ;  its  effect  upon  the  function  of  the  possible 
organs  affected,  and  particularly  as  to  the  presence  or  absence  of 
vomiting,  constipation,  diarrhoea,  or  jaundice. 

Tumor  in  the  region  about  the  umbilicus  may  be  from  tubercular 
disease  of  the  mesenteric  glands  {tabes  mesenterica).  It  occurs  nearly 
always  in  children,  and  presents  the  physical  signs  and  symptoms  of 
tubercular  peritonitis,  with  the  addition  that  enlarged  mesenteric 
glands  may  sometimes  be  felt.  Children  grow  pale  and  anaemic, 
waste  away,  have  apparently  causeless  diarrhoea,  the  passages  being 
foul  and  the  food  undigested.  The  abdomen  is  large,  but  appears 
larger  when  compared  with  the  emaciated  body.  It  is  tender,  its  walls 
are  thickened  and  less  elastic  than  normal.  Signs  of  tubercular  dis- 
ease in  other  organs  may  be  detected. 

Facts  gathered  in  this  way,  carefully  analyzed,  and  then  studied 
with  reference  to  the  physical  properties  of  the  tumor  (hard  or  soft, 
fluctuating,  doughy,  or  not),  will  generally  suffice  for  a  probable  diag- 
nosis. A  positive  diagnosis  often  cannot  be  made  at  the  first  examina- 
tion, and  sometimes  is  possible  only  after  watching  the  progress  of  the 
case  for  a  considerable  time. 

Enteroptosis. 

It  is  by  inspection,  palpation,  percussion,  and  auscultation  that  we 
discover  the  anatomical  cause  for  the  symptom-group  about  to  be  de- 
scribed. Attention  to  this  affection  may  only  be  called  by  the  sub- 
jective symptoms. 

This  disease  or  physical  condition,  called  sometimes  Glenard's  dis- 
ease, after  the  physician  who  first  called  attention,  in  1885,  to  its 
existence,  has  received,  of  late,  much  study.  It  is  characterized  by  the 
falling  down  or  descent  of  a  number  of  the  abdominal  organs.  This 
occurs  on  account  of  relaxation  of  the  supporting  ligaments,  the  num- 
ber of  which  Glenard  puts  at  six.  This  relaxation  is  largely  due  to  a 
flabbiness  and  hence  lack  of  support  of  the  abdominal  wall ;  or  to 
strain  from  undue  physical  exertion  ;  or  to  the  abuse  of  cathartics  ;  or 
possibly  to  injury.  It  is  far  more  common  hi  females  who  have  borne 
children.  It  may  be  the  result  of  feeble  muscle-tone,  following  pro- 
longed illness.  The  degree  of  descent,  and  hence  the  severity  of  the 
symptoms,  may  vary  from  slight  displacement  of  one  or  two  organs  to 
that  of  the  large  intestine,  the  stomach,  the  liver,  the  spleen,  and  the 
right  kidney  (sometimes  both).  In  moderate  cases  but  two  of  the  liga- 
ments are  relaxed — the  ligamentum  colico-hepaticum  and  the  ligamen- 
tuin  gastro-colicum  ;  in  the  more  severe  all  are  affected. 

Symptoms.  The  objective  symptoms  are  due  to  the  slight  displace- 
ment, and  are  either  purely  physical  or  arise  from  the  alteration  of  the 
function  of  the  stomach  and  the  intestines. 

The  subjective  symptoms  are  due  to  the  same  cause.  The  displace- 
ment gives  rise  to  local  symptoms  of  weight,  heaviness,  and  abdominal 
distress,  amounting  in  some  instances  to  pain,  especially  when  in  the 
upright  position,  and  to  protracted  and  pronounced  neurasthenia. 
Later,  we  have  the  subjective  symptoms  of  dyspepsia,  gastritis,  gastric 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     749 

dilatation,  and  intestinal  atony,  while  the  neurasthenic  symptoms  grow 
more  aggravated. 

The  earliest  objective  symptoms  are  :  (1)  Pulsation  of  the  abdomi- 
nal aorta  ;  (2)  a  linear  tumor  or  band  about  midway  between  the 
xiphoid  cartilage  and  the  umbilicus,  extending  transversely  from  four 
to  six  inches  in  length  ;  (3)  gastroptosis,  or  descent  of  the  stomach  ; 
(4)  movable  right  kidney.  Later,  the  liver  may  fall  from  one  to  four 
inches,  the  spleen  become  palpable,  and  the  left  kidney  movable.  The 
transverse  tumor  above  mentioned  was  held  by  Glenard  to  be  the 
thickened  transverse  colon.  Ewald,  however,  seems  to  have  demon- 
strated that  it  is  the  pancreas.  The  displacement  of  the  viscera  is 
recognized  by  the  methods  previously  detailed  for  physical  examina- 
tion of  the  various  organs.  The  patient  must  always  be  examined  in 
the  erect  as  well  as  in  the  recumbent  position.  Care  must  be  taken  to 
distinguish  gastric  dilatation  from  gastric  descent.  This  can  be  done 
by  careful  percussion  after  inflation  with  air,  by  gastric  diaphany,  by 
measurement  with  a  sound,  and  with  fluids.  Glenard  laid  much  stress 
upon  the  splashing  sound.  This  may  or  may  not  be  present ;  it  may 
be  of  gastric  or  intestinal  origin,  usually  the  former.  It  does  not 
depend  upon  the  displacement  as  much  as  upon  the  occurrence  of  gas- 
tric dilatation.     It  occurs  in  other  affections. 

An  objective  sign  of  diagnostic  value,  attention  to  which  has  been 
called  by  Treves,  is  the  relief  the  patient  experiences  when  the  lower 
half  of  the  abdomen  is  supported  by  a  belt  or  by  the  hands  of  the 
patient  or  surgeon,  when  in  the  upright  position. 

The  objective  signs  of  gastric  origin  depend  upon  functional  or 
organic  disease  of  that  organ.  We  may  have,  on  the  one  hand,  only  the 
perverted  gastric  secretion  and  digestion  that  go  with  gastric  neuroses  ; 
on  the  other  hand,  we  may  have  the  perverted  gastric  secretion  of  gas- 
tritis, gastric  atrophy,  or  dilatation,  and  the  evidences  of  diminished 
digestive,  motor,  and  absorptive  power  of  these  affections. 

The  subjective  symptoms  also  depend  upon  the  functional  or  organic 
changes  in  the  stomach  and  intestines,  upon  the  displacement  of  the 
organs,  with  or  without  the  above,  or  upon  the  associate  physical  mus- 
cular condition  of  the  individual  and  the  state  of  the  nervous  system. 

Glenard  divided  the  progress  of  the  subjective  symptoms  into  three 
periods  : 

In  the  first  there  is  gastric  atony,  when  the  patient  experiences 
weight  and  burning  after  eating ;  a  short  period  of  wakefulness  about 
two  o'clock  a.m.  ;  a  loose  stool  in  the  morning;  loss  of  strength. 

In  the  second  period  the  patient  cannot  eat  fats  and  starches,  and  the 
subjective  symptoms  arise  late  in  the  period  of  digestion.  A  dragging 
sensation  or  a  feeling  of  emptiness  occurs  about  three  hours  after  meals. 
The  patient  awakens  at  two  o'clock  a.m.,  and  remains  awake  for  two 
or  three  hours.  Constipation,  at  times  alternating  with  diarrhoea,  is 
present.  There  is  continued  loss  of  strength,  and  a  tired  feeling  is 
complained  of  on  rising. 

In  the  third  period  the  symptoms  of  neurasthenia  arc  most  pro- 
nounced. The  patient  is  emaciated,  and  complains  of  a  constant  weight 
and  of  cramps  in  the  stomach.     Constipation  is  obstinate,  and  the  stools 


750  SPECIAL  DIAGNOSIS. 

are  scybalous  and  mucous.  The  patient  is  much  prostrated  and  suffers 
from  sleeplessness.  The  constipation  and  the  intestinal  distress  are 
aggravated  by  aperients.  Enemata  must  be  resorted  to,  to  relieve 
the  symptoms.  Intestinal  catarrh  or  membranous  enteritis  is  very 
likely  to  follow. 

Pain  throughout  the  abdomen,  especially  when  walking  about  or  in 
the  erect  posture,  is  frequently  complained  of.  Some  authorities  speak 
of  tenderness  on  pressure  over  the  solar  plexus  and  of  tender  points 
along  the  vertebra. 

The  disease  is  overlooked  and  the  symptoms  are  attributed  to  neuras- 
thenia.   It  is  often  difficult  to  estimate  which  of  the  two  preponderates. 

Diseases  of  the  Peritoneum.     Peritonitis. 

Inflammation  of  the  peritoneum  may  be  acute  or  chronic.  It  may 
be  general  or  localized.  Acute  inflammation  is  rarely  primary  •  it 
may  occur  in  the  later  stages  of  chronic  Bright' s  disease,  or  other  dys- 
crasia,  as  a  terminal  infection.  If  it  follows  exposure  to  cold,  or 
trauma,  it  is  called  traumatic  peritonitis.  It  is  due  in  the  large 
majority  of  cases  to  extension  from  organs  which  the  peritoneum 
covers,  or  to  perforation  of  one  of  the  abdominal  organs.  In  the  first 
instance  it  may  follow  inflammation  of  any  portion  of  the  gastro- 
intestinal tract,  of  the  pelvic  viscera,  and  suppurative  inflammation  of 
the  spleen  and  liver  and  of  the  pancreas. 

Peritonitis  an  Infection.  In  all  instances  the  primary  inflammation 
in  the  organs  mentioned  is  due  to  some  micro-organism,  as  the  staphy- 
lococcus, the  streptococcus,  or  the  bacillus  coli  communis,  and  the 
peritoneal  inflammation  to  subsequent  extension  of  the  infection.  In 
peritonitis  from  perforation  the  element  of  infection  is  also  the  most 
important  part  in  the  process,  as  in  ulcer  of  the  stomach  or  bowels.  In 
inflammation  of  the  gall-bladder  perforation  may  take  place,  with  result- 
ing peritonitis.  Abscess  in  the  liver,  spleen,  or  kidneys,  bursting  into 
the  peritoneum,  also  leads  to  general  peritonitis.  The  most  common 
forms,  however,  are  due  to  appendicitis  or  disease  of  the  Fallopian 
tubes.  Acute  peritonitis  may  also  occur  in  tuberculosis  and  in  other 
systemic  infections  by  direct  infection. 

Symptoms.  The  onset  of  acute  peritonitis  depends  in  a  measure 
upon  the  cause.  When  there  is  perforation  the  onset  is  sudden. 
Chilly  feelings  or  a  rigor  occur,  with  intense  pain  in  the  abdomen. 
The  pain  is  at  first  localized,  but  rapidly  becomes  general.  It  is  con- 
stant, increases  in  exacerbations,  and  is  very  intense,  aggravated  by 
movements  and  by  pressure.  The  patient  lies  on  the  back  with  the  leg* 
drawn  up.  The  dorsal  decubitus  is  assumed,  in  order  that  the  tension 
of  the  abdominal  muscles  may  be  relieved.  The  location  of  the  pain 
depends  upon  the  seat  of  primary  infection  ;  this  is  usually  in  the 
right  or  left  lower  quadrant,  more  marked  about  the  tubes  or  the 
appendix.  In  perforation  of  an  ulcer  of  the  stomach  the  pain  may 
be  located  in  the  back,  or  in  the  chest  or  shoulders. 

Physical  Examination.  On  palpation  the  abdomen  is  extremely 
sensitive.     The  patient  is  unable  to  bear  the  weight  of  clothing  or  ex- 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     751 

ternal  applications.  The  abdomen  gradually  becomes  distended,  and 
is  tympanitic  on  percussion.  The  distention  may  become  so  great  as 
to  push  up  the  diaphragm  and  interfere  with  the  respirations,  so  that 
they  are  shallow,  and  may  dislocate  the  heart,  so  that  the  apex-beat  is 
seen  in  the  fourth  interspace.  The  splenic  dulness  may  be  obliterated 
entirely  and  the  liver-dulness  reduced.  It  is  said  that  in  some  in- 
stances this  may  be  obliterated,  although  recent  observations  show 
that  such  obliteration  only  occurs  in  the  anterior  portion  of  the  abdo- 
men. Liver-dulness  persists  in  the  axillary  region,  though  diminished 
in  extent.  This  obliteration  could  only  take  place  in  perforative  peri- 
tonitis. Osier  points  out  that  in  pneumoperitoneum  from  perforation 
the  anterior  hepatic  dulness  may  be  obliterated,  although  dulness  in 
the  lateral  region  continues,  on  account  of  the  effusion  of  fluid.  If  a 
patient  with  gas  in  the  peritoneum  is  turned  on  the  left  side,  a  clear 
note  is  heard  beneath  the  seventh  and  eighth  ribs  (hepatic  region). 
The  abdominal  muscles  are  more  or  less  rigidly  contracted.  Spasm  of 
the  muscle  over  the  seat  of  primary  inflammation  takes  place  at  once, 
and  is  a  valuable  indication  of  the  origin  of  the  infection.  In  some 
cases,  usually  when  the  inflammation  is  due  to  the  streptococcus,  there 
is  not  much  distention  of  the  abdomen,  or  it  may  be  flattened  entirely 
with  board-like  rigidity.  In  these  instances  pain  is  not  so  marked,  and 
tenderness  may  not  be  complained  of. 

The  respirations  are  hurried  and  the  superior  thoracic  type  of  breath- 
ing is  seen,  because  the  action  of  the  diaphragm  is  painful.  The  act  of 
speaking  or  coughing  increases  the  pain,  and  the  patients  are  unable 
to  take  a  full  breath  without  suffering.  With  the  occurrence  of  pain 
and  local  signs  vomiting  usually  sets  in.  It  is  painful  and  at  first 
is  complete,  the  contents  of  the  stomach  being  ejected  and  then  a  yel- 
lowish bile-stained  fluid  ;  later,  the  vomit  becomes  greenish  hi  color. 
Complete  vomiting  is  replaced  by  simple  regurgitation  of  fluid,  so  that 
on  the  slightest  motion  of  the  patient,  or  on  taking  a  small  amount  of 
fluid,  the  characteristic  greenish-colored  fluid  is  regurgitated  without 
action  of  the  diaphragm.  This  may  be  almost  continuous  for  from 
twenty-four  to  forty-eight  hours.  The  tongue  is  at  first  furred,  but 
later  becomes  dry,  and  often  is  cracked  and  red.  The  bowels  are  con- 
stipated. They  may  be  loose  at  first,  but  constipation  is  characteristic. 
The  intestines  are  paralyzed  from  overdistention  and  from  oedema  of 
the  walls  due  to  inflammation. 

The  general  symptoms  are  marked.  After  the  chill  the  temperature 
rises  to  104°  or  105°.  In  septic  cases  it  continues  at  this  point,  or 
may  rise  to  a  greater  height.  If  cases  progress  rapidly,  a  temperature 
of  105°  or  106°  on  the  second  or  third  day  is  not  uncommon.  In 
other  cases  after  the  initial  rise  the  subsequent  elevation  is  not  so  great, 
but  there  is  not  much  difference  between  morning  and  evening  temper- 
ature unless  there  is  an  abscess. 

The  urine  is  scanty  ;  micturition  may  be  frequent  and  painful,  par- 
ticularly if  the  inflammation  began  in  the  pelvic  organs.  The  urine 
usually  contains  a  large  amount  of  indican  in  the  suppurative  form. 

The  appearance  of  the  patient  at  the  height  of  the  disease  is  charac- 
teristic.     The   expression  is   anxious,  the  face  is    pinched,  the  eyes 


752  SPECIAL  DIAGNOSIS. 

sunken.  Vomiting  causes  wasting.  The  collapse  is  marked,  with 
the  characteristic  facies  previously  described.  (See  Expression.)  The 
pulse  is  rapid  and  feeble  and  soon  becomes  thready,  ranging  from  110 
to  150.  In  the  first  stages  it  may  be  small  and  hard.  Attention  has 
been  called  frequently  to  the  peculiar  wiry  pulse  of  the  early  stage  of 
peritonitis. 

In  severe  cases  death  may  take  place  in  from  thirty-six  to  forty-eight 
hours.  Usually  a  fatal  termination  does  not  take  place  for  five  or  six 
days,  and  may  be  delayed  longer.  The  vomiting  persists,  collapse 
with  falling  temperature  ensues,  the  pulse  becomes  rapid  and  thready. 
Throughout  the  entire  attack,  unless  symptoms  of  septicaemia  are 
marked,  the  mind  is  clear.  The  patient  dies  of  paralysis  of  the  heart. 
Septicemic  symptoms  are  indicated  by  a  dusky  color  of  the  face,  rapid 
and  irregular  pulse,  slight  delirium,  dry,  brown  tongue,  and  other  evi- 
dences of  the  typhoid  state. 

If  the  cases  are  prolonged,  some  effusion  may  take  place  into  the 
peritoneal  cavity.  Dulness  is  noted  in  the  flank,  and  if  it  is  possible 
to  move  the  patient,  it  alters  with  the  position.  If  recovery  takes 
place,  particularly  in  tuberculous  cases,  the  affection  may  become  cir- 
cumscribed and  be  indicated  by  dulness,  which  is  not  movable. 

Diagnosis.  It  is  essential  in  making  a  diagnosis  to  ascertain,  if 
possible,  the  primary  source  of  the  infection  or  inflammation.  To 
determine  this  we  inquire  the  age,  sex,  and  history  of  previous  disease 
of  the  patient.  In  young  male  adults  appendicitis  is  first  to  be  thought 
of ;  in  females  inflammation  of  the  pelvic  organs.  In  chlorotic  sub- 
jects, if  the  pain  is  high  up,  a  history  of  ulcer  of  the  stomach  must  be 
inquired  for.  Later  in  life,  particularly  if  there  has  been  jaundice, 
the  possible  history  of  frequent  attacks  of  gallstones  and  of  hepatic 
disturbances  must  be  ascertained.  All  forms  of  intestinal  obstruction 
must  be  sought  for.  Frequently,  however,  a  definite  cause  cannot  be 
ascertained.  If  it  occurs  in  the  course  of  typhoid  fever,  it  is  usually 
due  to  perforation,  but  the  occurrence  of  pain  may  not  be  complained 
of,  on  account  of  the  mental  state  of  the  patient.  Under  other  circum- 
stances the  symptoms  cannot  be  overlooked. 

Acute  peritonitis  must  be  distinguished  from  entero-colitis.  The 
distinction  is  not  usually  difficult  if  attention  is  paid  to  the  develop- 
ment of  the  case.  The  pain  is  not  so  severe  in  entero-colitis  ;  it  is 
more  colicky  in  character.  The  general  tenderness  is  not  so  great  as 
in  peritonitis,  and  the  distention  does  not  interfere  with  respiration  to 
such  a  marked  degree.  Diarrhoea  is  more  common  in  entero-colitis  ; 
collapse,  if  present,  is  not  so  pronounced. 

Acute  hemorrhagic  pancreatitis  may  simulate  peritonitis  in  the  sudden 
intensity  of  pain  and  the  occurrence  of  shock. 

The  diagnosis  from  obstruction  of  the  bowel  is  difficult  in  the  absence 
of  a  distinct  history,  but  in  peritonitis  we  do  not  have  stercoraceous 
vomiting  until  late.  The  tympanites  and  the  pain  are  more  general. 
Peritonitis  frequently  accompanies  or  is  due  to  obstruction.  A 
tumor,  if  present,  may  point  to  the  true  nature  of  the  case,  and,  if 
there  is  any  discharge  from  the  rectum,  invagination  may  be  the  ex- 
citing cause. 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     753 

Peritonitis  is  simulated  by  a  condition  to  which  the  name  hysterical 
peritonitis  has  been  applied.  It  occurs  in  hysterical  subjects,  and 
every  feature  of  the  true  form  is  imitated.  The  mode  of  onset,  the 
decubitus,  the  difficulty  in  micturition,  and  the  local  distention  and 
tenderness  of  the  abdomen  are  characteristic  of  both.  In  a  few  cases 
which  we  have  seen  the  vomiting  is  not  of  the  nature  of  true  periton- 
itis, either  in  the  mode  of  ejection  or  the  character  of  the  fluid.  It 
must  not  be  forgotten  that  even  the  temperature  may  be  elevated  and 
collapse  take  place  in  the  hysterical  form.  In  the  cases  which  I  have 
seen  the  abdominal  facies  does  not  develop,  while,  on  the  other  hand, 
the  facies  of  hysteria,  with  the  self-interest  which  the  patient  exhibits, 
and  the  precision  with  which  symptoms  are  narrated,  coupled  with 
emotional  or  other  manifestations  of  hysteria,  point  to  the  true  nature 
of  the  affection.  Other  symptoms  of  hysteria  may  arise.  The  case  is 
judged  by  the  history  of  these  associated  manifestations  and  the  per- 
manent stigmata  of  the  disease.  There  is  always  a  positive  absence  of 
cause  and  of  disease  in  any  of  the  abdominal  viscera.  Sometimes,  in 
these  cases,  if  the  attention  of  the  patient  is  diverted,  the  tenderness 
on  pressure  may  not  be  complained  of.  I  am  not  familiar  with  the 
results  of  examination  of  the  urine  in  this  form  of  peritonitis.  Indi- 
can  should  not  necessarily  be  increased,  as  we  find  it  to  be  in  acute 
suppurative  peritonitis. 

Rheumatism  of  the  Abdominal  Walls.  There  is  absence  of  a  history 
of  sudden  acute  pain  followed  by  general  pain.  The  fever  is  not  so 
great.  The  respirations  are  not  interfered  with,  the  pulse  is  not  so 
rapid,  and  symptoms  of  collapse  do  not  supervene.  A  rheumatic 
pharyngitis  or  inflammation  of  muscles  in  some  other  portion  of  the 
body  may  occur  simultaneously. 

Local  Circumscribed  Peritonitis.  The  causes  of  localized 
peritonitis  are  those  of  general  peritonitis — that  is,  extension  of  inflam- 
mation from  neighboring  viscera,  or  perforation  of  the  viscera.  In  the 
latter  instance  the  inflammation  does  not  become  general,  if  rapid  local 
inflammation  shuts  off  the  perforated  area  from  the  general  cavity  of 
the  peritoneum.  Local  peritonitis  of  mild  degree,  and  local  or  cir- 
cumscribed peritonitis  with  suppuration,  are  therefore  found  in  the 
regions  previously  indicated,  from  which  a  general  peritonitis  may 
develop.  The  inflammation,  however,  if  retained  by  a  limiting  wall, 
may,  after  suppuration  has  taken  place,  gradually  extend  and  the  pus 
burrow  in  various  directions.  In  such  cases  of  localized  peritonitis  as 
may  exist  in  the  upper  half  of  the  abdomen,  a  sub-diaphragmatic 
abscess  may  form,  or  an  abscess  containing  air  and  pus,  known  as  pyo- 
pneumothorax subphrenicus.  If  the  inflammation  is  secondary  to 
disease  of  the  pancreas,  it  may  be  limited  to  the  lesser  peritoneum  and 
cause  the  physical  signs  of  effusion  in  this  cavity.  (See  Disease  of 
the  Pancreas.)  Sub-diaphragmatic  abscess  is  not  limited  to  the  lesser 
peritoneum.  It  can  only  be  recognized  by  the  history  of  the  previous 
disease,  which  may  cause  perforation,  and  by  the  general  symptoms  of 
abscess.  If  the  abscess  is  on  the  left  side,  there  is  an  extension  of 
dulness  upward  toward  the  scapula,  the  lower  limit  of  the  lungs  in 
health  ceasing  at  the  eighth  or  ninth  interspace.    There  may  also  be 

48 


754  SPECIAL  DIAGNOSIS. 

dullness  in  the  axillary  region.  If  the  abscess  is  on  the  right  side,  it 
may  simulate  enlargement  of  the  liver,  and  be  characterized  by  marked 
increase  in  dullness  anteriorly,  laterally,  or  posteriorly.  Localized  peri- 
tonitis in  the  lower  half  of  the  abdomen  is  due  to  disease  of  the  vermi- 
form appendix,  or  to  disease  of  the  Fallopian  tubes.  The  localized 
signs  are,  first,  those  of  pain  and  tenderness ;  second,  the  development 
of  tumor. 

Chronic  Peritonitis.  The  symptoms  of  diffuse  peritonitis,  chronic 
in  course,  may  follow  the  acute,  or  may  occur  in  the  course  of  tuber- 
culosis. The  intestines  and  peritoneum  are  matted  together.  General 
pain  and  tenderness,  with  a  prolonged  period  of  ill  health,  attend  the 
diffuse  form.  (See  Tuberculous  Peritonitis.)  In  the  chronic  forms, 
if  there  is  considerable  fibrous  proliferation,  even  though  not  can- 
cerous or  tuberculous,  the  abdomen  becomes  retracted,  the  muscles 
rigid,  the  note  over  the  abdomen  modified  or  dull  tympanitic.  The 
modification  may  be  detected  in  the  upper  half  of  the  abdomen  par- 
ticularly, and  especially  over  the  liver.  Sometimes  a  fremitus  can  be 
felt.  The  patients  are  under  weight  and  without  strength.  The  pain 
may  continue  a  long  time.  It  finally  results,  at  least  clinically,  in 
such  compensation  that  the  patient  is  able  to  continue  his  usual  occu- 
pation. Localized  bands  form,  and  may  cause  local  sensations  of  a 
dragging  character,  or  pain  with  drawing  or  pulling  sensations  ;  but, 
save  the  local  symptoms,  these  are  not  serious,  unless  it  should  happen, 
as  has  been  seen  in  intestinal  obstruction,  that  coils  of  intestine  are 
twisted  about  the  bands  or  caught  in  them,  thus  leading  to  obstruction. 

Cancer  of  the  Peritoneum. 

It  usually  occurs  in  the  aged,  and  follows  cancer  in  other  organs, 
as  the  stomach,  liver,  or  uterus.  Occasionally  it  is  primary.  The 
omentum  is  indurated,  and  forms  a  mass  which  lies  transversely  across 
the  abdomen  in  the  upper  zone.  Ascites  usually  develops,  and  the 
exudation  is  bloody.  The  disease  occurs  more  frecmently  in  women 
than  in  men.  With  the  development  of  ascites  there  is  emaciation. 
The  surface  of  the  indurated  omentum  is  irregular.  It  may  be  pain- 
ful on  pressure.  A  tumor  of  the  same  physical  character  is  seen  in 
tuberculous  peritonitis,  and  I  have  seen  several  such  tumors  in  the 
aged  without  apparent  cause,  unless  from  proliferative  peritonitis.  (See 
Tumor.)  Progressive  emaciation,  chronic  ascites  without  cause,  and 
a  localized  tumor  without  the  occurrence  of  fever  point  to  the  proba- 
ble nature  of  the  case.  Sometimes  pain  is  the  most  pronounced  symp- 
tom. If  these  symptoms  are  present  with  signs  of  cancer  in  some 
other  organs,  as  the  stomach,  rectum,  or  uterus,  there  is  probably 
primary  cancer  of  the  peritoneum. 

Retroperitoneal  sarcoma,  or  Lobstein's  cancer,  is  central  or  lateral, 
deep-seated,  and  usually  fixed.  It  is  accompanied  by  the  general  symp- 
toms of  cancer  and  by  ascites.  The  growth  is  very  large.  It  can  be 
detected  above  the  sacrum  by  rectal  examination.  The  intestines  are 
in  front  of  the  growth,  causing  an  unusual  sensation  to  the  hand,  as  in 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     755 

Burrow's   case,    like   a   hydatid    fremitus.       Lockwood's  cases   were 
believed  to  be  solid  ovarian  tumors. 

Sarcoma  of  the  glands  and  the  tissues  in  the  above  mentioned  space 
is,  according  to  J.  Dutton  Steele,  slightly  more  common  in  males  than 
in  females  ;  more  common  in  the  first  decade  or  after  the  fiftieth  year. 
Its  duration  is  about  nine  months.  Of  the  sixty-five  cases  collected  by 
Steele  39  per  cent,  were  spindle-celled  sarcoma,  34  per  cent,  round- 
celled  sarcoma,  14  per  cent,  lympho-sarcoma,  and  13  per  cent,  were 
mixed  cases.  The  growth  originates  in  the  lymph  glands  or  in  fibrous 
connective  tissue  about  the  kidney,  the  spinal  column,  the  pelvis,  or 
the  sheaths  of  the  bloodvessels.  The  onset  is  insidious.  The  first 
symptoms  are  the  presence  of  a  tumor,  or  the  effects  of  pressure  upon 
the  vessels,  nerves,  or  viscera  of  the  abdominal  cavity ;  they  depend 
upon  the  site  of  the  tumor.  Varicocele  is  of  frecment  occurrence.  It 
is  often  impossible  to  distinguish  it  from  malignant  disease  of  the  kid- 
ney or  of  the  suprarenal  bodies.  The  diagnostic  features  are  («)  the 
rapid  growth ;  (6)  the  position  of  the  colon,  which  is  pushed  in  front 
of  it,  particularly  if  the  tumor  is  lateral ;  (c)  the  pressure  symptoms  ; 
(d)  the  tumor  may  move  with  respiration  or  independently,  and  may 
fluctuate. 

Tuberculosis  of  the  Peritoneum. 

The  tuberculous  process  in  the  peritoneum  may  be  either  acute  or 
chronic.  In  rare  instances  it  may  continue  without  any  symptoms, 
either  local  or  general. 

Acute  tuberculous  peritonitis  may  exactly  simulate  suppurative  peri- 
tonitis, although  usually  the  course  is  more  prolonged  and  the  fluctua- 
tions of  temperature  less  pronounced.  In  other  respects,  it  cannot  be 
distinguished  from  acute  general  peritonitis,  save  by  the  absence  of 
the  causes  of  the  latter.  A  history  of  exposure  to  tuberculous  infec- 
tion, or  the  presence  of  tuberculosis  in  some  other  portion  of  the  bodv, 
may  be  of  service  in  determining  the  nature  of  the  case.  Often  there 
occurs  in  a  short  time  associate  tuberculosis  of  other  serous  membranes, 
so  that  tuberculous  pleurisy  or  tuberculous  pericarditis  will  supervene, 
an  associate  process  which  does  not  take  place  in  ordinary  peritonitis. 
There  is  diarrhoea  in  most  cases — at  least  it  has  been  present  in  the 
few  instances  which  I  have  seen  of  this  form  of  tuberculosis.  Never- 
theless, the  diagnosis  is  sometimes  impossible.  Henry  has  called 
renewed  attention  to  the  occurrence  of  inflammation  about  the  navel  as 
a  sign  of  tuberculous  peritonitis.  He  believes  the  periumbilical  ery- 
thema is  pathognomonic  of  the  affection. 

Acute  tuberculosis  of  the  peritoneum  may  precisely  simulate  appen- 
dicitis in,  first,  the  local  symptoms  and  signs  ;  and,  second,  the  subse- 
quent infection  of  the  peritoneum.  In  acute  tuberculous  appendicitis, 
however,  the  signs  of  a  tumor  are  not  so  marked  as  in  true  appendi- 
citis. Nevertheless,  in  one  instance,  Keen  operated  upon  a  patient  of 
mine,  a  healthy  laborer  in  a  rolling-mill,  who  had  the  classical  symp- 
toms of  appendicitis.  At  the  operation  the  appendix  was  found  to  be 
perforated  and  hanging  in  a  local  abscess.  A  fecal  fistula  ensued 
which  did  not  heal,  and  within  two  months  the  patient  died  of  general 


756 


SPECIAL  DIAGNOSIS. 


tuberculosis.  The  appendix  was  the  seat  of  primary  tuberculous 
ulceration.  In  a  second  instance  the  appendicitis  arose  in  the  course 
of  tuberculosis. 

Iu  a  third  instance  the  patient,  aged  forty-five  rears,  was  admitted 
to  my  wards  in  the  Philadelphia  Hospital,  with  high  fever  and  pain 
in  the  abdomen,  at  first  more  marked  along  the  margin  of  the 
liyer.  By  the  end  of  twenty-four  hours  it  became  more  decided  in 
the  right  lower  quadrant  of  the  abdomen  ;  tenderness  at  McBurney's 
point  was  distinct ;  the  area  was  enlarged  and  dull  on  percussion,  the  sur- 
face slightly  oedematous.  Fluctuation  could  not  be  detected.  Exten- 
sion of  the  leg  was  painful.  Rapid  general  peritonitis  ensued,  during 
which  the  surgeon  saw  him,  but  declined  to  operate  until  the  subsi- 
dence of  the  attack.  "When  the  attack  subsided  the  local  signs  of 
tumor  were  not  present.  The  feyer  persisted  irregularly  for  a  short 
time,  while  the  more  acute  peritoneal  symptoms  subsided  ;  then  the 
right  pleura  became  infected,  and  cough  ensued  with  expectoration  of 
mucopurulent  fluid.  It  did  not  contain  tubercle  bacilli,  howeyer. 
Subsequently  the  left  pleura  and  the  pericardium  became  inyolyed. 
During  the  entire  course  of  the  disease  there  were  diarrhoea,  most  pro- 
nounced sweats,  rapid  emaciation,  and  exhaustion.  Death  took  place 
at  the  end  of  fiye  weeks,  and  at  the  autopsy  general  serous  tubercu- 
losis was  found. 

Fig.  193. 


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Tuberculous  peritonitis.    Subnormal  temperature. 


"While  in  a  number  of  instances  the  symptoms  are  acute  and  alarm- 
ing, in  the  larger  proportion  of  cases  the  process  is  more  chronic,  and 
is  attended  by  characteristic  local  and  general  symptoms.  In  the  pro- 
longed and  moderate  cases  there  may  be  continued  fever  of  moderate 
degree,  or  it  may  be  remitting  in  type.  In  old  people  the  temperature 
is  frequently  subnormal.  (See  Fig.  193.)  There  is  more  or  less 
rapid  emaciation.  The  sweating  is  profuse  and  characteristic.  The 
fever  is  high  but  irregular  in  type,  in  more  severe  cases  approaching 
the  remittent  form.  The  general  symptoms  resemble  typhoid  fever. 
Indeed,  symptoms  of  the  typhoid  state  may  ensue. 


PLATE    XXXVII. 


Tuberculosis  of  the  Peritoneum. 


Abdominal  exudate  (not  freely  movable);    omental    tumor,      Consoli- 
dation at  apices. 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     757 

The  Local  Symptoms.  Four  classes  are  seen  :  (1)  Abdominal  en- 
largement with  effusion  ;  (2)  enlargement  with  tumors  ;  (3)  a  combina- 
tion of  the  two  ;  (4)  enlargement  without  evidence  of  fluid  or  tumor 
in  the  abdomen.  In  the  latter  form  and  in  the  forms  in  which  tumors 
are  present  the  abdomen  subsequently  may  undergo  retraction. 

1.  Enlargement  with  Effusion.  The  local  symptoms  and  physical 
signs  are  those  of  ascites.  The  abdomen  is  never  as  distended,  however, 
as  in  the  ascites  of  cirrhosis  of  the  liver.  Often  the  fluid  is  confined 
by  adhesions  which  may  distinctly  localize  it  in  the  right  or  left  quad- 
rant of  the  abdomen,  in  which  situation  fulness  and  fluctuation  may 
be  readily  detected. 

2.  Tuberculosis  with  Tumors.  (Plate  XXXVII.)  The  tumors  are 
usually  in  the  upper  zone  of  the  abdomen,  and  may  be  localized  in  either 
quadrant,  or  extend  from  the  right  to  the  left.     They  are  usually  due 

Fig.  194. 


Tuberculous  peritonitis  ;  pulmonary  tuberculosis.     +  The  site  of  cardiac  impulse. 

to  tuberculosis  of  the  omentum,  with  secondary  contraction.  In  some 
instances  a  hard,  indurated  tumor,  somewhat  tender  on  pressure,  may 
extend  across  the  abdomen  midway  between  the  xiphoid  cartilage  and 
the  umbilicus.  It  may  be  as  low  as  the  umbilicus,  and  vary  from  two 
to  four  inches  in  width.  It  may  be  continuous  with  the  liver-dulness. 
In  other  instances  more  distinctly  localized  masses  may  be  felt.  These 
may  be  to  the  right  or  to  the  left  of  the  umbilicus.  In  other  instances 
they  are  hard,  slightly  tender,  with  an  irregular  surface.  They  may 
be    movable    and   vary   with   the   position   of    the   patient.     I  have 


758  SPECIAL  DIAGNOSIS. 

never  seen  tuberculous  masses  in  the  lower  quadrants.  In  chil- 
dren with  tabes  mesenterica  they  may  be  made  out  close  to  the  verte- 
bral column  in  the  median  line,  extending  to  the  brim  of  the  pelvis, 
although  at  the  lower  portion  they  are  not  so  distinct.  The  dulness 
over  the  tumors  is  varying,  depending  upon  the  relation  to  the  bowels 
and  the  degree  of  intestinal  distention.  Instead  of  dulness  a  modified 
tympany  may  be  observed,  or  muffled  resonance. 

3.  Cases  in  tohich  Effusion  and  Tumors  are  Present  at  the  Same  Time. 
These  present  symptoms  common  to  the  two  conditions,  although  the 
tumors  are  not  so  distinctly  defined. 

4.  Absence  of  Effusion  and  Tumors.  When  effusion  and  tumors 
are  not  present  the  thickened  peritoneum  and  more  dense  intestinal 
walls  lead  to  a  modified  dulness  over  the  entire  abdomen.  When  re- 
traction takes  place  the  resonance  is  of  a  woodeny  character,  the  abdo- 
men is  more  or  less  tender,  and  ill-defined  indurations  may  be  present. 
The  term  carreau  is  applied  to  this  induration. 

In  not  a  few  instances  the  local  physical  signs  may  apparently  be  due 
to  inflammation  of  the  liver,  on  account  of  extensive  perihepatitis.  In 
the  case  of  a  child  under  my  care  the  local  signs  during  life  were  of 
this  character,  and  the  symptoms  were  simply  those  of  loss  of  appetite, 
with  discomfort,  weight,  and  fulness  below  the  sternum.  Both  the  right 
and  left  lobes  of  the  liver  were  covered  with  an  enormous  thickening 
due  to  tuberculous  inflammation.  Simple  plastic  peritonitis  occupied 
the  lower  zone. 

Apart  from  the  general  symptoms  and  the  local  physical  signs  the 
other  symptoms  are  not  distinct  save  those  due  to  tuberculosis  in  other 
situations.  The  appetite  is  usually  poor,  there  is  some  atonic  dyspep- 
sia, vomiting  may  occur  at  regular  intervals  ;  the  bowels  may  be  con- 
stipated, although  in  my  experience  they  have  usually  been  relaxed. 
The  patient  becomes  anaemic,  the  skin  harsh  and  dry.  Emaciation 
may  progress  to  an  extreme  degree.  Eruptions  and  boils  may  break 
out,  some  oedema  of  the  ankles  may  occur.  Death  takes  place  from 
exhaustion  and  from  the  development  of  tuberculosis  in  other  localities. 

The  diagnosis  is  difficult.  Cases  belonging  to  the  first  and  fourth 
classes  above  mentioned  probably  present  the  greatest  difficulties. 
The  age  modifies  the  difficulty  of  diagnosis.  Peritoneal  tumors,  with 
or  without  effusion  in  young  subjects,  are  almost  always  due  to 
tuberculosis.  In  the  aged  they  must  be  distinguished  from  carci- 
noma or  chronic  peritonitis  from  other  causes.  The  association  of 
diarrhoea  with  the  symptoms  is  rather  against  carcinoma.  Sacculated 
effusions  may  be  confounded  with  abdominal  tumors,  as  of  the  ovary. 
The  resemblance  is  more  pronounced  if  the  tubercles  develop  primarily 
in  the  tubes  or  uterus.  In  a  recent  case  the  autopsy  disclosed  a  large 
caseating  ulcer  inside  of  the  uterus,  and  tuberculosis  of  the  Fallopian 
tubes  and  peritoneum.  The  right  tube  was  chiefly  affected.  The 
effusion  during  life  was  sacculated  in  the  right  lower  quadrant,  was  not 
movable  with  the  patient,  and  fluctuated  both  on  external  palpation 
and  with  bimanual  palpation  per  vaginam.  It  was  impossible  to  dis 
tinguish  it  except  that  there  was  dulness  instead  of  resonance  in  the 
flanks.      As  Osier  has   pointed  out,  the  association  with  salpingitis 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     759 

must  arouse  suspicion,  particularly  if  at  the  same  time  disease  is  found 
in  some  other  organ  of  the  body,  as  the  apex  of  the  lungs  or  the 
pleura.  In  males  the  primary  lesion  is  often  in  the  testicles.  The 
history  of  the  case  and  the  deyelopment  of  the  disease  in  an  irregular 
manner,  associated  with  gastro-intestinal  disturbance  rather  than  dis- 
turbance of  uterine  function,  are  points  in  favor  of  tuberculosis.  Tym- 
panites is  of  frequent  occurrence. 

Diseases  of  the  Stomach. 

The  stomach  is  a  canal  in  which  the  food  is  detained  for  the  purpose 
of  solution.  Its  walls  are  made  up  of  mucous  membrane,  muscle,  and 
peritoneum.  It  is  richly  supplied  with  bloodvessels.  Because  of  its 
great  functional  activity  it  has  an  abundant  nerve-supply.  It  is,  more- 
over, surrounded  by  rich  plexuses  of  sympathetic  nerves,  through  which 
and  its  special  nerve,  the  pneumogastric,  it  is  in  intimate  relation  with 
every  organ  of  the  body. 

The  Symptomatology.  The  local  symptoms  of  disease  of  the  stomach 
are  dependent  upon  :  (1)  The  morbid  process  which  affects  it ;  (2)  the 
effect  of  the  process  upon  the  anatomical  structure  of  the  organ  (atro- 
phy, dilatation,  tumor),  whereby  the  size  is  affected  ;  (3)  the  effect 
upon  its  function. 

1.  The  Morbid  Process.  The  symptoms  due  to  the  morbid  process  are 
not  different  from  the  symptoms  of  similar  morbid  processes  elsewhere, 
save  that  they  are  modified  by  the  function  of  the  organ  or  its  special 
construction  as  a  canal.  Hence,  congestions  are  attended  by  discharge 
of  mucus  ;  inflammations  are  attended  by  pain  and  by  a  flow  of  mucus 
and  pus  ;  ulcers  by  pain  and  the  accidents  of  ulceration  (hemorrhage) ; 
malignant  disease  by  pain  and  swelling  (tumor),  and  its  accidents,  hemor- 
rhage and  obstruction  ;  while  to  each  belong  the  general  phenomena 
which  attend  it.  But  the  stomach  is  highly  sensitive  and  resents  the 
intrusion  of  disease  or  of  that  which  (1)  causes  disease  or  (2)  irritates 
the  affected  part.  Expression  of  this  resentment  is  shown  in  hyper- 
aesthetic  symptoms  (see  the  Neuroses),  as  pain;  in  the  abolition  or 
derangement  of  function  ;  and  in  the  great  pathological  reflex  act  of 
the  stomach — vomiting.  It  will  be  seen  later  that  this  may  be  a  symp- 
tom of  eyery  local  morbid  process  of  the  organ,  either  directly  because 
of  the  disease  or  of  its  exciting  cause,  both  of  which  are  operative  in 
irritant  inflammations  ;  or  indirectly  because  the  process  has  set  up 
undue  sensitiveness.  In  the  latter  instance  any  material,  as  food,  which 
the  stomach  is  accustomed  to  receiye,  becomes  as  much  an  irritant  as 
mucus,  pus,  or  blood. 

2.  Anatomical  Symptoms.  The  morbid  processes  modify  the  ana- 
tomical structure  and  lead  to  other  morbid  conditions,  as  we  see  when 
dilatation  succeeds  inflammation  or  obstruction  of  the  orifices.  The 
symptoms  of  the  secondary  conditions  are  the  same  as  elsewhere — in 
atrophy,  diminution  in  size  ;  in  dilatation,  increase  in  size,  with  retention 
and  fermentation,  and  finally  discharge  of  the  contents  by  vomiting. 

Nerve  Mechanism.  In  the  consideration  of  the  symptomatology  of 
gastric  diseases  the  anatomical  relation,  by  its  vascular  and  nervous 


760  SPECIAL  DIAGNOSIS. 

connection,  must  be  considered.  The  student  is  sufficiently  familiar 
with  physiology  and  pathology  to  know  that  each  organ  has  a  represen- 
tative in  the  central  nerve-mass,  the  brain,  and  that  disease  in  one 
organ  will  influence  the  function  and  create  morbid  symptoms  in 
another  which  is  related  to  it  through  intimate  nervous  connections. 

The  central  representative  or  centre  is  influential  in  proportion  to 
the  power  and  activity  of  its  peripheral  adjunct.  It  is,  moreover,  in- 
fluenced by  higher  centres,  the  psychical,  and  it  in  turn  modifies  them. 
It  influences  or  modifies  lower  centres,  (1)  functional,  (2)  vasomotor, 
(3)  motor,  or  (4)  sensory.  The  result  of  this  mechanism  is  :  1.  That 
functional  alteration  or  organic  disease  of  (a)  the  gastric  centre,  or  (6) 
of  centres  of  higher  control,  or  (c)  of  the  nerve  that  connects  the  centre 
and  the  organ — pneumogastric  nerve — produces  gastric  symptoms.  2. 
That  gastric  diseases  produce  symptoms  in  other  organs,  as  cardiac 
palpitation  (reflex).  3.  That  disease  of  other  organs  produces  gastric 
symptoms  or  disease,  as  the  vomiting  of  pregnancy,  or  of  renal  calculus, 
or  of  disease  of  the  testicle,  or  the  gastritis  of  nephritis.  Thus  vomiting 
is  caused  by  emotion  (high  centre),  influencing  the  pneumogastric  (lower 
centre)  ;  by  a  tumor  pressing  or  destroying  the  pneumogastric  centre  ; 
or  by  a  tumor,  as  aneurism,  pressing  on  the  pneumogastric  nerve. 
I  have  taken  the  simplest  illustration.  When  we  come  to  the  study 
of  gastric  neuroses  the  extraordinary  influences  of  the  nervous  mechan- 
ism will  be  appreciated  ;  or,  when  hysteria  is  studied,  the  physiology 
of  its  extreme  gastric  symptoms  will  be  recognized.  When  the  mech- 
anism and  clinical  course  of  vomiting  are  studied  it  will  be  found 
among  other  causes  to  be  frequently  due  to  affections  of  the  blood,  the 
poisons  of  which  irritate  cerebral  centres  or  nerve  plexuses  in  the 
stomach. 

Vascular'  Mechanism.  But  gastric  diseases  also  arise  because  of  the 
vascular  supply.  Thus  in  heart  disease  with  venous  stasis  the  gastric 
veins  become  the  seat  of  congestion,  with  consequent  gastric  catarrh  ; 
or  hepatic  disease  will  cause  portal  congestion  and  gastric  catarrh. 

3.  Functional  Symptoms.  Any  local  disease  of  the  stomach  must 
influence  its  f miction ;  therefore,  conversely,  functional  symptoms 
must  be  present  in  all  local  diseases.  But  functional  disorder  may  be 
present  without  local  anatomical  change  ;  the  impairment  is  nearly 
always  induced  through  the  influences  of  the  nervous  system.  The 
functions  of  the  stomach  are  to  digest  and  to  absorb  the  products  of 
digestion.  The  former  function  is  motor  and  chemical,  the  complete- 
ness of  which  depends  upon  mixture  of  the  food  with,  and  solution  in, 
the  gastric  juice.  The  symptoms,  therefore,  must  be  due  to  changes 
(1)  in  the  motor,  (2)  in  the  secretory,  and  (3)  in  the  absorptive  func- 
tions of  the  organ.  The  functions  may  be  increased  or  diminished  ; 
the  former  are  the  primary  and  usually  temporary  aberrations  ;  the 
latter  succeed  the  former,  and  are  permanent.  The  functional  symp- 
toms, therefore,  are  the  symptoms  of  what  we  know  as  indigestion  or 
dyspepsia.  They  are  described  in  the  account  of  the  subjective  symp- 
toms and  also  in  the  section  on  Gastric  Neuroses. 

Toxic  Symptoms.  The  toxic  symptoms  arising  in  gastric  disease  are 
worthy  of  a  few  words.     They  are    nervous  symptoms   due  to   the 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     761 

absorption  of  ptomaines  or  imperfect  products  of  assimilation.  If 
absorption  of  the  toxines  takes  place  suddenly  and  in  large  amounts, 
coma  and  convulsions  occur  (Kussmaul's  symptom) ;  or,  if  gradually, 
hypochondriasis,  melancholia,  mental  depression,  with  vasomotor  phe- 
nomena of  various  kinds,  arise. 

It  is  observed,  therefore,  in  unravelling  the  symptomatology  of  gastric 
disease,  that  we  must  first  note  :  (A)  The  subjective  symptoms  due 
(1)  to  morbid  processes,  (2)  to  alterations  of  function,  (3)  to  alterations 
of  size  (sense  of  fulness,  etc.).  (B)  The  objective  symptoms  due  (1) 
to  morbid  processes,  (2)  to  alterations  of  function,  (3)  to  alterations  of 
size. 

Diagnosis  from  Disease  of  Contiguous  Organs  Functionally  Related. 
The  student  will  soon  learn  that  diseases  of  the  stomach  which  are 
functional  in  character  cannot  be  differentiated  with  ease  from  diseases 
in  other  organs  functionally  related.  He  will  find  that  to  draw  hard- 
and-fast  lines  between  gastric  and  intestinal  indigestion,  or  between 
so-called  disordered  gastric  and  hepatic  function,  is  generally  impos- 
sible. Organs  which  are  closely  related  in  physiological  function,  and 
which  have  nerve-supply  and  blood-supply  in  common,  cannot  be  dif- 
ferentiated when  disordered  function  is  considered.  Hence,  indigestion 
and  biliousness,  or  simple  acute  gastritis  and  duodenitis,  are  beyond 
the  pale  of  close  discrimination.  In  fact,  the  symptoms  of  each  blend 
in  a  manner. 

In  addition  to  the  examination  of  the  stomach,  in  order  to  judge  cor- 
rectly of  the  nature  of  gastric  lesions,  as  may  be  inferred  from  what 
has  been  written  above,  we  must  ascertain  (1)  whether  the  gastric  symp- 
toms are  dependent  upon  disease  of  other  organs — particularly  the  eye, 
nose,  and  genitalia,  the  heart  and  kidneys — by  an  examination  of  each 
organ  ;  and  (2)  whether  other  symptoms  are  created  by  gastric  disease. 

The  Stomach  in  Other  Diseases.  Diseases  of  the  stomach  may 
frequently  mask  other  diseases  ;  in  other  words,  patients  will  complain 
of  gastric  symptoms  which  are  but  concomitant  phenomena,  behind 
which  there  are  graver  conditions.  Thus,  in  disease  of  the  kidney,  in 
phthisis,  in  chronic  bronchitis,  in  emphysema,  in  valvular  disease  of 
the  heart,  catarrh  of  the  mucous  membrane  of  the  stomach  is  of  fre- 
quent occurrence,  depending  upon  the  primary  disease. 

In  tuberculosis  the  local  gastric  symptoms  often  are  the  more  promi- 
nent features.  Thus  in  the  earlier  stages  of  phthisis  loss  of  appetite 
and  vomiting  are  of  constant  occurrence.  The  dyspeptic  symptoms 
in  a  large  number  of  cases  precede  the  pulmonary  symptoms,  and  may 
be  so  pronounced  as  to  mask  them  entirely.  The  patients  are  usually 
delicate  and  anaemic  ;  they  complain  of  loss  of  appetite  and  mild  indi- 
gestion ;  there  is  some  regurgitation  of  food  ;  they  are  feeble  and 
languid.  They  are  treated  for  chronic  catarrhal  gastritis,  but  do  not 
improve.  On  examination  of  the  lungs  the  physician  is  surprised  to 
find  a  small  area  of  consolidation,  and  upon  inquiry  will  find  subjec- 
tive symptoms  of  tuberculosis  to  have  been  present  for  a  considerable 
time.  Every  practitioner  is  familiar  with  the  scores  of  patients  with 
phthisis,  even  when  the  disease  is  far  advanced,  who  believe  that  their 
symptoms  are  entirely  due  to  disorder  of  the  stomach.     In  addition 


762  SPECIAL  DIAGNOSIS. 

to  the  early  catarrh  that  precedes  tuberculosis,  other  gastric  symptoms 
may  occur.  The  well-known  association  of  simple  ulcer  and  phthisis 
is  familiar.  Both  occur  at  the  same  time  of  life,  yet  the  gastric  symp- 
toms may  prevent  investigation  into  those  of  pulmonary  origin.  In 
ancemia  and  chlorosis  changes  in  the  digestive  tract  are  common.  On 
account  of  the  general  blood-condition  the  functions  of  the  stomach 
are  impaired.  Here,  too,  we  frequently  have  the  association  of  ulcer 
with  the  general  condition.  Danger  of  overlooking  either  is  not  so 
great  as  in  tuberculosis. 

In  valvular  affections  of  the  heart,  chronic  catarrh  of  the  stomach 
may  result  from  venous  congestion.  The  symptoms  may  point  to  the 
gastric  condition  alone.  In  all  cases  of  chronic  gastric  catarrh  it  is 
necessary  to  examine  carefully  into  the  condition  of  the  heart.  Over 
and  over  again  patients  apply  for  treatment  not  on  account  of  cardiac 
symptoms,  but  because  of  gastric  disorder.  They  will  be  treated  in 
vain  unless  the  primary  cardiac  affection  is  ascertained.  Many  cases  of 
gastric  catarrh  have  been  cured  by  the  use  of  digitalis.  In  disease  of 
the  kidneys  the  stomach  is  frequently  involved.  Vomiting  and  other 
symptoms  of  gastric  disorder  may  occur  long  before  dropsy  or  any 
objective  sign  which  would  lead  to  a  correct  diagnosis.  The  gastric 
symptoms  are  due  to  chronic  uraemia.  In  other  conditions  of  the 
genito-urinary  tract  gastric  symptoms  also  occur.  This  is  particularly 
noticeable  in  long-standing  retention  from  chronic  obstruction.  Renal 
tumors  may  cause  only  disturbances  of  digestion,  while  gastric  symptoms 
due  to  movable  kidney  are  well  known.  The  symptoms  in  the  latter  con- 
dition arise,  first,  from  mechanical  causes,  as  the  pressure  of  the  kidney 
on  the  pylorus,  and,  secondly,  from  the  influence  on  the  nervous  system. 

Disease  of  the  Liver.  The  intimate  relationship  of  the  liver  and 
the  stomach  is  such  that  when  one  is  the  seat  of  serious  functional  dis- 
turbance the  other  is  likely  to  be  affected.  Frequently  it  is  impossi- 
ble to  draw  fast  lines  as  to  which  organ  is  the  primary  seat  of  disorder. 
The  abuse  of  alcohol  frequently  induces  chronic  gastritis,  and  also 
causes  cirrhosis  of  the  liver.  On  the  other  hand,  cirrhosis  of  the  liver 
is  frequently  the  cause  of  chronic  gastritis  secondary  to  the  portal 
congestion. 

Diseases  of  the  Nervous  System.  The  relationship  of  disease  of  the 
central  nervous  system  to  disturbance  of  the  gastric  functions  has 
frequently  been  adverted  to.  (See  Vomiting.)  In  sclerosis  of  the 
posterior  columns  of  the  cord  this  is  more  striking  than  in  any  other 
spinal  disease.  Not  only  do  we  have  gastralgia  and  gastric  crises,  but 
moderate  symptoms  of  indigestion,  with  hyperesthesia  and  slight  gas- 
tralgia, may  be  the  first  symptoms  of  locomotor  ataxia. 

Diabetes.  Diabetes  may  continue  (in  its  course)  for  a  long  period 
of  time,  during  which  the  patient  is  thought  to  have  stomach-trouble, 
before  an  examination  of  the  urine  reveals  the  true  nature  of  the  case. 

Opinions  differ  as  to  the  relationship  of  gout  and  rheumatism  to 
gastric  disorder.  Some  writers  believe  that  a  specific  gouty  inflammation 
of  the  stomach,  due  to  the  uric-acid  diathesis,  is  of  frequent  occurrence, 
and  that  one  of  the  prominent  manifestations  of  gout  is  dvspepsia  in 
all  its  forms.     The  French  consider  gastric  disturbances  to  be  frequent 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     763 

expressions  of  the  rheumatic  diathesis.  The  relationship  of  the  two, 
however,  is  thus  far  not  fully  developed,  although,  in  these  conditions, 
it  is  not  usual  to  overlook  the  presence  of  either  of  the  diatheses  when 
symptoms  of  gastric  disturbance  occur.  It  is  essential  to  bear  in  mind 
that  in  persons  of  a  rheumatic  or  gouty  diathesis  gastric  disturbances 
are  more  likely  to  occur  than  in  healthy  individuals  ;  their  successful 
management  depends  upon  the  recognition  of  the  fundamental  diathesis. 
It  is  more  than  probable  that  gastric  disorders,  along  with  defective 
metabolism,  is  primary  in  both  affections. 

The  Data  Obtained  by  Inquiry. 

The  Social,  History.  In  no  other  group  of  diseases  than  in 
those  about  to  be  considered,  unless  those  of  the  nervous  system,  is  it 
more  important  to  inquire  into  the  social  history.  This  is  true,  because 
most  of  the  so-called  gastric  disorders  have  their  foundation  in  neuras- 
thenic states,  the  probability  of  which,  of  course,  must  be  carefully 
sifted  from  the  many  possibilities.  Age.  Early  age  predisposes  notably 
to  gastro-intestinal  disorder.  In  later  life  the  catarrhs  which  arise 
from  improper  exposure  or  indiscretions  in  eating  or  occupation  are 
common.  The  menopause  is  often  associated  with  gastric  disorders. 
The  sex  is  not  of  great  diagnostic  significance,  except  from  its  relation- 
ship to  the  excesses  in  eating  and  drinking  of  one  class.  Those  occupa- 
tions which  prevent  out-door  exercise,  or  which  compel  exposure  to 
toxic  substances,  or  require  stooping  or  constrained  positions,  or  over- 
tax the  eyes,  invite  gastric  diseases.  Habits  of  eating  and  drinking, 
both  as  to  time  and  mode  of  eating,  and  the  character  of  food  and 
drink,  must  be  brought  out  in  the  inquiry.  The  use  of  tobacco  and 
other  stimulants  and  narcotics  must  be  noted.  The  hours  devoted  to 
vacation  and  work  are  to  be  learned,  as  fatigue  bears  a  great  part 
in  gastric  disease. 

The  Family  History.  Heredity  plays  but  a  small  part  except 
in  gastric  carcinoma  and  in  gastric  neurasthenia. 

The  History  of  Previous  Disease.  The  occurrence  of  infec- 
tious diseases  antecedent  to  the  gastric  disorder  must  be  inquired  about, 
for,  either  because  of  the  attendant  gastritis  or  of  the  resulting  defec- 
tive innervation,  they  predispose  to  gastric  disease.  The  excessive 
feeding  in  the  convalescence  of  typhoid  fever,  it  seems  to  the  writer, 
is  frequently  the  cause  of  gastric  dilatation.  Any  prolonged  illness 
which  weakens  the  muscular  system  and  lowers  the  tone  of  the  nervous 
system  will  be  likely  to  cause  gastric  disease. 

It  will  be  learned  elsewhere  that  gastric  affections  occur  secondary 
to  many  local  diseases,  as  of  the  heart,  the  lungs,  and  the  kidneys. 
Inquiry  as  well  as  an  objective  investigation  must  be  made,  to  deter- 
mine the  presence  of  possible  primary  diseases.  Disorders  which  inter- 
fere with  the  mechanical  support  to  the  intra-abdominal  organs  must 
be  inquired  for.  Pregnancy,  antecedent  ascites,  or  a  large  tumor  may 
so  weaken  the  abdominal  muscles  as  to  lead  to  gastro-enteroptosis. 
Finally,  a  history  of  the  ingestion  of  corrosive  poisons  must  be  sought 
for  in  cases  of  gastritis. 


764  SPECIAL  DIAGNOSIS. 

It  is  very  important  to  learn  whether  the  patient  has  been  subjected 
to  the  various  causes  of  neurasthenia,  which,  with  the  history  of  the 
occurrence  of  neuropathic  symptoms,  make  valuable  data,  pointing  to 
the  nature  of  many  gastric  neuroses. 

The  Subjective  Symptoms.  The  following  subjective  symptoms 
may  be  complained  of  :  Disorder  of  appetite,  bad  taste  in  the  mouth, 
thirst,  eructations,  pyrosis,  distress  or  weight  after  meals,  burning  after 
meals,  flatulency,  nausea,  vomiting,  constipation,  diarrhoea,  pain,  vertigo, 
and  cardiac  palpitation.  Nearly  all  the  subjective  symptoms  are  gastric 
neuroses,  and  will  be  detailed  in  the  chapter  devoted  to  the  neuroses. 

Bad  Taste.  It  is  usually  due  to  acute  catarrh.  It  may  be  present 
in  chronic  catarrh.  It  is  said  to  be  characteristic  of  the  acute  form  of 
gastritis  popularly  known  as  biliousness. 

Thirst.  Thirst  is  not  a  symptom  of  gastric  disorder  alone  ;  it  is  a 
symptom  of  diabetes  and  all  conditions  in  which  the  body  has  lost 
fluids,  as  water  by  sweating,  vomiting,  or  purging,  or  by' evaporation 
and  combustion  (fever) ;  or  blood  by  hemorrhage.  It  is  common  in 
acute  and  chronic  gastritis,  particularly  in  the  alcoholic  form. 

Distress,  Weight,  axd  Burxixg.  They  are  frequent  complaints, 
and  may  come  on  immediately  after  meals.  They  may  be  due  to  dys- 
pepsia, hyperacidity,  dilatation,  bacterial  fermentation,  and  flatulency. 
They  exist  in  varying  degrees,  either  singly  or  combined.  (See  Gas- 
tric Hypersesthesia.) 

Nausea.  This  symptom  is  usually  associated  with  vomiting.  In 
some  persons  it  is  impossible  to  excite  vomiting,  although  they  may 
suffer  intolerably  from  nausea.  Xausea  is  akin  to  vomiting  in  its 
mechanism  and  clinical  associations  (q.  v.).  It  is  a  common  incident 
in  chronic  interstitial  nephritis.  In  old  people,  with  arterial  sclerosis 
and  defective  renal  elimination,  it  is  common.  It  may  be  due  to  irri- 
tating iugesta,  to  hyperacidity,  to  gastrectasia,  or  to  toxins  formed 
within  the  stomach. 

Vomitixg.  Vomiting  takes  place  when  the  stomach  is  compressed 
by  the  abdominal  muscles  and  diaphragm,  coincidently  with  relaxation 
of  the  so-called  cardiac  sphincter  of  the  oesophagus.  Sometimes  there 
are  nausea  and  violent  efforts  at  expulsion  on  the  part  of  the  stomach, 
but  no  vomiting  occurs,  because  the  cardiac  orifice  of  the  stomach  is 
not  opened  at  the  same  time.  Again,  there  may  be  profound  relaxa- 
tion of  the  oesophagus,  but  no  compression  of  the  stomach  by  the  dia- 
phragm and  abdominal  muscles.  Both  factors  must  operate  at  the 
same  time  to  result  in  vomiting.  This  explains  why  it  is  that  some 
persons  suffer  extreme  nausea  and  have  even  violent  retching,  but  are 
unable  to  vomit. 

It  is  to  modern  physiologists — Schiff  and  Budge  and  Brunton — that 
we  owe  a  correct  explanation  of  the  physiology  of  vomiting. 

From  them  we  learn  that  there  is  a  nervous  centre  for  vomiting, 
which  is  seated  in  the  medulla  oblongata,  in  close  proximity  to  and 
intimately  connected  with  the  respiratory  centre.  It  is  to  this  centre 
that  impressions  are  sent  from  the  brain  itself  or  from  various  portions 
of  the  body  by  their  nerve-supply,  and  from  this  centre  motor  im- 
pulses are  transmitted  to  the  muscles  concerned  in  the  act  of  vomiting, 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     765 

and  to  the  stomach  and  oesophagus.     In  his  usually  graphic  manner 
Brunton  has  described  the  entire  mechanism. 

By  a  very  good  diagram  (see  Fig.  195)  the  author  indicates  the 
afferent  nerves  which  transmit  impulses  to  the  vomiting-centre,  ex- 
citing it  to  action.  They  are  :  pharyngeal  branches  of  the  glosso- 
pharyngeal ;  pulmonary  branches  of  the  vagus  ;  gastric  branches  of 
the  vagus  ;  gastric  branches  of  the  splanchnic  ;  renal,  mesenteric, 
uterine,  ovarian,  and  vesical  nerves.  Fibres  pass  downward  from  the 
brain,  conducting  impressions  to  the  vomiting-centre  from  the  organs 
of  special  sense,  from  the  brain-substance  or  its  membranes  when  the 
seat  of  disease,  or  from  central  ganglia  excited  by  emotion  or  imagi- 
nation. 

Fig.  195. 


BRAIN 


NERVOUS    CENTRE 
OF    VOMITING    IN 
THE    MEDULLA 
OBLONGATA 


SPINAL    CORD 


PULMONARY 
I    BRANCHES 

SPLANCHNICS 

GALL-DUCT 


RENAL    NERVES 


/  mesfnter;c 

I         NERVES 


UTERUS- 
BLADDER 

VESICA 
NERVE 


The  nervous  mechanism  of  vomiting. 


From  this  it  is  seen  that  vomiting  is  a  reflex  act ;  that  its  mechanism 
is  quite  simple  ;  and  that  a  proper  understanding  of  this  mechanism 
is  essential  to  a  correct  appreciation  of  its  pathology  and  treatment. 
Reference  has  not  been  made  to  the  vomiting  that  occurs  in  the  initial 
stage  of  many  fevers,  and  in  septicaemia,  uraemia  and  allied  affections, 
and  to  the  vomiting  of  hysteria.  In  the  former  it  is  doubtless  due  to 
the  direct  action  of  the  poisoned  blood  on  the  centre,  but  it  can  also 
readily  be  seen  to  be  due  to  the  propagation  of  impulses  to  the  centre 
from  the  brain  that  is  irritated  by  the  blood.  If  the  phenomena  of 
hysteria  are  due  to  an  abeyance  of  the  processes  of  inhibition,  the 
occurrence  of  vomiting  can  be  said  to  arise  from  the  non-control,  by 


766  SPECIAL  DIAGNOSIS. 

higher  centres,  of  this  centre.  (From  "Vomiting,  Physiological  and 
Clinical."     Trans.  Penna.  State  Med.  Soc,  1887.     Musser.) 

The  significance  of  vomiting  in  a  given  case  can  sometimes  be  deter- 
mined very  readily,  and  sometimes  it  remains  in  donbt  after  very 
careful  examination  and  questioning  of  the  patient.  In  seeking  for 
an  explanation  of  vomiting  it  is  of  importance  to  find  out  the  previous 
health  of  the  patient ;  whether  it  occurred  after  the  patient  had  been 
ill  for  a  longer  or  shorter  time,  or  suddenly,  when  he  was  in  apparent 
health,  or  whether  it  formed  one  of  the  initial  symptoms  of  an  acute 
disease. 

Again,  inquiry  should  be  made  as  to  the  supposed  cause  of  the 
vomiting  ;  whether  it  was  excited  by  the  taking  of  food,  drink,  or 
medicine,  or  by  some  disgusting  sight  or  odor. 

Further,  the  time  of  the  occurrence  of  the  vomiting  should  be  ascer- 
tained, as  well  as  its  frequency,  and  whether  preceded  by  nausea,  pain 
(noting  its  locality),  injury,  coughing,  jaundice,  or  constipation. 

The  position  of  the  patient  at  the  time  the  vomiting  occurs  some- 
times furnishes  a  valuable  clue  to  its  cause. 

The  effect  of  the  vomiting  is  sometimes  of  aid  in  diagnosis.  In 
ulcer  and  migraine,  for  example,  it  affords  marked  relief. 

Finally,  the  appearance  and  quantity  of  the  matter  vomited  are 
very  important.     (See  Objective  Signs.) 

Character.  Vomiting  may  occur  occasionally,  persistently,  or  peri- 
odically. It  may  be  projectile  and  painless,  or  difficult  and  painful. 
The  former  is  characteristic  of  cerebral  disease  or  reflex  vomiting  ; 
the  latter  of  local  gastric  disease.  When  vomiting  occurs  suddenly, 
without  antecedent  illness,  it  usually  indicates  some  local  affection  of 
the  stomach,  or  is  due  to  some  nervous  impression,  or  marks  the  onset 
of  some  acute  general  disease. 

Vomiting  in  Gastric  Disease.  The  local  affections  of  the  stomach 
attended  by  vomiting  are  acute  and  chronic  gastritis  (especially  the 
catarrhal  form),  dyspepsia,  ulcer,  cancer,  and  dilatation. 

In  acute  gastritis  there  will  be  a  history  of  an  acute  illness  marked 
by  severe  local  and  general  symptoms.  The  cause  of  the  gastritis  may 
be  found  to  be  overeating  of  highly  seasoned  or  indigestible  food  ;  abuse 
of  alcohol,  narcotics,  or  sedatives  ;  drinking  water  to  which  the  patient 
is  unaccustomed  ;  poisoning  with  such  drugs  as  arsenic  and  mercury  ; 
sudden  changes  in  atmospheric  conditions  in  susceptible  persons.  The 
vomiting  is  preceded  by  nausea,  epigastric  pain  and  tenderness,  and 
often  followed  by  profound  prostration. 

The  vomited  matters  consist,  first,  of  the  contents  of  the  stomach 
(which  may  throw  light  on  the  cause  of  the  attack),  then  of  mucus, 
saliva  (which  has  been  swallowed),  bile,  and,  in  grave  cases,  altered 
blood. 

In  chronic  gastritis  vomiting  often  occurs  in  from  half  an  hour  to  an 
hour  and  a  half  after  eating,  the  food  being  only  partly  digested  and 
sometimes  coated  with  mucus.  It  does  not  produce  the  prostration 
that  vomiting  in  acute  gastritis  does,  and  is  followed  by  some  relief  to 
the  gastric  uneasiness  and  pain.  The  emaciation  may  suggest  cancer 
of  the  stomach. 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     767 

In  ulcer  of  the  stomach  vomiting  is  rarely  absent.  It  occurs  usually 
soon  after  taking  food,  and  its  occurrence  affords  relief  to  the  gastric 
pain.  There  is  nothing  characteristic  in  the  vomit  unless  it  contains 
blood.  Welch  thinks  that  gastric  hemorrhage  in  recognizable  amount 
occurs  in  about  one-third  of  the  cases. 

In  cancer  of  the  stomach  vomiting  is  an  almost  constant  symptom, 
but  it  may  not  occur  until  comparatively  late  in  the  disease,  or,  more 
rarely,  may  be  one  of  the  earliest  symptoms.  Usually  it  does  not 
appear  until  dyspeptic  symptoms  have  persisted  for  some  time.  There 
is  no  uniformity  in  the  frequency  of  its  occurrence  or  in  the  character 
of  the  vomit.  As  a  rule,  vomiting  occurs  at  a  longer  interval  after 
taking  food  than  in  the  case  of  ulcer,  and  the  ejection  of  food  does  not 
give  as  much  relief  to  the  patient.  Vomiting  may  occur  every  day  or 
several  times  a  day  in  the  early  stages,  but  if  dilatation  of  the  stomach 
develops,  as  it  usually  does  in  cancer  of  the  pylorus,  vomiting  may  be 
deferred  for  several  days,  and  then  be  correspondingly  more  copious 
in  amount.  Blood,  frequently  altered  by  gastric  juice  so  as  to  resem- 
ble coffee-grounds,  is  a  common  constituent  of  the  vomit.  (See  Under 
Inspection.) 

Vomiting  in  Infections.  Vomiting  frequently  marks  the  onset  of  acute 
diseases,  especially  pneumonia  and  the  eruptive  fevers  and  yellow  fever. 
Excessive  vomiting  generally  indicates  that  the  case  will  be  severe. 

Reflex  Vomiting.  Nausea  and  vomiting  are  excited  in  some  persons 
by  the  sight  of  blood,  or  by  a  horrible  or  loathsome  spectacle  ;  others 
are  more  susceptible  to  foul  odors  and  disgusting  tastes. 

Vomiting  is  frequently  reflex,  that  is  to  say,  irritation  at  some  point 
is  transmitted  by  the  proper  afferent  nerve  to  the  vomiting-centre  and 
then  reflected  to  the  stomach.  Vomiting  of  this  character  occurs  in 
pregnancy,  diseases  of  the  appendix  vermiformis,  ovaries,  uterus,  bladder, 
prostate  gland,  lungs,  nose,  eyes,  kidneys,  intestine,  peritoneum,  liver,  gall- 
bladder, and  bile-ducts. 

Vomiting  is  found  to  be  of  reflex  origin  when  there  is  no  local  affec- 
tion of  the  stomach  present  and  no  general  disease  to  account  for  it, 
and  when  a  remote  source  of  irritation  can  be  discovered,  the  removal 
or  mitigation  of  which  checks  this  vomiting.  The  particular  organ 
which  is  the  source  of  the  irritation  must  be  determined  by  a  careful 
physical  examination  guided  by  the  indications  furnished  by  the  age, 
sex,  time  of  occurrence,  habits,  and  other  symptoms  which  accompany 
the  vomiting. 

The  nausea  and  vomiting  from  which  many  women  suffer  during 
the  early  months  of  pregnancy  are  most  marked  on  rising  in  the  morn- 
ing ;  they  are  aggravated  if  the  patient  has  been  on  her  feet  much  or 
has  been  subjected  to  any  exhausting  or  worrying  influence  ;  on  the 
other  hand,  they  are  relieved  by  quiet  and  the  recumbent  posture.  In 
diseases  of  the  ovary,  uterus,  bladder,  and  prostate  there  are  local  pain, 
catarrhal  symptoms,  inflammation  or  noticeable  enlargement. 

The  lungs  are  probably  not  often  the  cause  of  reflex  vomiting. 
Rarely,  however, phthisis  is  so  masked  by  gastric  symptoms  and  vomit- 
ing as  to  be  overlooked.  More  frequently  it  is  the  act  of  coughing 
and  the  effort  to  expel  the  sputa  from  the  throat  that  produce  the 


768  SPECIAL  DIAGNOSIS. 

vomiting.  Expectoration  tickles  the  throat,  and  may  have  the  same 
effect  as  the  finger  or  feather  in  inducing  vomiting.  This  seems  to  be 
the  explanation  of  the  vomiting  which  follows  a  hard  spell  of  coughing 
in  pertussis. 

Peritonitis  may  be  suspected  to  be  the  cause  of  vomiting  if  there  has 
been  injury  to  the  peritoneum  from  a  surgical  operation,  or  if  it  has 
been  exposed  to  infection  through  the  uterus  and  tubes,  or  from  disease 
of  organs  surrounded  by  it,  as  the  vermiform  appendix.  Vomiting 
may  be  the  only  symptom  present  except  collapse.  The  fluid  is  not 
only  ejected,  but  regurgitated,  and  may  appear  to  flow  from  the  stom- 
ach.    Large  amounts  of  fluid  are  discharged,  clear  or  of  a  green  color. 

In  the  vomiting  due  to  the  passage  of  a  renal  calculus  or  gallstone 
the  colicky  pains  and  their  location  definitely  point  to  the  source. 

Vomiting  in  Toxcemias.  Vomiting  is  also  a  marked  symptom  of  tox- 
aemias ;  they  produce  vomiting  probably  by  direct  irritation  of  the 
vomiting-centre.  Among  such  diseases  are  the  specific  fevers,  notably 
scarlet  fever  and  yellow  fever  ;  sewer-gas  poisoning  ;  diseases  of  the  liver 
and  kidney,  which  produce  chokemia  and  urcemia.,  particularly  cirrhosis 
of  the  liver  and  interstitial  nephritis. 

Cyclic  Vomiting.  This  condition  was  described  by  Ley  den  in  1882 
as  periodic  vomiting.  Cases  in  children  have  been  recorded  by  Snow 
and  others.  Clinically,  the  vomiting  is  sudden  in  onset,  severe,  and 
consists  first  of  the  contents  of  the  stomach,  and  later  of  acid  mucus. 
There  is  usually  a  febrile  reaction  at  the  onset,  but  this  may  be  absent 
in  adults.  The  abdomen  is  almost  invariably  retracted.  There  is 
usually  a  degree  of  prostration  which  is  out  of  proportion  to  the  local 
manifestations,  and  may  be  dangerous.  There  may  be  narcosis,  del- 
irium, or  great  restlessness.  These  gastric  crises  recur  at  intervals  of 
six  weeks  to  six  months,  and  will  recur  periodically  in  spite  of  the 
utmost  care  as  to  diet.  This  disease  is  probably  a  gastric  neurosis, 
and  has  analogies  with  migraine.  There  is  no  reason  to  believe  that 
it  is  reflex  in  origin.  It  may  be  due  to  the  accumulation  of  toxic  sub- 
stances. 

The  vomiting  of  urcemia  usually  occurs  in  the  morning.  It  is  ac- 
companied by  nausea  and  depression.  Whenever  morning  nausea  and 
vomiting  occur  in  an  adult  without  obvious  local  cause  the  urine  should 
be  examined.  Other  confirmatory  signs  are  high-tension  pulse,  accent- 
uation of  the  aortic  second  sound,  and  hypertrophy  of  the  heart. 

Cerebral  Vomiting.  Vomiting  due  to  cerebral  disease  is  well  recog- 
nized. In  early  life  it  is  a  characteristic  feature  of  meningitis  and 
tumor  of  the  brain.  It  is  likewise  of  moment  in  later  life.  I  am 
of  the  conviction,  however,  that  it  is  not  sufficiently  recognized  as  one 
of  the  first  symptoms  of  apoplexy.  True,  we  find  that  apoplexy  occurs 
after  a  full  meal,  when  the  attack  is  associated  with  indigestion,  with 
efforts  at  vomiting  ;  and  I  do  not  here  refer  to  such  cases,  but  to  cases 
of  painless,  often  watery  vomiting,  occurring  without  nausea  and  with- 
out retching.  A  sudden,  violent  expulsion  of  the  stomach-contents, 
ceaseless,  unrelieved  by  remedial  measures,  has  been  seen  by  the  writer 
to  precede  other  signs  of  apoplexy  by  from  thirty  minutes  to  twenty- 
four  hours.     In  all  cases  of  apoplectic  character  the  pulse  is  slow  and 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     769 

full,  while  in  nausea  and  vomiting;  from  other  causes,  in  the  aged  par- 
ticularly, it  is  weak  and  feeble.  Moreover,  some  alteration  of  breath- 
ing is  noticed.  It  is  either  irregular,  or  slow,  or  unduly  hurried.  It 
proves  the  intimate  relation  of  the  vomiting  and  the  respiratory  centres. 
Further,  strength  is  seen,  not  weakness  ;  in  the  apoplectic  the  face  is 
congested,  not  pallid  as  in  simple  sick  stomach.  The  other  peculiari- 
ties of  cerebral  vomiting  have  been  indicated. 

Crises.  Sudden  attacks  of  vomiting  with  hyperacidity,  with  or 
without  pain,  often  occur  in  locomotor  ataxia.  Such  attacks  occur  in 
other  affections,  as  hysteria.  They  occur  in  movable  kidney,  and  are 
known  as  Dietl's  crises. 

Diagnosis.  Vomiting  is  readily  recognized.  It  is  often  productive 
of  serious  symptoms.  It  may  cause  apoplexy  or  cerebral  congestion  ; 
it  may  cause  acute  overdistention  of  a  dilated  heart,  as  in  aortic  re- 
gurgitation. If  it  continues  for  any  length  of  time,  and  much  fluid  is 
ejected,  it  is  attended  by  anuria,  and  rapidly  followed  by  collapse.  It 
also  induces  thirst. 

Flatulency.  Flatulency  is  an  accumulation  of  gas  in  the  stomach 
or  intestines.  It  is  a  very  common  source  of  complaint  on  the  part  of 
patients.  Gastric  flatulency  is  marked  by  a  distention  of  the  stomach, 
with  the  discomfort  which  it  occasions,  and  by  the  eructation  of  gas  at 
variable  intervals  after  the  taking  of  food.  When  the  gas  is  the  result 
of  the  fermentation  which  accompanies  the  production  of  the  fatty 
acids  flatulency  is  frequently  accompanied  by  pain,  which  is  relieved 
by  eructations.  When  the  distention  is  great  or  long  continued,  dis- 
turbances in  the  action  of  the  heart,  particularly  palpitation  and  inter- 
mittency,  are  likely  to  occur.  Occasionally  it  interferes  with  the 
breathing,  and,  from  the  apprehension  which  this  symptom  and  palpi- 
tation excite,  faintness  and  inaptitude  for  mental  and  physical  work 
may  arise. 

Flatulence  may  be  due  to  carbonic  acid,  which  is  generated  and  re- 
tained on  account  of  motor  deficiency.  It  is  seen  in  the  middle-aged 
and  in  the  old.  Air  swallowed  with  the  food  or  the  saliva  is  an  occa- 
sional cause.  Flatulence  may  also  be  due  to  the  regurgitation  of 
pancreatic  juice,  as  in  fixation  of  the  stomach- wall  and  open  pylorus. 
It  comes  on  four  or  five  hours  after  eating,  and  is  caused  by  de- 
composition of  the  carbonates  of  the  pancreatic  juice  setting  free  car- 
bonic acid.  Flatulence  from  bacterial  fermentation  is  seen  in  dilatation 
of  the  stomach,  and  is  usually  continuous.  It  also  occurs  in  chronic 
indigestion.  Flatulence  in  rare  instances  is  due  to  disturbance  of  the 
interchange  of  gas  between  the  blood  and  the  contents  of  the  stomach. 
Normally  it  is  known  as  g astro-intestinal  respiration. 

Excessive  flatulency  is  a  common  manifestation  of  hysteria.  Such 
patients  may  complain  of  something  rising  into  the  throat  from  the 
stomach  and  smothering  them  (globus  hystericus).  There  may  also  be 
tympanites,  and  even  phantom  tumor.  It  may  be  necessary  to  anaes- 
thetize the  patient  completely,  to  diagnosticate  the  latter  from  genuine 
tumor. 

Vertigo.  The  stomach  is  but  one  of  a  number  of  sources  of  ver- 
tigo.    Some  patients  find  by  experience  that  certain  articles  of  food, 

49 


770  SPECIAL  DIAGNOSIS. 

such  as  oysters  or  lobsters,  have  to  be  avoided  because  they  produce 
vertigo,  although  digestion  is  good,  and  more  indigestible  articles  can 
be  taken  without  inducing  any  such  result. 

In  other  cases  acute  indigestion  from  overeating,  particularly  if  it 
result  in  the  development  of  an  acid  condition  of  the  stomach,  is  apt 
to  be  accompanied  by  vertigo  when  the  stomach  symptoms  are  most 
severe.  Usually  the  vertigo  is  associated  with  headache,  more  or  less 
intense  ;  it  is  relieved  by  lying  down  and  closing  the  eyes,  but  does 
not  wholly  disappear  until  all  the  symptoms  gradually  subside  after 
free  vomiting.  Some  persons  are  subject  to  so-called  "  blind  "  head- 
aches— headaches  accompanied  by  dimness  of  vision,  more  or  less 
mental  confusion,  and  uncertainty  of  gait,  possibly  with  staggering,  and 
often  with  vertigo.  Such  headaches  appear  to  be  due  to  an  acid  con- 
dition of  the  stomach,  and  are  relieved  by  alkalies  or  vomiting. 

It  is  difficult  to  separate  the  vertigo  of  chronic  gastric  or  gastroin- 
testinal dyspepsia  from  that  of  lithsemia  or  latent  gout.  Probably 
both  are  due,  not  to  any  local  irritation  transmitted  to  the  brain,  but 
to  the  circulation  in  the  blood  of  toxic  products  of  digestion  which 
act  upon  the  brain.  The  vertigo  is  not  so  severe  as  in  acute  indiges- 
tion or  acute  dyspepsia,  but  is  cftnstant.  In  some  patients  it  is  asso- 
ciated with  an  unconquerable  aversion  to  walking  alone  upon  the  street. 

Pain.  Cardialgia  is  a  form  of  discomfort  in  the  epigastrium 
scarcely  amounting  to  pain,  but  attended  by  heartburn  or  acidity. 
Gastrodynia  is  a  violent  pain  spoken  of  as  cramp  or  spasm  of  the 
stomach.  The  pain  is  transient.  Gastralgia  is  a  form  of  pain  with 
features  like  that  of  neuralgia,  occurring  when  the  stomach  is  empty. 
(See  Gastric  Neuroses.) 

Location.  Pain  in  the  Epigastrium.  Pain  referred  to  the  stomach 
is  situated  in  the  upper  zone  of  the  abdomen,  below  the  ensiform  carti- 
lage, between  the  ribs  of  the  two  sides,  usually  in  the  median  line.  It 
may  be  along  and  under  the  left  ribs.  Pain  in  this  situation  may  be 
due  to  a  number  of  causes  :  1.  To  myalgia,  neuritis,  or  neuralgia  of 
the  intercostal  nerves,  which  terminate  in  this  situation.  (See  Abdom- 
inal Pain.)  2.  Localized  peritonitis  or  perigastritis,  which  may  be 
secondary  to  or  caused  by  infection  or  injury  of  the  peritoneum  from 
disease  of  contiguous  organs.  3.  Affections  of  the  pancreas  may  cause 
pain  :  a.  Pancreatic  colic,  a  rare  condition  associated  with  diarrhoea, 
intestinal  dyspepsia,  and  salivation.  The  pain  is  paroxysmal,  the 
attacks  lasting  two  or  three  hours,  b.  Pain  due  to  carcinoma  of  the 
pancreas,  darting  or  lancinating  in  character,  associated  usually  with 
tumor,  jaundice,  and  emaciation,  c.  Pain  clue  to  pancreatic  hemor- 
rhage. It  is  sudden  and  extremely  severe,  attended  by  collapse.  4. 
Pain  in  this  situation  may  be  due  to  aneurism  of  the  aorta  or  of  the 
cceliac  axis.  It  is  constant,  of  a  boring  character,  and  may  be  associ- 
ated with  shooting  pains  along  the  course  of  the  lumbar  nerves.  The 
physical  signs  of  aneurism  are  present.  5.  Pain  in  this  region  may  be 
due  to  hepatic  colic.  6.  It  may  be  due  to  disease  of  the  vertebra?. 
We  should  look  for  the  sixth  or  seventh  dorsal  vertebra  to  be  affected, 
hence  higher  up  posteriorly  than  the  area  affected  in  front  would  indi- 
cate.    7.  Affections  of  the  stomach.     Of  these  we  have  :  a.  Gastralgia 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     771 

in  all  its  forms.  (See  Gastric  Neuroses.)  b.  Acute  and  chronic  gas- 
tritis, c.  Gastric  ulcer,  d.  Carcinoma  of  the  stomach.  To  the  first 
class  belongs  a  peculiar  pain  which  occurs  in  locomotor  ataxia,  and 
which,  on  account  of  its  sudden  onset,  with  alarming  and  frequently 
repeated  vomiting,  is  known  as  a  gastric  crisis. 

Pain  in  the  Left  Hypochondrium.  It  may  be  due  to  a  dilated  stomach 
or  distended  colon. 

Pain  of  Gastric  Origin.  In  diseases  of  the  stomach  pain  is  a  very 
common  symptom.  It  is  of  all  degrees,  from  a  mere  sense  of  discom- 
fort or  uneasiness  to  agony.  In  atonic  dyspepsia  there  may  be  no  local 
gastric  symptoms  except  a  feeling  of  weight  and  fulness,  while  in  ner- 
vous dyspepsia  there  is  usually  uneasiness  or  discomfort  after  eating. 
In  gastralgia  the  pain  is  characteristic  :  it  usually  comes  on  while  the 
stomach  is  empty,  and  frequently  recurs  daily  at  the  same  hour.  At 
first  the  pain  is  slight  and  easily  borne,  but  it  gradually  increases  in 
severity.  Each  succeeding  paroxysm  is  worse  than  the  preceding  one, 
until  a  climax  of  agony  is  reached.  In  character  the  pain  is  gnawing 
and  cramp-like,  doubling  the  patient  up,  and  after  subsiding  leaving 
him  moist  with  cold  sweat  and  in  partial  collapse. 

In  catarrhal  dyspepsia  there  are  pain  and  uneasiness  in  the  stomach 
after  eating,  with  tenderness  on  pressure.  If  flatulence  coexists,  there 
will  be  temporary  relief  to  the  discomfort  upon  the  eructation  of  gas. 

In  ulcer  there  is  a  more  or  less  constant  feeling  of  soreness  in  the 
epigastrium.  After  taking  food  the  dull  pain  is  aggravated  and  becomes 
sharply  localized.  Frequently  there  is  pain  in  the  back  at  the  same 
point,  a  little  to  the  left  of  the  spine  and  between  the  midscapular 
region  and  the  lumbar  vertebra?.  The  pain  usually  occurs  sooner  after 
taking  food  than  in  the  case  of  cancer,  and  is  more  frequently  relieved 
by  vomiting.  Attacks  of  gastralgia  are  not  rare,  and  the  pain  may 
shoot  down  the  arm. 

In  gastric  cancer  pain  may  be  wholly  absent  throughout  the  entire 
course  of  the  disease  ;  but,  as  a  rule,  pain  is  more  continuous  than  in 
ulcer,  less  severe,  not  so  sharply  localized,  does  not  come  on  so  soon 
after  taking  food,  and  is  not  relieved  to  the  same  degree  by  vomiting. 
Paroxysms  of  gastralgia  are  not  so  common. 

In  acute  gastritis  the  pain  and  its  character  vary  with  the  intensity 
of  the  inflammation.  If  due  to  the  irritation  of  some  toxic  agent 
which  has  been  swallowed,  the  pain  is  severe  and  burning ;  if  the 
result  of  imprudence  in  eating  and  drinking,  the  pain  is  of  a  dull, 
sickening  character.  In  either  case  there  is  more  or  less  tenderness  on 
pressure.  Sometimes,  in  mild  cases  of  catarrhal  gastritis,  firm  press- 
ure from  a  broad  surface  affords  at  least  temporary  relief  to  the  dis- 
tress. 

Time  of  Pain.  The  significance  of  pain  depends  on  the  time  of  its 
occurrence.  Pain  coming  on  before  eating  or  when  the  stomach  is 
empty  is  due  to  gastralgia.  It  is  relieved  by  food.  When  it  comes 
on  after  eating,  it  is  usually  due  to  organic  disease  of  the  stomach,  as 
ulcer  or  carcinoma  ;  but  it  may  be  due  to  neurasthenia.  It  must  not 
be  confounded  with  the  pain  that  occurs  from  two  to  four  hours  after 
meals,  caused  by  intestinal  indigestion  or  some  pancreatic  affection. 


772  SPECIAL  DIAGNOSIS. 

When  the  pain  is  diffused,  it  is  due  to  hyperacidity  and  bacterial  fer- 
mentation, as  in  dilatation,  catarrhal  gastritis,  and  simple  indigestion. 
When  localized,  it  is  due  to  ulcer  or  cancer,  and  is  associated  with  ten- 
derness.    It  may  extend  to  the  back. 

Alterations  of  Appetite.  Loss  of  appetite,  or  anorexia,  may  be 
due  to  a  number  of  diseases.  It  is  present  in  all  forms  of  organic  disease 
of  the  stomach  except  occasionally  in  ulcer.  In  the  majority  of  cases  of 
this  affection  it  is  present.  It  may  or  may  not  be  present  in  gastric  neu- 
roses. Every  one  is  familiar  with  the  loss  of  appetite  due  to  nervous 
impressions,  as  emotions,  anxiety,  or  mental  care.  It  is  of  frequent 
occurrence  in  disorders  remote  from  the  stomach,  which  modify  the 
condition  of  the  organ  reflexly.  In  the  section  on  Vomiting  will  be 
found  statements  showing  the  influence  of  central  disease  and  disease 
of  distant  organs  upon  the  stomach.  Through  the  same  channels  and 
through  the  same  mechanism,  and  hence  by  the  same  group  of  causes, 
loss  of  appetite  may  be  produced.  Loss  of  appetite  is  a  constant 
accompaniment  of  the  moderate  gastritis  which  attends  all  fevers. 
Reference  cannot  well  be  made  to  all  the  conditions  which  induce  this 
symptom.  In  all  forms  of  anaemia,  in  all  chronic  wasting  diseases,  and 
in  functional  and  organic  disease  of  the  nervous  system  the  appetite  is 
lost.  The  writer  has  been  particularly  impressed  with  the  importance 
of  determining  the  presence  or  absence  of  suppuration  in  some  portion 
of  the  body,  in  all  cases  in  which  there  is  loss  of  appetite  or  disgust  for 
food,  the  cause  of  which  is  not  of  gastric  origin. 

Boulimia,  or  excessive  appetite,  sometimes  occurs.  It  is  popularly 
thought  to  be  due  to  worms  in  children.  It  is  a  common  symptom  in 
the  earlier  periods  of  diabetes,  and  is  said  to  be  present  in  disease  of 
the  mesenteric  glands.  It  occurs  also  in  gastric  neuroses.  Perversion 
of  the  appetite,  in  which  all  sorts  of  substances  are  greedily  swallowed, 
occurs  in  hysteria,  dementia,  and  pregnancy.     It  is  known  as  pica. 

Regurgitation  of  gases  or  food  matter  is  a  frequent  symptom  of 
gastric  disorder.  It  is  also  known  as  belching  or  eructation.  It  may 
be  limited  to  the  discharge  of  gas,  although  sometimes  imperfectly 
digested  food  also  regurgitates.     (See  Rumination.) 

Regurgitation  of  the  gastric  juice  alone  causes  an  unpleasant  taste, 
and  the  fluid  is  hot  and  acrid.  The  juice  is  usually  brought  up  in  the 
belching  of  gas. 

Pyrosis,  or  waterbrash,  is  a  common  symptom  in  some  forms  of 
dyspepsia.  It  may  occur  in  the  morning  when  the  stomach  is  empty, 
at  which  time  large  amounts  of  fluid  are  ejected.  The  fluid  is  thin 
and  watery,  sometimes  acid,  sometimes  tasteless.  In  other  cases  the 
fluid  is  slightly  alkaline.  The  fluid  is  ejected  without  vomiting. 
Sometimes  the  discharge  begins  immediately  after  eating.  The  late 
Dr.  Chambers  thought  that  the  fluid  was  saliva  which  was  swallowed 
and  retained  in  the  lower  part  of  the  oesophagus  by  a  spasm  of  the 
cardiac  orifice,  and  when  a  sufficient  amount  was  collected,  gushed  back 
into  the  mouth.  Pavy  and  Handfield  Jones  believe  that  the  fluid  is 
secreted  by  the  stomach,  while,  on  the  other  hand,  Roberts,  who  found 
the  liquid  to  possess  diastatic  power,  believes  it  to  be  due  to  saliva. 
Acid  eructations  from  hyperacidity  or  fermentation  occur  one  or  two 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     773 

hours  after  meals.     They  rarely  occur  in  dilatation,  but  are  common 
in  overfeeding. 

Palpitation.  Increased  action  of  the  heart  is  a  common  symptom 
of  indigestion  due  to  flatulency  or  an  overloaded  stomach.  It  occurs 
in  the  middle  period  of  life,  in  the  anaemic  and  neurotic,  in  cardiac 
disease,  and  in  those  who  use  tea  and  tobacco  to  excess. 

Cough.  Cough  is  a  frequent  symptom  of  gastric  disorder.  It  may 
be  due  to  the  pharyngitis,  which  has  been  set  up  by  acid  eructations  ; 
it  may  be  mechanical,  when  a  distended  stomach  presses  upon  the  dia- 
phragm, or  it  may  be  reflex.  Cough  after  meals  in  patients  with 
tuberculosis  or  other  pulmonary  affection  is  usually  due  to  pressure 
upon  the  diaphragm. 

Dyspncea.  This  occurs  in  many  cases  of  dyspepsia  if  the  subject 
is  the  victim  of  asthma,  is  anaemic,  or  subject  to  cardiac  disease.  In 
asthma  it  is  usually  reflex  ;  in  anaemia  it  is  due  to  atony 'of  the  stomach 
and  gaseous  accumulation ;  in  cardiac  disease  it  is  mechanical  from  the 
pressure  of  a  gaseous  distended  stomach. 

Hiccough,  or  singultus,  is  a  spasm  of  the  diaphragm.  The  con- 
tractions take  place  at  more  or  less  regular  intervals,  attended  by  a 
peculiar  clicking  sound.  This  sound  is  due  to  the  sudden  passage  of 
air  through  the  glottis.  Hiccough  may  be  a  serious  symptom.  It 
may  last  but  a  few  minutes  or  continue  for  several  days.  In  the  latter 
case  it  causes  extreme  exhaustion.  Its  occurrence  in  chronic  disease 
is  of  bad  prognostic  omen. 

Drowsiness  is  frequently  seen  in  dyspeptics  after  meals.  Sleepless- 
ness is  of  frequent  occurrence.  It  may  be  due  to  the  irritation  of  food 
remaining  in  the  stomach  over  night  or  to  the  absorption  of  toxic  products. 

Constipation.  This  symptom  will  be  discussed  in  the  chapter  on 
Intestinal  Diseases.  It  is  present  with  gastric  dilatation.  In  pyloric 
stenosis  it  is  always  present. 

Diarrhcea.  The  digestion  is  impaired  and  peristalsis  is  in  excess. 
Lienteric  diarrhoea  is  an  accompaniment  of  a  gastric  motor  neurosis, 
or  it  may  be  due  to  the  absence  of  HO.  In  gastrectasia  the  fer- 
mentative products  set  up  gastro-intestinal  catarrh,  which  induces 
diarrhoea. 

The  Data  Obtained  by  Observation. 

The  Objective  Symptoms.  One  of  the  objective  expressions  of  the 
morbid  process  or  of  altered  function  is  seen  in  changes  in  the  charac- 
ter of  the  contents  of  the  stomach.  The  contents  are  obtained  for 
examination  when  discharged  from  the  stomach  (vomit)  or  when  re- 
moved artificially  (washings).  Both  fluids  are  studied  by  inspection, 
including  microscopical  examination  and  by  chemical  and  bacteriologi- 
cal examination.  The  sense  of  smell  enables  one  to  differentiate  many 
varieties  of  fluids.  Alteration  of  function  is  also  seen  in  alteration  of 
digestion,  and  is  estimated  by  chemical  and  physiological  methods. 
The  activity  of  the  digestion  must  be  determined  by  ascertaining  the 
duration  of  digestion  and  its  degree  of  completeness,  which  depend  upon 
three  factors :  (1)  The  motor  power ;  (2)  the  absorptive  power ;  (3) 
the  digestive  power  of  the  gastric  secretions. 


774  SPECIAL  DIAGNOSIS. 

To  secure  objective  data,  therefore,  the  following  are  necessary  : 

I.  Physical  examination,  to  determine  tenderness  and  the  size,  posi- 
tion, and  movement  (peristalsis)  of  the  stomach. 

II.  Examination  of  the  gastric  contents. 

III.  Examination  of  the  digestive  power  of  the  stomach. 

IV.  Examination  of  the  motor  power  of  the  stomach. 

V.  Examination  of  the  absorptive  power  of  the  stomach. 

I.  Physical  Examination  of  the  Stomach.  Inspection. 
Direct  inspection  of  the  stomach  region  often  affords  much  positive  in- 
formation. When  there  is  much  loss  of  abdominal  fat  and  the  stomach 
is  well  distended  its  outlines  can  sometimes  be  traced  with  the  eye. 
The  best  position  is  behind  and  above  the  patient's  head  while  he  is 
lying  down.  If  the  lower  curvature  can  be  traced  considerably  below 
the  navel,  the  stomach  is  almost  certainly  dilated,  and  if,  at  the  same 
time,  there  is  a  prominent  swelling  in  the  pyloric  region,  accompanied 
by  progressive  loss  of  weight  and  cachexia,  the  dilatation  is  probably 
due  to  cancer  of  the  pylorus.  A  marked  groove  extending  from  the 
umbilicus  to  the  ribs,  about  or  to  the  left  of  the  nipple-line,  is  seen  in 
cases  of  dilatation  when  the  stomach  has  fallen.  It  is  the  position  of 
the  lesser  curvature.  The  lower  border  is  also  marked  by  a  groove 
extending  in  a  curve  from  the  pubis  toward  the  first  groove. 

Peristaltic  waves  may  be  seen  to  move  spontaneously,  or  after  tap- 
ping the  region  or  applying  an'  ether  spray  or  faradism.  When  the 
pylorus  is  obstructed  anti-peristaltic  waves  may  also  be  seen.  The 
waves  of  the  muscular  contraction  begin  at  the  cardiac  end  or  fundus, 
and  extend  to  the  pylorus ;  hence,  they  begin  under  the  ribs  of  the 
left  side  and  extend  downward  toward  the  right  lower  quadrant.  They 
vary  in  extent  with  the  amount  of  dilatation.     (See  page  729.) 

Distention  of  the  stomach  with  carbonic  oxide  (see  Percussion),  or, 
better,  with  air  by  means  of  a  hand-bulb  syringe,  frequently  brings 
the  outlines  of  tumors  of  the  pylorus  plainly  into  view,  while  at  the 
same  time  any  tumor  lying  behind  the  stomach  becomes  less  distinct, 
and  false  tumors  due  to  spasm  of  the  gastric  muscular  coat  vanish.  Dis- 
tention also  helps  to  map  out  the  whole  stomach  and  to  separate  it  from 
surrounding  viscera.  It  enables  one  to  estimate  the  size  and  position  of 
the  stomach.     Hence,  by  this  means  descent  can  be  told  from  dilatation. 

Gastrodiaphany  or  Transillumination  of  the  Stomach.  Einhorn  has 
succeeded  in  transilluminating  the  stomach  by  an  Edison  lamp  fastened 
to  a  soft-rubber  tube.  The  wires  to  the  battery  are  carried  through 
the  tube.  After  the  stomach  contents  have  been  removed  the  patient 
is  to  take  one  or  two  glassf uls  of  water.  The  apparatus  after  lubri- 
cation is  then  inserted.  The  examination  must  be  made  in  a  dark 
room.  By  means  of  gastrodiaphany  the  position  and  size  of  the  stom- 
ach are  determined,  to  a  certain  extent,  and  the  presence  of  tumors  of 
the  anterior  wall  of  the  stomach  is  recognized.  The  results  are  not 
strictly  accurate,  however,  as  transillumination  of  the  intestines  is 
brought  about  if  they  are  empty.  The  form  and  size  of  the  stomach 
are  not  so  readily  brought  out  as  the  topographic  relation  of  tumors  of 
the  stomach  and  those  in  the  vicinity  of  that  organ.  It  is  of  service 
in  some  cases  to  distinguish  dilatation  from  gastroptosis. 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     775 

Rontgen  Light.  The  outline  of  the  stomach  may  be  observed  by 
the  use  of  X-rays,  provided  the  patient  has  been  given  10  or  20  grains 
of  subnitrate  of  bismuth. 

Palpatiox.  Palpation  of  the  stomach  is  closely  associated  with 
auscultation,  inasmuch  as  the  former  also  elicits  sounds  (succussion, 
gurgling)  which  are  helpful  in  diagnosis.  The  hand  must  be  placed 
flat  upon  the  abdomen  and  pressure  made  by  bending  the  ends  of  the 
phalanges.  To  make  deep  palpation,  gradually  increasing  pressure 
with  a  rotary  movement  must  be  employed.  It  may  be  of  advantage 
to  palpate  in  the  knee-elbow  position,  so  that  deeply  seated  tumors,  if 
movable,  may  fall  to  the  abdominal  wall.     (See  Auscultation.) 

But  palpation  elicits  information  independently  of  auscultation, 
chiefly  in  conditions  of  disease.  Epigastric,  'pulsation  is  common  in 
anaemia  ;  in  nervous  dyspepsia  ;  in  valvular  disease  of  the  heart,  par- 
ticularly tricuspid  regurgitation,  producing  a  liver-pulse  ;  and  in  the 
rare  cases  of  aneurism  of  the  abdominal  aorta. 

Increased  resistance  may  be  due  to  the  hypertrophy  of  the  muscular 
coat  which  coexists  with  distention  of  the  stomach.  When  the  stomach 
is  shrunken  and  the  resistance  increased,  it  may  be  due  to  a  diffused 
carcinoma  of  the  Avails  of  the  stomach  ;  or,  rarely,  to  the  so-called 
"  fibroid  stomach,"  the  atrophy  and  thickening  of  the  walls  being  due 
to  chronic  gastritis. 

Increased  resistance  limited  to  the  pylorus  is  found  in  carcinoma. 
The  same  effect  produced  by  a  tense  right  rectus  muscle  must  be  ex- 
cluded. 

Position  of  Gastric  Tumors.  Cancers  of  the  pylorus  are  situated 
usually  between  the  xiphoid  cartilage  and  the  umbilicus,  frequently  a 
little  to  the  right  of  the  median  line  ;  but  they  may  be  found  below 
the  umbilicus,  and,  exceptionally,  still  lower  down.  Adhesions  to 
neighboring  organs  commonly  prevent  the  tumor  from  being  moved. 
When  it  has  formed  adhesions  to  the  liver  or  diaphragm  it  moves  with 
respiration. 

As  a  rule,  tumors  due  to  gastric  cancer  are  small,  hard,  and  irregu- 
lar, and  gradually  increase  in  size. 

Non-malignant  tumors  are  occasionally  found,  and  also  tumors  due 
to  adhesions  around  old  ulcers,  and  to  puckered  scars.  The  latter  are 
distinguished  from  cancerous  tumors,  not  by  the  physical  examination, 
but  by  their  duration  and  clinical  history. 

Another  method  of  determining  the  position  and  size  of  the 
stomach  is  by  internal  exploration  combined  with  external  palpation. 
A  bougie  is  introduced  into  the  stomach  and  swept  over  its  entire  in- 
ternal surface,  the  position  of  the  bougie  being  followed  from  point  to 
point  by  the  palpating  hand.  This  method  is  not  advisable  when  it  is 
possible  to  make  a  diagnosis  without  it. 

Pain  and  Tenderness.  Tenderness  is  elicited  by  palpation  in  gas- 
tritis, in  dyspepsia,  especially  the  catarrhal  form,  in  ulcer,  and  in 
cancer.  In  gastritis  and  dyspepsia  the  tenderness  is  usually  diffuse 
and  is  not  constant ;  in  cancer  the  tenderness  is  usually  limited  to  the 
seat  of  the  tumor,  but  is  not  so  marked  nor  so  sharply  localized  as  in 
ulcer.     In  ulcer  tenderness  is  rarely  absent ;  even  when  there  is  no 


776  SPECIAL  DIAGNOSIS. 

pain,  it  is  very  decided,  and  is  so  localized,  sometimes,  that  it  can  be 
covered  with  the  tip  of  the  finger.  Pain  in  the  stomach  from  ulcer  is 
chronic,  circumscribed,  and  variously  described  as  burning  and  wound- 
like. It  is  aggravated  by  palpation,  and  by  food  or  drink,  especially 
hot  stimulating  drinks,  and  relieved  by  cold,  soothing  drinks.  It  is 
accompanied  frequently  by  pain  in  the  corresponding  vertebrae. 

Diffuse  pain  is  met  with  in  acute  and  chronic  gastritis,  and  in  cancer 
of  the  stomach-walls. 

Peecussiox.  Position  of  the  Stomach.  (Plate  XXXVIII.,  Fig.  1.) 
The  stomach  does  not  occupy  a  fixed  position,  and  is  a  distensible 
organ.  It  is  depressed  by  downward  pressure  of  the  diaphragm  in 
deep  inspiration,  by  emphysema,  left  pleural  effusions,  enlargements 
of  the  liver  and  spleen,  and  tight  lacing ;  it  is  raised  by  any  causes 
which  greatly  distend  the  bowels  or  peritoneal  cavity — tympanites, 
peritoneal  effusions,  tumors,  etc.  Moreover,  after  food  is  taken,  the 
stomach  is  distended  and  its  position  changed,  being  rotated  anteriorly 
from  below,  the  greater  curvature  rising  and  looking  more  forward, 
while  the  anterior  surface  has  a  more  upward  presentation. 

The  cardiac  orifice  of  the  stomach  is  fixed  by  its  passage  through 
the  diaphragm  and  by  peritoneal  attachments  which  it  receives  there. 
It  is  behind  the  sternal  insertion  of  the  left  seventh  rib.  The  pylorus, 
on  the  contrary,  is  freely  movable  when  the  stomach  is  empty  ;  it  is 
nearly  in  the  median  line,  but  when  the  stomach  is  full  it  is  pushed 
several  inches  to  the  right ;  it  lies  between  the  right  sternal  and  para- 
sternal lines,  on  a  level  with  the  tip  of  the  xiphoid  cartilage. 

Obrastzow  (Deut.  Arch,  fur  klin.  Medicin,  Bd.  xliii.  5,  417-456) 
divides  the  space  between  the  navel  and  the  xiphoid  cartilage  into 
three  equal  parts,  and  says  that  the  lower  border  of  the  stomach,  both 
in  men  and  in  women,  is  in  the  lower  or  supra-umbilical  third. 

In  children  under  fifteen  years  the  lower  border  rarely  extends  to 
the  umbilical  line  ;  after  fifty  years,  on  the  contrary,  it  often  extends 
below  the  navel.  In  conditions  of  bad  nutrition  it  falls  nearly  to  the 
navel. 

According  to  Pacanowski  and  Wagner,  the  upper  border  of  the 
stomach,  in  the  left  parasternal  line,  lies  at  the  lower  border  of  the  fifth 
rib  or  in  the  fifth  intercostal  space,  rarely  at  the  fourth  rib  or  in  the 
sixth  intercostal  space.  In  the  left  nipple-line  it  lies  from  the  fifth 
interspace  to  the  sixth  rib,  occasionally  in  the  fourth  interspace  or  at 
the  seventh  rib.  In  the  anterior  axillary  line  it  lies  at  the  lower 
border  of  the  seventh  or  eighth  rib,  rarely  above  the  sixth  rib,  never 
under  the  eighth  rib. 

Tranbe  has  called  special  attention  to  the  left  lower  portion  of  the 
thorax  which  projects  over  the  stomach,  "  the  half -moon-shaped  space." 
The  upper  limit  is  a  crescentic  line  starting  from  the  sternum  in  the 
sixth  interspace  and  extending,  in  a  curved  line  corresponding  approx- 
imately to  the  curve  of  the  rib,  to  the  axillary  line.  It  is  known  as 
"  Traube's  line."  In  health  this  space  gives  a  tympanitic  note,  unless 
the  stomach  or  transverse  colon  is  full,  or  the  omentum  very  fatty. 
In  left  pleural  effusion  it  is  dull.     (See  Diseases  of  Lungs.) 

A  part  of  the  anterior  portion  of  the  stomach  and  its  lower  border 


PLATE    XXXVIII. 


FIG.   1. 


Vb 


Normal  Position  and  Displacements  of  the  Stomach. 

Solid    red   line — Normal   position  of   distended  stomach.      Blue  line — Atonic 
dililation.     Dotted  red  line — Gastroptosis. 


, 


M M> 


V5 


% 


Carcinoma  of  the  Stomach  with   Pyloric  Stenosis. 
Metastases    in   the  Liver. 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     777 

can  be  determined  by  percussion.  Ordinarily,  the  most  suitable  posi- 
tion for  examining  the  stomach  is  the  recumbent  one,  with  the  knees 
drawn  up,  so  as  to  relax  the  abdominal  muscles. 

The  stomach  contains  air  at  all  times,  but  the  amount  varies  greatly. 

The  percussion-note  is  tympanitic,  high  in  pitch,  frequently  with  a 
metallic  ring  ;  its  quality  is  peculiar — "  stomach  tympany." 

The  percussion-area  of  the  stomach  is  increased  (1)  by  causes  exter- 
nal to  the  stomach  ;  contraction  of  the  liver,  old  pleurisy  with  retrac- 
tion of  lung,  emphysema,  former  pregnancies,  bad  nutrition,  and 
tumors  pulling  down  the  stomach  ;  (2)  by  intrinsic  causes  ;  distention 
of  the  stomach. 

Conversely,  the  percussion-area  is  diminished  by  causes  external  to 
the  stomach  ;  enlargement  of  the  liver  and  spleen,  left-sided  pleural 
effusion,  pneumothorax,  and  hypertrophy  of  the  heart. 

Actual  diminution  in  size  of  the  stomach  itself  is  difficult  to  demon- 
strate clinically  with  certainty.  If  upon  inflation  the  great  curvature 
remains  at  a  higher  level  than  3  to  5  cm.  above  the  umbilicus,  diminu- 
tion in  size  is  highly  probable.  But  even  then  the  lower  border  may 
be  prevented  from  descending  by  adhesions  to  surrounding  viscera. 

Enlargement  of  the  stomach  is  generally  due  to  dilatation,  and  is 
best  marked  clinically  by  a  low  position  of  the  greater  curvature. 
Dilatation  of  the  stomach,  according  to  Boas,  can  be  separated  from 
descent  of  the  organ  only  when  the  greater  curvature  is  more  or  less 
below  the  level  of  the  navel,  and  when  the  greatest  height  of  the  stom- 
ach exceeds  10-14  cm.  (4  to  5 J  inches).  But  descent  and  dilatation 
are  frequently  present  together.  (Plate  XXXVIII.,  Fig.  1.)  It 
must  not  be  forgotten  that  when  there  is  descent  the  normal  tympany 
is  lowered  and  the  tympanitic  area  above  the  ribs  is  replaced  by  dulness. 

Sometimes  when  the  stomach  is  distended  by  air  the  right  margin 
will  be  seen  to  extend  far  beyond  the  ordinary  limits.  Michaelis 
points  out  that  this  may  be  due  to  defective  motor  power,  especially 
if  the  right  margin  is  more  than  9  cm.  from  the  median  line.  The 
distention  to  the  right  is  due  to  actual  enlargement  and  not  to  disloca- 
tion. The  author  believes  that  dilatation  of  the  antrum  of  the  pylorus 
causes  this  enlargement.  Enlargement  of  the  stomach  downward  is 
usually  associated  with  good  motor  power,  whereas  enlargement  to  the 
right  is  an  indication  of  feeble  motor  power. 

Auscultatory  percussion  is  a  most  satisfactory  method  of  determining 
the  borders  of  the  stomach  and  its  size.  Its  area  can  readily  be  de- 
fined from  that  of  the  liver,  spleen,  and  colon  :  First,  with  the  stomach 
normal  ;  second,  inflated  by  gas  ;  third,  filled  with  fluid.  It  is  well 
to  determine  the  results  in  the  recumbent  posture,  and  then  in  the 
upright,  so  as  to  determine  if  the  stomach  falls  from  its  normal  posi- 
tion. Liquid  maybe  injected  through  the  stomach-tube,  or  the  patient 
may  drink  successive  portions,  percussion  being  employed  after  each 
amount  (eight  ounces)  taken.  After  the  site  of  the  dulness  is  fixed, 
have  the  patient  lie  down.  The  fluid  falls  backward  and  the  air  in 
the  stomach  comes  anteriorly  ;  the  dull  note  is  replaced  by  a  tympan- 
itic note.  The  change  is  a  sign  the  fluid  is  in  the  stomach,  and  serves 
to  distinguish  stomach  from  colon  tympany.     The  force  required  for 


778  SPECIAL  DIAGNOSIS. 

percussion  should  be  very  light ;  indeed,  a  fillip  with  the  nail  is  some- 
times sufficient.  It  may  even  be  well  to  allow  the  blow  to  glance  from 
the  surface,  as  the  perpendicular  stroke  brings  out  the  general  abdomi- 
nal resonance.  The  use  of  coins  is  sometimes  of  advantage.  In  dila- 
tation of  the  stomach  the  percussion-note  sometimes  varies  in  tone  over 
the  viscus  from  dull  to  tympanitic,  or  vice  versa,  because  the  organ  con- 
tracts under  the  influence  of  the  blows.  Some  have  described  a  clink- 
ing percussion-sound,  not  unlike  that  of  the  "  cracked  pot,"  over  the 
thorax. 

Auscultatory  friction  is  also  employed  in  the  same  manner  as  auscul- 
tatory percussion,  while  rubbing  the  finger  tips  over  the  surface  lightly. 
As  long  as  the  rubbing  is  made  over  the  hollow  organ  over  which  the 
stethoscope  is  placed,  and  not  moved  more  than  two  inches  from  it, 
the  friction  is  heard  distinctly. 

In  order  to  separate  stomach  tympany  from  that  of  the  colon,  which 
resembles  it,  the  stomach  may  be  distended  with  gas,  while  the  colon 
contains  solid  or  liquid  matter  ;  or,  if  the  colon  be  filled  with  gas,  the 
patient  may  be  allowed  to  stand  and  drink  a  glass  or  two  of  water. 
In  either  case  the  contrast  between  a  dull  and  a  clear  note  marks  the 
boundary  between  stomach  and  colon. 

Ziemssen  recommends  carbonic  acid  (developed  by  mixing  sodium 
bicarbonate  and  tartaric  acid)  to  distend  the  stomach  ;  the  quantity 
employed  for  adult  men  is  seven  grammes  of  bicarbonate  of  soda  and 
six  grammes  (one  and  one-half  drachms)  of  tartaric  acid.  Adult 
women  should  receive  one  gramme  less  of  each. 

As  carbonic  acid  sometimes  causes  an  uncomfortable  oppression, 
ordinary  air  is  preferred  by  some.  It  can  be  forced  in  by  a  hand- 
bulb  syringe  attached  to  an  ordinary  stomach-tube.  The  percussion- 
note  over  tumors  of  the  pylorus  is  imperfectly  tympanitic.  Welch 
describes  it  as  "  tympanitic  dulness."  Less  frequently  it  is  dull,  and 
rarely  it  is  flat. 

Auscultation-.  Auscultation  can  determine  whether  or  not  there 
is  obstruction  at  the  cardiac  orifice.  On  listening  over  the  oesophagus 
with  the  stethoscope,  Avhen  the  patient  is  swallowing  a  liquid,  a  spurt- 
ing sound  is  heard,  followed  in  from  five  to  ten  or  twelve  seconds  by 
a  second  sound,  which  marks  the  escape  of  the  fluid  from  the  cardiac 
orifice  of  the  oesophagus  into  the  stomach,  so-called  "  deglutition-mur- 
mur." When  there  is  obstruction  of  the  cardiac  orifice  the  second 
sound  may  be  delayed  as  long  as  a  minute. 

When  the  stomach  is  partly  filled  with  fluid  a  succussion  or  splashing 
sound  can  be  produced  by  moving  the  patient  quickly  from  side  to 
side,  or  by  quickly  compressing  the  stomach  and  allowing  it  to  rebound 
again  immediately.  Such  compression  may  be  made  alternately,  first 
in  the  neighborhood  of  the  fundus  of  the  stomach  and  then  in  the 
region  of  the  umbilicus.  Both  hands  should  be  employed.  The 
splashing  sounds  are  also  developed  by  rapidly  tapping,  with  the  finger 
tips  held  perpendicularly,  the  region  between  the  ribs  and  the  trans- 
verse umbilical  line  on  the  left  side.  The  ear  need  not  be  applied  to 
the  body,  but  kept  near  by  while  the  movements  are  made.  Such 
sounds  are  abnormal  if  they  are  heard  lon^  after  digestion  should  be 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     779 

completed  and  the  stomach  empty.  If  they  are  heard  more  than  three 
hours  after  a  light,  or  six  hours  after  a  full  meal,  it  indicates  slow 
digestion  or  deficient  motility,  and  gives  the  approximate  position  of 
the  lower  boundary  of  the  stomach. 

Normally,  after  drinking  fluids,  a  splashing  sound  is  not  developed 
lower  than  the  umbilical  line.  If  it  is  heard  below  this  line,  it  is  an 
indication  of  dilatation  or  of  deep  position  of  the  whole  stomach.  Dil- 
atation is  very  probable  if  the  splashing  sound  is  heard  below  the  navel 
in  a  fasting  stomach.  A  good  idea  of  the  extent  and  location  of  the 
splashing,  and  hence  of  the  lower  boundary,  can  be  secured,  if  aus- 
cultation is  conducted  when  inflation  is  practised  with  air. 

Furthermore,  this  sound  is  a  sign  of  atony.  If  50  to  100  grammes 
of  water  be  swallowed,  no  splashing  sound  is  heard  unless  there  is 
atony  of  the  stomach-walls  ;  but,  if  the  atony  is  pronounced,  a  smaller 
quantity  will  be  sufficient  to  develop  the  sound.  It  is  to  be  remem- 
bered that  the  splashing  sound  of  itself  does  not  indicate  disease.  It 
is  significant  only  when  taken  with  other  signs,  and  also  when  it  is 
found  after  more  than  one  examination. 

II.  Examination  of  the  Gastric  Contents.  Either  the  con- 
tents are  secured  with  a  stomach-tube  or  the  vomitus  is  examined. 

Mode  of  Procedure.  1.  A  test-breakfast  (Ewald),  or  a  test-dinner 
(Leube),  is  administered,  or  the  fasting  stomach  contents  removed. 
jEwald's  iest-breahfast :  It  consists  of  one  or  two  ounces  (35  grammes) 
of  bread  and  a  cup  of  tea  (J  litre),  or  the  same  amount  of  water. 
Leube-Riegel  test-dinner :  A  large  plate  of  soup  (400  c.c),  a  large  por- 
tion of  beefsteak  or  other  meat,  some  potatoes,  and  a  roll  are  taken, 
and  examination  is  made  three  or  four  hours  after  the  meal.  (See 
Boas'  Meal.  Lactic  Acid.)  2.  Remove  the  contents  of  the  stomach 
one  hour  after  breakfast  is  taken,  by  aspiration  or  by  expression. 
Aspiration  consists  in  the  withdrawal  of  the  stomach-contents  by  suc- 
tion ;  either  with  the  ordinary  stomach-pump,  by  means  of  a  bottle 
exhausted  of  air,  as  employed  for  paracentesis,  and  connected  with  the 
stomach-sound,  or  by  connecting  the  sound  with  a  hand-ball  aspirator 
or  Politzer  bulb. 

Expression  consists  in  compression  by  the  abdominal  muscles,  as  if 
straining  in  defecation.  The  patient  takes  a  deep  inspiration  and  then 
contracts  the  muscles  as  above.  If  the  tube  is  long  enough  it  can  be 
bent,  so  as  to  assist  expression  with  siphonage. 

Aspiration  is  less  disagreeable  to  the  patient,  and  is  necessary  when 
the  stomach-contents  are  not  fluid  enough  to  flow  easily. 

Expression  is  not  to  be  employed  when  there  are  old  ulcers,  ulcer- 
ating carcinoma,  phthisis  with  antecedent  haemoptysis,  or  a  disposition 
to  menorrhagia; 

These  methods  supply  the  most  reliable  information  of  the  condition 
of  the  stomi  :li  and  its  secretions  ;  because,  when  once  withdrawn,  the 
character  of  the  secretions  can  be.  ascertained  accurately  and  the  quan- 
tity measured  ;  moreover,  being  able  to  choose  the  time  of  examination, 
we  can  decide  whether  or  not  what  is  found  corresponds  with  health,  and 
if  not,  in  what  particular  it  indicates  disease.  These  methods  permit  a 
diagnosis  to  be  made  before  other  methods  supply  sufficient  data. 


780  SPECIAL  DIAGNOSIS. 

A  soft-rubber  tube,  with  two  good-sized  openings  near  its  distal  ex- 
tremity, should  be  selected.  Stockton  suggests  a  tracing  of  rings 
around  the  tube  one  inch  apart,  beginning  twenty  inches  from  and 
ending  thirty  inches  from  the  lower  extremity,  for  the  purpose  of 
measuring  the  length  of  the  tube  inserted.  In  healthy  adults  the  dis- 
tance from  the  incisor  teeth  to  the  lower  border  of  the  stomach  is  about 
twenty-two  inches.  In  dilatation  it  may  be  from  twenty-four  to 
thirty.  The  distance  is  partly  determined  by  success  in  the  siphon- 
age.  If  the  return  flow  of  fluid  does  not  take  place,  it  is  well  either 
to  withdraw  the  tube  or  push  it  further  on  ;  for,  if  too  long,  it  may 
curve  above  the  level  of  the  fluid,  or,  if  too  short,  it  may  not  reach 
the  fluid. 

After  the  tube  is  moistened,  oiled,  or  coated  with  the  white  of  an 
egg,  the  patient  should  be  seated,  and  the  tube  at  once  passed  to  the 
back  of  the  pharynx,  and,  with  or  without  guiding  by  the  finger, 
pushed  toward  the  oesophagus.  It  is  at  once  grasped  by  the  oesopha- 
gus or  lower  pharynx,  and,  if  the  patient  is  instructed  to  swallow  and 
to  breathe  slowly,  it  is  rapidly  carried  downward  by  deglutition. 
Mucus  that  accumulates  in  the  mouth  after  the  tube  is  passed  should 
be  allowed  to  dribble  outward  and  not  be  swallowed.  It  is  often  of 
advantage  to  reassure  the  patient  by  having  him  pronounce  the  letter 
"  a  "  or  some  small  syllable.  It  is  not  necessary  to  extend  the  head 
backward.  The  tube  is  then  attached  to  the  apparatus  used  for  para- 
centesis, or  to  a  tube  entering  a  bottle  in  which  a  vacuum  is  created  by 
an  ordinary  rubber  bulb  apparatus  ;  or  to  the  aspirator  of  Boas,  which 
is  a  modification  of  the  ball-syringe.  A  valve  is  placed  between  the 
stomach-sound  and  the  syringe. 

If  a  hard  tube  is  used,  it  must  be  guided  by  the  operator,  who 
should  stand  back  of  the  patient,  supporting  the  head,  which  should 
not  be  thrown  too  far  backward.  The  tube  can  be  passed  by  the  oper- 
ator seated  in  front  of  the  patient.  This  kind  of  tube  is  used  with 
the  stomach-pump. 

Normal  Gastbic  Contents.  The  amount  of  fluid,  after  digestion 
of  a  test-breakfast  has  continued  for  one  hour,  is  from  30  to  40  c.c. 
After  filtering  the  filtrate  is  clear,  yellow,  or  yellowish-brown  in  color. 
If  the  digestion  is  normal,  the  fluid  should  contain  free  hydrochloric 
acid  and  no  lactic  acid.  It  should  also  contain  pepsin,  rennin  (the 
milk-curdling  ferment),  and  organic  acids.  Albuminoids  should  be 
converted  into  proteoses  and  peptone,  and  starches  into  achroodextrine, 
dextrose,  or  maltose. 

Physical  and  Chemical  Examination.  The  steps  taken  are 
as  follows  : 

A.  Physical  examination  : 

1.  The  reaction. 

2.  The  odor. 

3.  The  character  and  quantity.     Inspection. 

B.  Chemical  examination. 

It  is  to  be  observed  that  perfect  familiarity  with  the  products  of 

and  the  length  of  time  required  by  normal  digestion  is  very  essential. 

1.  Reaction.     The  normal  reaction  of  the  contents  of  the  stomach 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     781 

is  usually  acid,  from  the  hydrochloric  acid  of  the  gastric  juice.  It 
may  be  alkaline  in  cases  of  hemorrhage,  or  in  the  vomiting  known  as 
waterbrash. 

2.  Odor.  The  odor  is  sour  normally,  but  it  may  be  aromatic  from 
the  presence  of  the  fatty  acids,  fecal  in  obstruction  of  the  bowels  with 
fecal  vomiting,  and,  finally,  may  indicate  the  nature  of  poisonous  in- 
gesta — ammonia,  phosphorus,  carbolic  acid.  The  dark,  frothy  mate- 
rial from  a  dilated  stomach  is  of  a  foul,  yeasty  odor. 

3.  Inspection  of  the  Stomach-contents.  By  ordinary  inspec- 
tion the  quantity  and  the  character  of  the  vomitus  or  stomach-contents 
are  noted.  With  the  aid  of  the  microscope  the  various  micro-organ- 
isms are  sought  for.  In  this  manner  most  valuable  information  as  to 
the  digestiye,  motor,  and  absorptiye  power  is  ascertained.  Not  only 
do  we  learn  whether  digestion  has  taken  place  or  not,  but  also  the 
variety  of  food  that  is  undigested — albuminoids  or  hydrocarbons. 

The  Quantity.  Fasting  Stomach.  If  a  person  has  taken  no  food  or 
drink  between  the  evening  meal  and  the  following  morning,  the 
stomach  should  not  contain  more  than  three  and  one-half  fluidounces  ; 
more  than  this  is  abnormal. 

The  Character.  By  it  we  learn  the  digestive  poiver.  If  undigested 
food  is  found  after  digestion  should  be  normally  completed,  there  is 
deficient  digestive  energy.  No  undigested  food  should  be  found  longer 
than  six  or  seven  hours  after  an  ordinary  meal  of  mixed  foods. 

By  inspection  of  the  gastric  contents  we  learn  much  regarding  the 
motor  poiver.  Boas  states  that  an  abnormally  great  quantity  of  solid 
matter  and  a  small  amount  of  chyme  indicate  an  abnormal  retention  of 
the  latter,  which  is  usually  brought  about  by  motor  weakness  (atony, 
dilatation  of  the  stomach),  or  dilatation  in  conjunction  with  insufficient 
absorptive  power.  Sometimes,  when  there  is  a  large  residue  in  the 
stomach,  the  contents  separate  into  three  layers.  The  uppermost  is 
mucus  or  undigested  food ;  the  second,  generally  the  thickest  layer, 
-consists  of  fluid  ;  and  the  lowest  layer  is  chyme.  Such  a  formation, 
he  says,  points  to  abnormally  long  retention  as  the  result  of  stenosis 
and  consecutive  dilatation,  or  to  motor  weakness. 

The  stomach  should  be  empty  much  sooner  if  only  starches  are 
taken,  as  in  Ewald's  test-breakfast.  One  hour  after  the  administra- 
tion of  a  test-breakfast  of  35  grammes  of  white  bread  and  300  grammes 
of  water  there  should  remain  40  c.c.  Hence,  if  after  such  a  break- 
fast there  is  found  a  much  greater  quantity,  then  motor  or  absorptive 
insufficiency  may  be  considered  to  exist.  A  filtrate  of  100  to  300  c.c. 
is  very  probably  due  to  organic  obstruction  to  the  outflow,  stenosis  of 
the  pylorus,  adhesions,  or  dislocation  of  the  pylorus.  Of  course,  to 
make  sure  that  the  stomach  contains  nothing  at  the  time  of  giving  the 
breakfast,  it  must  first  be  emptied.  The  character  of  the  food  taken 
is  observed,  as  undigested  particles  may  be  seen  in  the  contents. 

We  can  discover  by  inspection  if  food  is  brought  up  by  vomiting  or 
regurgitation.  Regurgitation  of  food  from  the  oesophagus  can  be  told 
from  vomiting  by  the  appearance  of  muscle-fibres,  if  meat  has  been 
taken.  If  it  is  vomited,  the  fibre  is  in  a  state  of  disintegration  ;  if 
not,  it  is  whole. 


782  SPECIAL  DIAGNOSIS. 

Mucus  is  found  in  small  quantity  normally,  but  is  increased  in 
catarrhal  affections  of  the  mouth,  throat,  or  stomach.  When  its  source 
is  the  mouth,  saliva  also  is  generally  present.  Mucus  is  recognized  by 
its  stringy,  tenacious  character.  Chemical  diagnosis.  Add  the  mucus, 
gently  shaking,  to  cold  water  ;  pour  off  the  supernatant  water  ;  add 
a  little  liquor  potassse.  The  mucus  is  dissolved  by  the  alkali.  To 
the  solution  acid  acetic  acid  ;  a  precipitate  is  formed  which  is  insol- 
uble in  an  excess  of  acetic  acicl.  In  this  manner  mucus  is  distin- 
guished from  the  precipitate  of  syntonin,  as  the  latter  is  soluble  in 
an  excess.  Pigmented  mucus  in  vomitus  is  usually  from  the  bronchial 
tubes. 

Bile  and  intestinal  juice  may  be  regurgitated  into  the  stomach  as  the 
result  of  violent  emesis,  or  when  the  pylorus  is  much  relaxed,  or  in 
stenosis  of  the  duodenum  below  the  common  duct ;  bile  is  then  present 
in  large  quantity  if  the  stomach  is  dilated.1  Bile  is  recognized  by  the 
usual  tests  (see  under  Examination  of  Urine),  and  intestinal  juice  by 
its  peculiar  properties  and  the  presence  of  leucin  and  tyrosin.  Absence 
of  bile  in  the  vomitus  is  an  indication  of  pyloric  stenosis. 

Blood  is  found  in  ulcer  ;  cancer  ;  acute,  especially  toxic,  gastritis  ; 
injuries  to  the  mucous  membrane  from  the  use  of  the  sound  for  expres- 
sion, and  violent  retching.  It  is  also  common  in  cirrhosis  of  the  liver, 
and  may  occur  in  purpura,  peliosis  rheumatica,  the  hemorrhagic 
diathesis,  and  in  yellow  fever.  Blood  mixed  with  gastric  mucus  may 
come  from  the  lung,  the  act  of  coughing  having  excited  vomiting. 

If  the  blood  is  unaltered,  it  can  be  distinguished  from  all  other  sub- 
stances by  microscopic  examination.  Occasionally  the  blood  has  the 
appearance  of  coffee-grounds.  The  hemorrhage  has  taken  place  slowly 
under  these  circumstances.  In  fact,  the  more  rapid  the  bleeding  the 
brighter  the  red  color  of  the  blood.  The  hosmin  test  serves  to  distin- 
guish it.  The  suspected  material  is  filtered  and  a  little  of  the  filtrate 
evaporated  in  a  watch-glass  ;  when  dry  a  small  portion  is  mixed  with 
finely  pulverized  salt  upon  a  glass  slide  ;  it  is  then  covered  with  a 
cover-glass  and  one  or  two  drops  of  glacial  acetic  acid  allowed  to  flow 
under  the  cover-glass.  The  acetic  acid  is  evaporated  by  slowly  heat- 
ing the  slip  over  a  small  flame,  and  when  dry  a  few  drops  of  water 
are  allowed  to  flow  under  the  cover-glass,  to  dissolve  the  salt.  If  the 
vomit  contained  blood,  brown  rhombic  crystals  of  heeinin  (hydrochlo- 
rate  of  heemin)  will  appear  under  the  microscope.  As  they  are  very 
small,  a  magnification  of  about  300  diameters  will  be  necessary  to 
bring  them  readily  into  view.  The  guaiacum  test  may  be  fallacious, 
as  the  same  color-reaction  takes  place  when  bile  or  saliva  or  a  starch, 
like  potato,  is  in  the  test-liquid.  It  is  performed  as  follows  :  Add  two 
or  three  drops  of  the  tincture  of  guaiacum  to  a  small  portion  of  the 
gastric  contents  in  a  test-tube  and  pour  ozonic  ether  on  the  surface. 
When  the  liquids  meet  a  blue  color  develops.  Bile  may  be  distin- 
guished from  blood  by  Gmelin's  test  for  the  former — color-reaction 
with  nitric  acid.  If  blood  is  present  in  the  stomach-contents,  it  may 
be  detected  by  the  test  for  iron.     To  the  gastric  contents,  "  coffee- 

1  Hochhaus.     Berlin,  klin.  Woch.,  1891,  No.  17. 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     783 

grounds,"  in  a  porcelain  capsule,  add  a  small  quantity  of  potassium 
chlorate  and  a  few  drops  of  a  strong  acid,  HC1.  Heat  over  a  flame 
and  add  a  few  drops  of  a  5  per  cent,  solution  of  potassium  ferrocya- 
nide.     If  iron  is  present,  Prussian  blue  is  formed. 

Pas  is  rarely  present  in  sufficient  quantity  to  be  detected  by  the 
naked  eye,  but  it  sometimes  occurs  in  phlegmonous  gastritis  and  when 
an  abscess  has  ruptured  into  the  stomach.  In  microscopic  amounts 
it  may  be  found  in  severe  catarrhal  affections.  Pus  may  be  in 
the  vomitus  and  yet  come  from  the  lungs.  It  is  usually  a  muco- 
pus,  and  is  told  by  the  pigmented  pellets  or  strings  of  mucopurulent 
material. 

Fecal  matter  is  vomited  in  complete  obstruction  of  the  bowels,  and, 
according  to  Vierordt,  in  severe  diffuse  peritonitis.  It  is  recognized 
partly  by  its  appearance  and  partly  by  its  odor. 

Worms  are  sometimes  vomited  ;  the  round  worms  not  so  very  infre- 
quently ;  oxyurides  and  ankylostomata  rarely. 

Fig.  196. 


U  'i 


■   3 


Microscopical  appearance  of  stomach-contents. 
1,  red  blood -corpuscles  ;  2,  leucocytes;  3,  squamous  epithelium;  4,  fat-globules;  5,  starch  gran- 
ules; 5',  starch  changed  by  action  of  the  gastric  juice  ;  6,  muscular  fibre  ;  7,  sarcinse  ventriculi ; 
8,  fat-crystals  ;  9,  piece  of  orange  ;  10,  phosphatic  crystal ;  11,  yeast  fungi ;  12,  bacilli  and  micrococci- 


Microscopical  Examination.  The  illustration  (Fig.  196)  shows  the 
various  matters  which  may  be  found  in  vomited  matter.  Briefly,  they 
are  columnar  and  squamous  epithelium  ;  white  blood-corpuscles  acted 
on  by  gastric  juice  ;  red  blood-corpuscles.  The  corpuscles  are  usually 
isolated.  The  red  are  rarely  perfect,  and  in  the  white  little  more  than 
the  nucleus  remains.  From  the  food  we  may  also  find  muscle-fibres, 
fatty  globules,  and  fat-needles,  clastic  fibres  and  connective  tissue, 
starch-granules,  and  vegetable  cells.  Muscle-fibres  are  recognized  by 
their  transverse  striation.  Fat-globules  are  soluble  in  ether,  and  are 
recognized  by  their  refracting  powers.  Starch-granules  stain  blue 
with  iodo-potassic-iodide  solution. 

In  addition,  fungi  of  many  forms  are  found,  as  the  mould-fungi ; 


784  SPECIAL  DIAGNOSIS. 

the  yeasts  (torulse),  and  fission-fungi.  The  latter  are  recognized  after 
staining  by  the  iodo-potassic-iodide  solution,  which  colors  them  blue. 
The  most  important  fission-fungi  are  the  sarcinse  ventriculi.  They 
are  of  a  dark  gray  tint,  stain  mahogany-brown  to  reddish-brown  with 
the  above-mentioned  solution,  and  resemble  in  shape  corded  bales  of 
goods.  (See  Bacteriological  Diagnosis.)  The  torulce  and  sarcince  are 
present  when  fermentation  is  in  progress,  and  hence  indicate  delayed 
digestion  from  motor  insufficiency  or  deficient  digestive  energy. 

B.  Chemical  Examination.  A  chemical  examination  is  made  to 
determine  (1)  the  presence  of  free  acids  ;  (2)  the  degree  of  total  acidity 
of  the  stomach-contents  ;  (3)  the  presence  of  free  HC1 ;  (4)  the  presence 
of  lactic  acid  ;  (5)  the  presence  of  volatile  acids  ;  (6)  the  presence  of 
products  of  digestion  and  the  digestive  power ;  (7)  the  presence  of 
pepsin  ;  (8)  the  presence  of  rennin  ;  (9)  the  carbo-hydrates.  Hydro- 
chloric acid  is  the  normal  acid  of  the  gastric  juice.  Normally  lactic 
acid  is  found  during  the  first  half-hour  of  digestion,  when  starches 
have  been  taken.  When  only  meats  have  been  taken  lactic  acid  is 
not  found  early  in  digestion.  The  secretion  of  hydrochloric  acid  is  not 
delayed  until  then,  but  is  at  first  combined,  and  cannot  be  detected 
as  free  acid  until  half  or  three-quarters  of  an  hour  afterward. 

1.  Free  Acids.  The  most  sensitive  test  for  free  acids  is  Congo  red. 
Filter-paper  soaked  in  a  saturated  solution  of  the  dye  and  allowed  to 
dry  is  turned  a  deep  blue  if  free  acid  is  present.  Prepared  with  a 
weak  solution,  the  filter-paper  is  turned  to  a  light  blue  by  HC1  and 
violet  by  organic  acids.  Wolff  l  was  able  to  detect  one  part  of  HC1 
in  20,000  parts  of  water.  When  no  reaction  is  obtained,  therefore, 
entire  absence  of  acidity  may  be  assumed. 

Benzo-purpurin  test-papers  are  made  as  follows  :  Soak  strips  of 
filter-paper  in  a  saturated  solution  of  benzo-purpurin  and  dry.  They 
are  purple.  If  hydrochloric  acid  is  present  they  are  turned  dark  blue. 
The  color  is  not  removed  by  shaking  with  ether.  If  organic  acids 
(butyric  or  lactic)  are  present,  it  is  turned  brownish-black,  but  the 
color  is  removed  by  shaking  with  ether.  Von  Jaksch  states  that  if 
hydrochloric  acid  and  the  organic  acids  are  present  a  brownish-black 
color  is  also  produced,  hence  the  dark  blue  and  the  volatile  brownish- 
black  reactions  only  are  important. 

The  presence  of  free  acids,  as  indicated  by  the  Congo  red  or  benzo- 
purpurin  tests,  shows  that : 

a.  HC1 — inorganic  acid — may  be  present  alone. 

6.  Lactic,  butyric,  or  acetic  acid — organic  acids — one  or  all,  may  be 
present  without  HC1. 

c.  HC1  and  one  or  more  of  the  organic  acids  may  be  present  together. 

Free  acidity  may  be  due  (1)  to  fixed  acids— hydrochloric  or  lactic 
acid,  fixed  acidity  ;  (2)  to  volatile  acids — butyric  or  acetic  acid,  volatile 
acidity. 

2.  The  Total  Acidity.  This  is  determined  by  titration.  The 
stomach-contents  must  be  well  shaken  ;  if  there  is  mucus  in  excess,  it 
must  be  strained  off  through  coarse  muslin.     Fill  a  Mohr's  burette 

1  Trans.  Philadelphia  County  Medical  Society,  1889,  vol.  x.  p.  305. 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     785 

with  a  decinormal  solution  of  caustic  soda.1  To  10  c.c.  of  the  filtered 
gastric  fluid  add  two  drops  of  a  saturated  alcoholic  solution  of  phe- 
nolphthalein.  Allow  the  caustic-soda  solution  to  drop  slowly  from  the 
burette  into  the  fluid,  until  a  faint  rose-red  color  is  produced  which  does 
not  disappear  on  shaking.  The  color  is  produced  by  the  action  of 
the  alkali  on  the  phenolphthalein.  Four  to  6  c.c.  of  the  caustic  soda 
solution  are  required  to  neutralize  the  acid  in  normal  digestion.  The 
degree  of  acidity  is  expressed  in  percentage.  Thus  if  4  c.c.  neutralize 
10  c.c,  the  total  acidity  will  amount  to  40  per  cent.,  or  if  6  c.c.  are 
required,  to  60  per  cent. 

If  more  or  less  than  the  amount  just  indicated  of  the  alkaline  solu- 
tion is  required  to  neutralize  the  acid,  the  total  acidity  is  increased  or 
diminished,  and  hence  is  abnormal. 

Topfer's  method  :    To  10  c.c.  of  stomach-contents  in  a  beaker,  add 

3  to  4  drops  of  a  1  per  cent,  solution  of  sodium  alizarin  sulphonate, 
then  add  a  decinormal  solution  of  sodium  hydrate  until  a  violet  tint 
appears  corresponding  to  the  hue  produced  by  adding  4  drops  of 
alizarin  solution  to  5  c.c.  of  a  1  per  cent,  solution  of  sodium  carbonate. 
The  solution  reacts  to  all  factors  producing  gastric  acidity  except  com- 
bined HO. 

Martin  recommends  the  following  modification  of  the  above  :  "To 
20  c.c.  of  the  stomach-contents  add  three  or  four  drops  of  a  saturated 
alcoholic  solution  of  phenolphthalein,  and  dilute  with  water  to  300 
c.c.  Place  150  c.c.  of  this  mixture  in  each  of  two  flasks,  and  place 
them  side  by  side  on  a  sheet  of  white  paper.  To  one  of  the  flasks  add 
decinormal  solution  of  sodium  hydrate  until  a  red  color  appears  ;  the 
exact  time  of  appearance  can  be  determined  by  comparison  with  the 
liquid  in  the  other  flask.  When  a  pinkish  tinge  appears  the  acid 
liquid  is  neutralized.  A  control  estimation  may  be  made  with  the 
second  flask." 

Ewald's  method  of  expressing  the  total  acidity  is  by  a  number. 
The  number  is  the  same  as  the  quantity  of  decinormal  sodium  hydrate 
solution  requisite  to  neutralize  100  c.c.  of  the  gastric  contents.  Thus 
if  50  c.c.  of  the  soda  solution  neutralized  100  c.c.  of  the  stomach-con- 
tents, the  acidity  of  the  latter  would  be  expressed  by  the  figure  50. 
The  figures  can  be  converted  into  terms  of  hydrochloric  acid,  as  a  deci- 
normal solution  of  sodium  hydrate  is  a  liquid  of  a  constant  strength, 
100  c.c.  of  which  exactly  neutralize  0.365  gramme  of  hydrochloric 
acid.  It  may  be  expressed  in  terms  of  hydrochloric  acid.  If  50  c.c. 
of  decinormal  sodium  hydrate  are  required  to  neutralize  100  c.c.  of  the 
stomach-contents,  this  would  be  equal  to  0.18  gramme  per  cent,  hydro- 
chloric acid,  as  3.65  grammes  hydrochloric  acid  are  neutralized  by  the 

4  grammes  of  soda  in  a  litre  (1000  c.c.)  of  the  decinormal  solution. 

3.  Free  Hydrochloric  Acid.  The  gastric  contents  are  now 
filtered.  Tropceolin  00  is  declared  by  Boas  to  be  an  absolutely  certain 
test  for  HO.     A  saturated  alcoholic  solution  is  of  an  orange-yellow 

1  Decinokmal  solution  of  sodium  hydrate  is  of  the  strength  of  4  grammes  of 
pure  sodium  hydrate  to  the  litre  of  distilled  water.  The  sodium  hydrate  must  be 
pure  and  made  from  sodium.  This  weight  of  sodium  hydrate  (4  grammes)  will  exactly 
neutralize  3.65  grammes  of  hydrochloric  acid. 

50 


786  SPECIAL  DIAGNOSIS. 

color.  Three  or  four  drops  of  it  are  placed  in  a  white  porcelain  dish 
and  spread  upon  the  sides  by  rotating  it.  The  same  amount  of  the 
fluid  to  be  tested  is  then  allowed  to  trickle  down  the  sides  of  the  dish 
and  intimately  mixed  with  the  tropseolin.  (Or  evaporate  the  dye  to  dry- 
ness and  then  add  the  suspected  liquid.)  Upon  heating  the  dish  over 
a  small  flame  splendid  lilac-blue  to  blue  streaks,  characteristic  of  HC1, 
will  appear  if  that  acid  is  present.  Xo  organic  acid  gives  the  same 
color. 

Tropeeolin  paper  is  turned  brown  by  gastric  juice  containing  HO, 
the  brown  changing  to  blue  upon  the  paper  being  heated.  Organic 
acids  give  a  brown  color  also,  but  it  disappears  upon  heating. 

Tdpfer's  test  for  the  detection  of  free  HC1  is  as  follows  :  Dimethyl- 
amidoazobenzol  is  employed  in  a  0.5  per  cent,  solution  of  alcohol. 
To  a  few  cubic  centimetres  of  filtered  stomach-contents  one  to  four 
drops  of  the  reagent  are  added  in  a  test-tube  or  beaker.  If  hydro- 
chloric acid  is  free  a  rose-red  color  is  produced  when  the  filtrate  is 
added  to  the  reagent.  The  drug  reacts  to  HC1  only  when  the  latter 
is  in  a  free  state.  Its  reaction  is  not  interfered  with  by  salts,  peptone, 
glucose,  chloride  of  sodium,  or  starch.  If  organic  acids  are  present 
in  a  concentration  of  from  0.5  to  0.8  per  cent,  a  reaction  may  be 
brought  about,  providing  albumin  or  peptone  is  present. 

Phloroylucin  vanillin,  introduced  by  Giinzburg,  is  also  a  very  sensi- 
tive test  for  HC1.  The  following  combination  is  said  by  Boas  to  be 
more  sensitive  than  the  ordinary  one,  which  contains  only  30  grammes 
of  absolute  alcohol  : 

Phloroglucin 2.0  (gr.  xxx). 

Vanillin 1.0  (gr.  xv). 

Alcohol  (80  per  cent  )  ....      100.0  ffgiij). 

Three  drops  are  put  into  a  porcelain  dish  and  an  equal  quantity  of 
the  stomach  filtrate.  Upon  cautious  heating  over  a  small  flame  a  beau- 
tiful carmine  surface  is  formed,  especially  at  the  edges.  The  same 
color  is  not  produced  by  inorgauic  acids.  Filter-paper  soaked  in  it  and 
moistened  with  a  few  drops  of  stomach-filtrate,  containing  HC1, 
changes  on  heating  to  a  beautiful  carmine,  which  is  unaltered  upon  the 
addition  of  ether.  Giinzbun/s  original  test  is  employed  with  the  same 
solution,  except  that  30  parts  of  alcohol  are  used.  "  One  drop  of  the 
solution  and  one  drop  of  the  fluid  to  be  examined  are  evaporated  to 
dryness  on  a  water-bath.  The  appearance  of  a  rose-red  color  indicates 
the  presence  of  hydrochloric  acid. 

Congo-red  Test,  Boas'  method  is  a  modification  of  that  of  Mintz. 
Ten  c.c.  of  the  gastric  fluid  are  shaken  with  100  c.c.  of  ether  until 
organic  acids  are  removed.  The  Congo-red  test  is  then  employed 
until  the  grayish-blue  discoloration  cannot  be  secured. 

Boas'  Resorein  Test.  Dissolve  5  grammes  (gr.  lxxv)  of  resorcin 
and  3  grammes  (gr.  xlv)  of  cane-sugar  in  100  c.c.  (f  giijss)  of  weak 
spirit,  Apply  the  test  in  exactly  the  same  way  as  Gunzburg's.  A 
similar  rose-red  coloration,  if  free  hydrochloric  acid  be  present,  is  pro- 
duced.    It  is  the  cheapest  solution  that  can  be  emploved. 

Caution.  In  testing  for  the  presence  of  HO  it  is  better  to  give  the 
patient  a  meal  which  is  known  to  be  digestible  within  a  certain  time 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     787 

by  stomachs  in  a  normal  state,  otherwise  HC1  may  appear  to  be  absent, 
because  it  is  still  combined  with  albuminoids.  Ewald's  test-breakfast 
is  the  simplest.  In  one  hour  the  contents  of  the  stomach  may  be  aspi- 
rated and  tested  for  HC1. 

Amount  of  Free  HOI.  If  by  previous  tests  HC1  is  found  alone,  its 
percentage  is  easily  calculated.  To  a  measured  quantity  of  the  gastric 
fluid  add,  drop  by  drop,  from  a  burette  a  decinormal  alkaline  solution 
until  the  acid  is  neutralized.  This  can  be  determined  by  checking 
the  titration  from  time  to  time,  and  examining  with  Giinzburg's  reagent. 
One  c.c.  of  the  alkaline  solution  is  equivalent  to  0.003646  HC1,  the 
limit  of  Giinzburg's  reaction.  Multiply  the  number  of  c.c.  required 
to  neutralize  10  c.c.  of  the  gastric  solution  by  0.003646,  and  again  by 
10,  the  result  will  be  the  percentage  of  acidity.  If  6  c.c.  are  used,  the 
percentage  will  be  6  X  0.003646  X  10  =  0.218,  within  the  normal 
range,  which  is  from  0.14  to  0.24  per  cent.  Giinzburg's  test  can  be 
used  to  estimate  the  quantity  of  HC1.  This  is  applied  by  diluting  the 
stomach-contents  until  the  test  is  not  responded  to.  In  health  the 
limit  of  response  is  found  when  one  part  of  HC1  is  found  in  20,000 
parts  of  the  fluid.  In  abnormal  conditions,  when  the  gastric  fluid  is 
diluted  one-half,  the  proportion  is  2  to  20,000,  or  1  to  10,000.  If  the 
fluid  is  diluted  to  ten  times  its  original  strength,  it  is  10  to  20,000,  or 
1  to  2000. 

The  following  method  is  reliable  and  easy  of  employment.  To  two 
or  three  drops  of  Topfer's  solution  of  dimethylamidoazobenzol  are  added 
10  c.c.  of  gastric  contents,  and  a  decinormal  soda  solution  allowed  to 
flow  in,  drop  by  drop,  until  a  yellow  color  takes  the  place  of  the  red. 
The  number  of  c.c  of  solution  of  soda  which  will  neutralize  the  free 
HC1  in  100  c.c.  of  stomach-contents  is  multiplied  by  0.00365.  The 
result  is  the  percentage  of  HC1.  If  4  c.c.  of  soda  solution  is  required 
to  remove  the  red  color,  multiply  0.00365  by  40,  the  number  equals 
0.14  per  cent,  free  hydrochloric  acid. 

4.  Lactic  Acid.  If  the  stomach-contents  are  colorless,  apply  the 
following  tests  ;  if  they  are  yellowish,  make  an  ethereal  extract,  as 
described  below,  and  then  use  the  tests.  Its  presence  may  be  deter- 
mined by  Uffelmann's  reagent  :  Mix  one  drop  of  pure  carbolic  acid 
with  fiye  drops  of  a  dilute  solution  of  neutral  ferric  chloride.  Add 
sufficient  water  to  render  the  whole  of  an  amethyst-blue  color.  To 
this  add  a  few  drops  of  the  gastric  fluid.  A  mere  trace  of  lactic  acid 
will  change  the  blue  to  a  light  yellow  or  greenish  yellow.  The  test 
for  lactic  acid  is  simulated  when  phosphates,  glucose,  or  alcohol  are 
present  in  the  gastric  juice.  The  lactic  acid  should  be  removed  by 
extracting  with  ether,  as  follows  :  50  c.c.  of  gastric  contents  are  re- 
duced to  10  c.c.  by  heat  in  an  evaporating-dish  over  a  water-bath. 
After  the  concentrated  solution  cools  add  50  c.c.  of  ether.  The  vola- 
tile acids  are  driven  off  by  heat,  the  lactic  acid  is  dissolved  by  ether, 
and  hydrochloric  acid  remains  in  the  residue.  Apply  the  test  for  lactic 
acid  to  the  ethereal  extract  if  it  is  acid.  The  following  is  more  deli- 
cate :  Add  one  drop  of  liq.  ferri  perchloridi  to  50  c.c.  of  water  ;  add 
suspected  solution  ;  the  presence  of  lactic  acid  causes  a  yellow  coloration. 

Boas  uses  the  following  :  When  a  substance  containing  lactic  acid 


788  SPECIAL  DIAGNOSIS. 

is  heated  with  oxidizers,  such  as  manganese  dioxide  and  sulphuric  acid, 
the  lactic  acid  is  decomposed  into  formic  acid  and  acetic  aldehyde  ;  the 
latter  is  detected  by  the  formation  of  iodoform  with  an  alkaline  solu- 
tion of  iodine  ;  peptone  and  alcohol,  which  react  similarly,  are  elimi- 
nated by  concentrating  the  filtrate  to  a  syrup.  As  carbohydrates  also 
yield  aldehyde  when  treated  with  oxidizers,  a  watery  solution  of  an 
ethereal  extract  of  the  condensed  gastric  filtrate  of  a  trial-meal  free  from 
lactic  acid  must  be  used. 

Arnold  (Joum.  Am.  lied.  Assoc,  Chicago,  1898,  vol.  viii.  p.  21) 
gives  a  new  test  for  the  detection  of  lactic  acid  in  the  stomach-con- 
tents. 

a.  0.2  c.c.  saturated  alcoholic  solution  of  gentian-violet  in  500  c.c. 
of  distilled  water, 

b.  Tinctura  ferri  perchloridi  (U.  S.  Pharm.,  1890),  5  c.c.  ;  distilled 
water,  20  c.c. 

A  drop  of  solution  b,  added  to  1  c.c.  of  solution  a  in  a  porcelain 
basin,  gives  a  blue  color,  which  changes  to  a  green  or  yellow-green  on 
the  addition  of  a  few  drops  of  filtered  stomach-contents  should  lactic 
acid  be  present. 

5.  The  Volatile  Acids.  These  acids  are  best  detected  by  their 
smell,  their  volatility,  and  their  reaction. 

Butyric  acid  is  recognized  by  the  pungent  odor  of  rancid  butter 
given  off  when  the  stomach-contents  are  evaporated.  It  is  recognized 
by  the  following  reaction  :  To  a  small  quantity  of  the  liquid  add  a 
small  quantity  of  alcohol  and  two  drops  of  strong  sulphuric  acid  ; 
heat  for  a  short  time  ;  a  characteristic  smell  of  butyric  ether,  like  that 
of  "  pineapple  rum,"  is  given  off. 

Butyric  acid  is  also  detected  by  Uffelmann's  reagent.  A  few  c.c.  of 
the  filtered  gastric  fluid  are  shaken  with  three  or  four  times  the  amount 
of  ether.  The  ether  is  poured  off  when  it  rises  on  the  top,  and  fresh 
ether  added  and  the  washing  repeated.  After  the  third  washing  the 
ether  that  cannot  be  poured  off  is  evaporated  by  means  of  a  water- 
bath.  Add  a  few  drops  of  water  to  the  residue  and  then  an  equal 
amount  of  the  reagent.  The  characteristic  color  is  produced.  It 
strikes  a  tawny  yellow  color  with  a  reddish  tinge.  As  much  as  one 
part  of  the  reagent  in  2000  is  required. 

In  addition  to  Uffelmann's  test  the  volatile  acids  may  be  detected 
by  boiling  a  few  c.c.  in  a  test-tube,  over  the  mouth  of  which  blue  lit- 
mus-paper is  attached.  If  acid  is  present,  its  vapor  will  change  the 
blue  to  red.  Acetic  acid  is  recognized  by  its  odor,  particularly  after 
heating  the  solution.  It  may  be  detected  as  follows  :  Secure  an 
ethereal  extract  of  the  gastric  contents  (as  above),  evaporate  in  a  water- 
bath,  and  dissolve  the  residue  in  water.  Neutralize  the  watery  solu- 
tion with  sodium  carbonate,  and  then  add  neutral  ferric  chloride  solu- 
tion.    A  blood-red  color  results  if  acetic  acid  is  present. 

Alcohol  is  detected  by  its  odor  and  by  Lieben's  iodoform-test. 
Distill  the  stomach-contents,  add  to  a  portion  a  small  quantity  of  liquor 
potass®,  and  then  a  few  drops  of  iodine-iodide  of  potassium  solution. 
A  precipitate  of  iodoform  takes  place  slowly  if  alcohol  is  present.  If 
acetone  is  present,  it  forms  rapidly. 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     789 

6.  The  Products  of  Digestiox.  The  ultimate  products  of  diges- 
tion are  the  proteoses  and  peptones.  If  they  are  present  in  the  stomach- 
contents,  it  shows  that  hydrochloric  acid  and  pepsin  must  have  been 
secreted  in  the  stomach.  If  vomiting  occurs  soon  after  food  is  taken, 
or  if  there  is  obstruction  at  the  lower  end  of  the  oesophagus,  these 
products  are  not  present.  Syntonin  is  a  product  of  digestion  which 
precedes  the  two  above  given.  To  ascertain  if  digestion  has  taken 
place,  it  is  necessary  only  to  test  for  syntonin  and  then  employ  the 
biuret  test.  Syntonin  is  detected  by  neutralizing  the  gastric  contents 
with  a  solution  of  sodium  hydrate.  The  precipitate  is  syntonin,  which 
is  soluble  in  an  excess  of  alkali,  and  may  be  again  precipitated  by  an 
alkali.  After  nitration  and  removal  of  the  syntonin,  proteoses  and 
peptone  are  detected  by  the  biuret  test. 

7.  Pepsix.  If  HC1  is  present,  add  5  c.c.  of  a  gastric  filtrate  to  a 
small  piece  of  egg-albumin.  Allow  digestion  to  take  place  for  several 
hours  at  37°  to  40°  C.     Non-digestion  indicates  absence  of  pepsin. 

If  HC1  is  absent,  pepsinogen  is  found  alone.  Add  two  drops  of  a 
25  per  cent.  HC1  solution  to  10  c.c.  of  the  gastric  contents.  Add  to 
this  solution  a  small  portion  of  egg-albumin.  If  it  is  dissolved,  pep- 
sinogen was  converted  into  pepsin  by  HC1. 

8.  Rexxix  (the  milk-curdling  ferment).  This  may  be  detected  as 
follows  :  From  5  to  10  c.c.  of  cow's  milk  of  neutral  reaction  is  boiled  and 
added  to  neutralized  and  filtered  gastric  juice.  Place  the  mixture  on  a 
warm  bath  heated  to  30°  or  40°  C.  The  casein  of  the  milk  is  precipi- 
tated in  flakes  in  from  twenty  to  thirty  minutes  if  the  ferment  is  present. 

9.  The  Carbohydrates.  Add  a  few  drops  of  Lugol's  solution  to 
the  gastric  contents.  If  starch  is  present,  it  turns  blue.  If  erythrodex- 
trin,  it  becomes  purple.  If  the  digestion  has  proceeded  so  far  as  to 
change  starch  into  dextrose,  the  iodine  hue  remains  unchanged.  The 
starches  should  be  completely  digested  an  hour  after  they  are  taken 
into  the  stomach,  hence  in  health  the  iodine  hue  should  not  change  after 
this  time. 

III.  The  Digestive  Power.  Giinzburg  has  introduced  the  use 
of  iodide  of  potassium  in  the  following  way  :  From  three  to  five  grains 
are  placed  in  a  rubber  tube  with  extremely  thin  walls  ;  the  ends  of 
the  tube  are  then  bent  and  brought  into  apposition  with  each  other 
and  fastened  in  that  position  with  three  fibrin  threads  made  firm  by 
preservation  in  alcohol.  The  whole  packet  is  then  pressed  into  an 
empty  gelatin  capsule  and  given  to  a  patient  to  swallow  one-half  hour 
after  a  test-breakfast.  The  saliva  is  tested  for  iodine  every  fifteen 
minutes.  The  more  rapid  the  solution  of  the  capsule  and  fibrin 
threads  the  sooner  the  iodine  can  be  absorbed  and  appear  in  the 
saliva,  and  hence  this  rapidity  is  an  index  of  the  digestive  energy. 

The  method  is  liable  to  fallacies.  Solution  of  the  fibrin  may  take 
place  in  the  intestine  instead  of  the  bowel,  and  the  threads  may  be 
loosened  by  the  acids  of  fermentation  instead  of  by  digestion.  Never- 
theless, the  test  is  a  valuable  one,  especially  when  aspiration  is  inad- 
missible. 

The  digestive  power  can  be  estimated  by  ascertaining  (1)  the  pres- 
ence of  gastric  juice  and  (2)  its  activity. 


790  SPECIAL  DIAGNOSIS. 

1.  The  Gastric  Juice.  Wash  out  the  fasting  stomach  with  400  c.c. 
of  lukewarm  water  ;  test  by  litmus-paper  for  neutrality,  then  inject 
50  c.  c.  of  a  3  per  cent,  solution  of  soda.  Allow  the  solution  to  remain 
twelve  minutes  and  then  remove  by  washing  out  the  stomach  with 
400  c.c.  of  water.  If  the  HC1  secretion  is  normal,  the  soda  solution 
is  neutralized.  If  it  is  deficient,  the  solution  remains  alkaline.  The 
presence  of  pepsin  is  then  to  be  determined. 

2.  The  Activity  of  the  Gastric  Juice.  The  white  of  one  or  two  eggs 
should  be  boiled  in  four  ounces  of  water  and  then  administered. 
Remove  the  stomach-contents  one-half  hour  later.  The  stomach  should 
be  emptied  by  lavage  beforehand.  The  residue  removed  will  show 
if  digestion  is  complete,  and  proteoses  and  peptones  may  be  tested  for 
by  the  biuret  reaction. 

Test  for  the  Activity  of  the  Gastric  Juice  and  of  the  Movements  by  a 
Test-meal.  Ewald's  test-breakfast  must  be  employed  if  the  patient 
cannot  bear  more  solid  food,  otherwise  Leube's  test-meal  should  be 
used.  If  digestion  is  normal,  the  stomach-contents  removed  from  five 
to  seven  hours  after  a  test-meal  are  neutral  and  contain  a  few  flakes  of 
mucus.  At  the  end  of  five  hours  the  stomach-contents  are  acid  and 
contain  peptone,  some  undigested  muscle-fibres,  and  starch-grains.  If 
the  stomach  contains  undigested  food  at  the  end  of  seven  hours,  the 
contents  are  acid  and  contain  peptones,  indicating  delay  in  digestion. 

IV.  The  Motor  Power.  Ewald  and  Sievers  have  suggested  the 
use  of  salol ;  fifteen  grains  are  given,  and  normally  salicylic  acid 
should  be  detected  in  the  urine  in  from  forty  to  sixty  minutes,  or  in 
seventy-five  minutes  at  the  latest.  If  it  is  deferred  still  longer,  motor 
insufficiency  is  indicated.  The  sign  is  of  value  only  when  the  excre- 
tion is  delayed.  Urine  containing  salicylic  acid  gives  a  dark,  brown- 
ish-red color  upon  the  addition  of  a  drop  of  tincture  of  the  chloride  of 
iron. 

Klemperer's  oil-test  is  more  accurate,  although  disagreeable.  One 
hundred  grammes  of  oil  are  placed  in  the  stomach  by  the  stomach- 
tube.  In  two  hours  the  stomach-contents  are  removed  by  aspirating, 
previously  adding  a  little  water.  The  amount  of  oil  is  dissolved  by 
ether,  the  solution  evaporated,  and  the  residuum  of  oil  weighed.  Sev- 
enty-five to  eighty  per  cent,  of  the  oil  should  be  discharged  in  two 
hours. 

V.  The  Absorptive  Power.  Penzoldt  and  Faber  recommend  the 
administration  of  three  grains  of  chemically  pure  iodide  of  potassium 
— i.  e.,  free  from  iodic  acid — a  short  time  before  dinner.  Any  frag- 
ments of  free  iodine  adhering  to  the  iodide  of  potash  are  first  carefully 
washed  away.  The  saliva  is  tested  for  iodine  with  starch-paper  and 
fuming  nitric  acid.  If  absorption  is  active,  a  violet  color  is  obtained 
in  from  six  and  one-half  to  eleven  minutes,  and  a  blue  color  in  from 
seven  and  one-half  to  fifteen  minutes.  Zweifel  directs  that  3  grains 
(0.2  gramme)  of  iodide  of  potassium  be  administered  in  a  gelatin  cap- 
sule, and  3|  oz.  of  water  (100  c.c.)  taken  ;  iodine  is  detected  in  about 
eight  minutes  in  the  saliva.  The  character  of  the  food  taken  is  said 
to  have  considerable  influence  in  retarding  the  appearance  of  the  reac- 
tion, so  that  the  blue  reaction  may  not  appear  for  forty-five  minutes. 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     791 

Boas  states  that  in  dilatation  of  the  stomach  the  reaction  may  be  de- 
layed to  two  hours,  and  in  cancer  as  long  as  eighty-two  minutes. 
Both  motor  and  absorptive  power  are  recognized  also  by  digestive  delay. 

Clinical  Value  of  a  Chemical  Examination  of  the  ^romitus  or  Stomach- 
contents.  It  cannot  be  gainsaid  that  the  chemical  examination  of  the 
stomach-contents  is  of  the  utmost  clinical  value.  It  is  just  as  certain, 
however,  that  the  results  attained  by  such  examination  should  not  be 
final  in  the  formation  of  a  diagnosis  ;  that  alone  they  do  not  meet  the 
expectations  of  clinicians.  This  is  particularly  so  when  we  attempt  to 
deduce  a  scientific  therapeusis  from  such  examination.  To  rely  upon 
the  results  of  such  examination  alone  would  lead  to  failure.  The  diag- 
nosis, and,  therefore,  the  rational  therapeusis,  must  rest  not  alone  upon 
a  chemical  examination,  but  also  upon  other  methods  of  examination 
of  stomach-contents,  the  physical  examination  of  the  stomach,  the  his- 
tory and  progress  of  the  case,  and  the  subjective  symptoms.  In  short, 
a  general  view  must  be  taken,  and  all  methods  of  inquiry  employed. 

Diseases  of  the  stomach  require  for  their  correct  estimation  broader 
lines  of  investigation  than  almost  any  other  organ  of  the  body.  More- 
over, the  practitioner  must  not  be  discouraged  if  he  cannot  employ 
chemical  methods  with  the  skill  of  the  laboratory  expert.  The  simple 
methods  detailed  above  can  be  conducted  by  any  educated  physician. 
For  practical  purposes,  it  is  only  necessary  to  determine  the  total  acid- 
ity, the  presence  of  free  acids,  the  presence  of  free  HC1,  the  presence 
of  lactic  acid  and  of  the  volatile  acids. 

Finally,  the  clinician  must  not  be  discouraged  if  the  stomach- 
contents  cannot  be  secured,  on  account  of  the  contraindications  pre- 
viously detailed.  An  approximate  diagnosis — probably  not  so  precise 
or  final — can  usually  be  made  by  means  of  a  physical  examination  of 
the  stomach  and  a  consideration  of  the  symptoms. 

The  results  of  the  chemical  examination  have  the  clinical  value 
estimated  herewith.  In  the  first  place,  we  find  whether  the  acidity 
is  increased  or  diminished. 

1.  Diminished  acidity,  or  anacidity,  means  deficiency  in  the  amount 
of  HC1  secreted.  Diminished  acidity  may  be  due  to  functional  or 
organic  disease  of  the  stomach.  It  occurs  in  fever,  in  chlorosis,  and 
pernicious  anaemia,  chronic  wasting  diseases,  including  tuberculosis, 
and  acute  infectious  diseases  from  functional  disturbance  of  nervous  or 
hgemic  origin.  It  occurs  in  chronic  dyspepsia  from  irregularities  in 
diet.  It  is  also  deficient  in  congestion,  acute  catarrh  or  atrophy  of  the 
mucous  membranes,  and  in  carcinoma,  which  apparently  modifies  gas- 
tric secretion. 

2.  Increased  acidity  may  be  due  to  an  increase  of  hydrochloric  acid 
— hyperacidity,  or  to  an  increase  of  the  organic  acids — increased  acidity. 
a.  Hypersecretion  of  HC1  takes  place  in  the  early  stages  of  gastric 
irritation — dyspepsia.  It  may  be  increased  in  gastric  ulcer,  b.  In- 
creased acidity  (organic  acids)  may  be  due  to  excess  of  (1)  lactic  acid  ; 
(2)  of  butyric  acid,  and  (3)  of  acetic  acid.  Excess  of  lactic  acid  is  due 
to  fermentation  of  carbohydrates  from  the  growth  of  the  bacillus  acidi 
lactici  or  bacillus  lactis  aerogenes  ;  of  butyric  acid,  to  butyric  acid 
fermentation  ;  of  acetic  acid,  to  alcoholic  fermentation  of  the  above- 


792  SPECIAL  DIAGNOSIS. 

mentioned  class  of  foods.  Alcoholic  fermentation  is  often  due  to  the  sar- 
cinse.  In  short,  these  acids  result  from  bacterial  fermentation,  a  process 
which  takes  place  only  when  there  is  delayed  motor  power,  or  when 
the  normal  antiseptic — the  HC1 — is  absent  or  diminished.  Hence,  we 
find  these  acids  in  weakness  of  the  muscles,  as  in  dilatation,  in  organic 
obstruction  of  the  pylorus,  and  in  cancer  of  the  stomach  ;  while  the 
bacteria  are  found  on  microscopical  examination. 

3.  Free  hydrochloric  acid  is  diminished  in  acute  and  chronic  catarrh 
of  the  stomach  (gastritis),  in  chronic  dyspepsia,  in  ulcer  of  the  stomach 
and  duodenum,  in  gastric  atrophy,  in  dilatation,  in  gastric  carcinoma 
(early  stage),  and  from  all  general  causes  which  lessen  the  total  acid- 
ity, including  diabetes  and  Addison's  disease.  Of  course,  deficiency 
of  hydrochloric  acid  means  deficiency  of  functional  activity,  and  goes 
hand-in-hand  with  diminished  motor  and  absorptive  power.  The  acid 
is  increased  in  the  early  stages  of  irritative  dyspepsia  and  in  ulcer  of 
the  stomach,  and  at  different  periods  in  the  gastric  neuroses.  The 
most  common  causes  of  increase  of  HC1  are  the  gastric  neuroses. 
Hydrochloric  acid  is  absent  entirely  in  advanced  chronic  gastritis  and 
in  the  gastric  neuroses.  In  the  former  there  are  evidences  of  fermen- 
tation. HC1  is  often  absent  in  cancer,  but  unless  constantly  absent, 
and  two  or  more  other  facts  of  value  can  be  secured,  the  diagnosis 
cannot  be  made  on  the  chemical  examination  alone. 

4.  Lactic  acid.  Its  presence  points  to  fermentation,  hence  it  is  asso- 
ciated with  lesions  that  are  accompanied  by  bacterial  fermentation. 

It  is  present  in  carcinoma,  as  pointed  out  by  Boas.  Fermentation 
is  not  the  only  condition  in  which  it  occurs.  It  is  nearly  always  found 
after  a  meal  of  meat,  and  is  known  as  sarcolactic  acid.  It  may  occur  in 
chronic  catarrhal  gastritis.  In  cancer  of  the  stomach  lactic  acid  is  the 
most  common  objective  sign.  Its  absence  does  not  exclude  carcinoma. 
It  may  be  detected  before  a  tumor  is  palpable.  Therefore,  if  lactic 
acid  is  present  and  free  HC1  absent,  cancer  can  be  pretty  safely  diag- 
nosticated, particularly  if  stagnation  of  stomach-contents  is  also  pres- 
ent. Boas  recommends  a  meal  which  will  not  yield  sarcolactic  acid. 
It  consists  of  one  to  two  litres  of  oatmeal  gruel,  to  which  a  little  salt 
may  be  added.  It  should  be  removed  by  expression  one  hour  after  it 
has  been  taken.  It  is  well  to  remove  all  food  by  lavage  six  hours 
before  the  test-meal  is  given. 

The  clinical  value  of  the  remaining  chemical  tests  and  investigations 
need  not  be  explained.  They  indicate  inability  of  the  gastric  function 
to  accomplish  digestion,  but  do  not  point  to  any  special  gastric  affec- 
tion. They  are  of  value  in  distinguishing  between  gastric  neuroses  and 
an  organic  disease.  In  both  there  are  pronounced  gastric  symptoms  ; 
if  the  examination  shows  normal  digestive  powers,  a  neurosis  is  indi- 
cated. 

Gastric  Hemorrhage.  Hemorrhage  of  the  stomach,  ho?.mateme- 
sis,  or  vomiting  of  blood,  is  due  to  an  organic  lesion,  or  the  effects  of 
acute  irritant  poisoning.  The  blood  is  vomited.  Care  must  be  taken 
to  see  that  the  blood  is  not  from  the  upper  air-passages,  and  previously 
swallowed.  If  hemorrhage  is  profuse,  the  blood  may  cause  irritation 
of  the  larynx,  and  provoke  paroxysms  of  coughing.     It  is  often  diffi- 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     793 

cult,  therefore,  to  distinguish  between  hemorrhage  from  the  lungs  and 
hemorrhage  from  the  stomach. 


H-EITATEMESIS. 

1.  Previous   history   points   to   gastric, 
hepatic,  or  splenic  disease. 

2.  The  blood  is  brought  up  by  vomiting, 
prior  to  which  the  patient  may  experience 


HiEMOPTYSIS. 

1.  Cough  or  signs  of  some  pulmonary 
or  cardiac  disease  precedes,  in  many  cases, 
the  hemorrhage. 

2.  The  blood  is  coughed  up,  and  is  usu- 
ally preceded  by  a  sensation  of  tickling  in 


a  feeling  of  giddiness  or  faintness.  ;  the  throat.     If  vomiting  occurs,  it  follows 

!  the  coughing. 

3.  The  blood  is  usually  clotted,  mixed  3.  The  blood  is  frothy,  bright  red  in 
with  particles  of  food,  and  has  an  acid  re-  ;  color,  alkaline  in  reaction.  If  clotted,  it  is 
action.  It  may  be  dark,  grumous,  and  rarely  in  such  large  coagula,  and  muco- 
fluid.  pus  may  be  mixed  with  it. 

4.  Subsequent  to  the  attack  the  patient !  4.  The  cough  persists,  physical  signs  of 
passes  tarry  stools,  and  signs  of  disease  of !  local  disease  in  the  chest  may  usually  be 
the  abdominal  viscera  may  be  detected.        |  detected,   and   the   sputa  may   be   blood- 

|  stained  for  many  days.  (  Osler.  ) 

The  hemorrhage  may  continue  within  the  stomach  without  exciting 
vomiting.  The  general  symptoms  of  hemorrhage  may  appear,  first,  as 
pallor,  dimness  of  vision,  giddiness,  or  faintness.  The  blood  which 
conies  from  the  stomach  is  usually  acted  upon  by  the  gastric  juice,  and 
is  dark,  clotted,  and  partly  digested.  It  is  often  mixed  with  food. 
Its  reaction  is  acid.  In  large  hemorrhages  the  blood  may  be  fluid 
and  of  a  scarlet  color  ;  but  if  retained  for  any  length  of  time,  it  is 
coagulated.  The  vomited  matter  has  the  appearance  of  coffee-grounds, 
when  there  is  a  small  amount  of  blood.  When  large  in  amount  and 
digested,  it  appears  like  tar. 

Vomiting  is  usually  followed  by  movements  of  the  bowels.  The 
matter  discharged  is  of  characteristic  appearance.  It  is  black  or  tarry. 
It  is  distinguished  from  hemorrhage  of  the  intestinal  canal  below  the 
duodenum  by  the  color  of  the  blood.  In  intestinal  hemorrhage  the 
blood  is  dark  red,  and  not  necessarily  tarry.  The  dark  stools  must  not 
be  confounded  with  the  same  character  of  stools  seen  when  iron  or 
bismuth  is  taken.  In  rare  instances  a  hemorrhage  into  the  stomach 
may  take  place  from  disease  of  the  lower  part  of  the  oesophagus. 

Causes.  1.  General  diseases,  from  changes  in  the  blood,  cause  gas- 
tric hemorrhage,  as  scurvy,  purpura,  hemorrhagic  smallpox,  yellow 
fever,  acute  yellow  atrophy  of  the  liver,  and  severe  anaemia,  leukaemia, 
Hodgkin's  disease,  and  pernicious  anaemia.  2.  Ulcer  of  the  stomach. 
3.  Cancer  of  the  stomach.  4.  Ulcer  of  the  duodenum.  5.  Portal 
congestion,  as  in  cirrhosis  of  the  liver,  and  other  forms  of  chronic 
hepatic  disease.  6.  Disease  of  the  spleen.  7.  Congestion  due  to  dis- 
ease of  the  heart.  8.  In  chronic  Bright' s  disease  with  atheroma.  9. 
Rupture  in  aneurism.  10.  Vicarious  menstruation.  11.  Cohen  asserts 
that  it  occurs  in  vasomotor  ataxia. 

Profuse  and  sudden  hemorrhage,  in  the  absence  of  well-marked 
symptoms  of  disease,  is  in  nearly  all  cases  due,  either  to  latent  ulcer, 
or  to  congestion  of  the  stomach  from  early  cirrhosis  of  the  liver. 

General  Examination.  The  objective  examination  has  thus  far 
been  confined  to  a  study  of  the  stomach.  The  student  will  infer  from 
the  previous  chapters  that  in  order  that  on  the  one  hand  the  possible 


794  SPECIAL  DIAGNOSIS. 

cause  of  the  gastric  disorder  may  be  determined,  or,  on  the  other,  the 
effect  of  gastric  disorder  upon  the  other  organs  ascertained,  they  must 
be  examined  carefully.  Moreover,  valuable  data  in  the  recognition  of 
gastric  affections  and  the  diagnosis  of  the  various  forms  are  secured  by 
such  examination.  The  general  appearance  of  the  patient,  the  state  of 
nutrition,  and  the  degree  of  strength  furnish  suggestive  facts  in  the 
diagnosis.     As  well  said  by  Stockton  : 

"  The  preoccupied  and  dejected  manner  observed  in  those  suffering 
from  continued  gastric  flatulency  ;  the  restless,  discomposed  behavior, 
the  stooped  posture  and  half -surprised  expression  often  seen,  in  the 
victims  of  gastralgia  ;  the  emaciated,  weak,  and  cachectic  appearance 
frequently  accompanying  chronic  food  stagnation,  are  good  examples 
of  the  value  of  the  general  appearance  in  the  diagnosis." 

It  must  be  remembered  that  any  local  source  of  irritation  distant 
from  the  stomach,  as  the  eyes,  the  nose  and  pharynx,  the  uterus  and 
ovaries,  and  the  rectum,  may  be  the  primary  cause  of  gastric  disorder. 
The  study  of  the  hepatic  and  intestinal  functions  assist  in  the  diag- 
nosis. Examination  of  the  urine  and  the  blood  may  enable  us  to 
determine  the  nature  of  a  gastric  morbid  process.  Even  the  study  of 
the  skin  is  of  importance. 

"  A  sallow,  earthy-colored  skin,  showing  improper  secretion  ;  a  dry, 
harsh  skin,  with  too  rapid  loss  of  epithelium,  showing  poor  nutrition  ; 
a  skin  showing  oedema,  poor  capillary  circulation,  lividity,  or  acne  ; 
certain  forms  of  eczema,  excess  of  pigment,  or  syphilides  may  afford 
important  information  as  to  the  digestion,  inasmuch  as  some  of  these 
may  be  the  results  and  others  accompaniments  of  gastric  disturbance  " 
(Stockton). 

The  Blood.  Examination  of  the  blood  enables  us  to  determine 
the  degree  of  anaemia  Avhich  may  be  the  cause  of  digestive  failure. 
The  examination  must  be  exhaustive.  If  a  leucocytosis  is  present,  the 
gastric  neuroses  may  be  excluded.  In  carcinoma  there  is  not  only  a 
severe  secondary  anaemia,  but  also  poikilocytosis  and  a  multinuclear 
leucocytosis.  Such  changes  are  without  doubt  the  result  of  interference 
with  the  digestion  because  of  motor  inactivity.  Moreover,  certain 
gastric  diseases  have  specific  effects  upon  the  blood.  Gastric  ulcer 
may  be  distinguished  from  gastric  carcinoma,  by  the  fact  that  digestive 
leucocytosis  occurs  in  the  former  while  it  is  absent  in  the  latter. 

The  Urine.  No  study  of  a  gastric  disorder  is  complete  without 
an  exhaustive  examination  of  the  urine.  For  diagnostic,  but  chiefly 
for  therapeutic  purposes,  the  presence  of  renal  insufficiency,  hyper- 
lithuria,  indicanuria,  glycosuria,  peptonuria,  and  albuminuria  must  be 
tested  for. 

The  Reaction.  The  reaction  of  the  urine  is  modified  by  the  state  of 
the  stomach.  In  health  the  urine  is  alkaline  after  a  full  meal  of  ordi- 
nary character.  When  HC1  is  absent  from  gastric  contents,  this  normal 
alkalinity  does  not  occur.  Alkalinity  is  rarely  seen  in  gastric  carci- 
noma. 

The  Chlorides.  The  chlorides  are  lessened  when  a  small  amount  of 
food  is  taken  ;  a  similar  cause  lessens  the  amount  of  urea.  Both  are 
decreased  in  carcinoma  and  in  benign  diseases  of  the  stomach.     But 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     795 

the  chlorides  are  diminished  in  carcinoma  without  a  proportionate 
lessening  of  the  urea.  It  is  this  disproportion  which  is  of  diagnostic 
value,  as  pointed  out  by  Nothnagel,  in  carcinoma  ventriculi. 


Diseases  of  the  Stomach  Characterized  by  Fever,  with  Pain  and 

Vomiting. 

Acute  Gastritis.  The  simple  variety  of  acute  gastritis  varies 
according  to  the  cause,  from  a  slight  attack  of  vomiting  after  indiscre- 
tion in  diet,  with  ordinary  symptoms  of  indigestion,  to  the  more  severe 
forms  ushered  in  by  chill  and  attended  with  fever. 

In  the  mild  forms  there  is  a  sense  of  fulness  and  discomfort  in  the 
epigastrium,  attended  with  nausea.  The  appetite  is  lost,  and  there 
may  be  disgust  for  food,  and  the  flow  of  saliva  is  increased.  There  is 
undue  acidity.  On  examination  the  epigastrium  is  found  to  be  tender. 
The  onset  of  the  attack  is  attended  with  giddiness,  flashes  of  light 
before  the  eyes,  frontal  headache,  and  some  prostration.  The  pulse  is 
increased  in  frequency.  When  this  nausea  is  most  pronounced  the 
face  is  pale  and  the  extremities  cold.  Vomiting  then  occurs,  the 
matter  ejected  consisting  of  ingesta  only  slightly  changed,  with  mucus 
and  watery  fluid.  It  is  very  bitter.  It  is  often  colored  green  from 
bile-pigment.  Another  attack  of  vomiting  may  be  sufficient  to  give 
relief,  or  it  may  be  repeated  for  twenty-four  to  forty-eight  hours  every 
hour  or  two.  After  the  stomach  is  relieved  of  food,  mucus  and  bile 
alone  are  vomited. 

Examination  of  Stomach-contents.  The  reaction  of  the  vomited 
matter  is  neutral  or  faintly  acid.  No  free  hydrochloric  acid  is  present, 
but  later  lactic  and  fatty  acids  are  found.  Pepsin  is  diminished  in 
quantity. 

Twelve  to  twenty-four  hours  after  the  gastric  symptoms  intestinal 
symptoms  may  arise.  Borborygmi  and  colicky  pains  are  complained 
of,  followed  by  diarrhoea,  with  some  tenesmus. 

Herpes  labialis  may  occur,  and  some  writers  speak  of  a  peculiar 
odor  which  is  exhaled  from  the  skin.  The  more  severe  cases  are 
ushered  in  with  chill  followed  by  fever.  The  local  symptoms  are 
much  aggravated.  The  tongue  is  furred,  and  the  breath  foul.  The 
vomiting  is  frequent  and  severe.  The  skin  is  livid  and  the  pulse  be- 
comes rapid. 

Diagnosis.  In  the  acute  cases  attended  by  fever  it  may  be  mistaken 
for  meningitis,  peritonitis,  or  hepatitis.  The  same  gastric  symptoms 
may  usher  in  an  attack  of  pneumonia.  The  possibilities  of  a  mistake 
are  to  be  borne  in  mind,  and  in  all  cases  of  vomiting  with  fever  due 
regard  must  be  paid  to  the  possibility  of  the  gastric  symptoms  being 
symptomatic  only.  It  must  be  borne  in  mind  that  the  same  group 
of  symptoms  that  belong  to  gastritis  accompanies  the  exanthematous 
diseases,  and  diphtheria,  dysentery,  pyaemia,  and  puerperal  fever. 
They  may  be  of  reflex  origin,  or  due  to  the  action  of  fever,  poison,  or 
ptomaines  on  the  stomach.  Ewald  calls  it  sympathetic  gastritis  when 
the  symptoms  are  the  same  as  in  the  simple  variety,  masked,  however, 


796  SPECIAL  DIAGNOSIS. 

by  the  primary  disease.  Sometimes,  however,  as  in  the  eruptive 
fevers,  attention  is  directed  to  the  state  of  the  stomach,  to  the  exclusion 
of  other  conditions.  And  often,  to  the  surprise  of  the  student,  an  erup- 
tion or  inflammation  ensues,  which  indicates  the  true  nature  of  the  case. 

In  cases  of  gastritis,  therefore,  endeavor  to  find  a  local  cause  for  the 
symptoms.  If  there  is  no  history  of  indiscretions  in  diet,  of  exposure, 
of  exhaustion,  or  mental  shock,  on  account  of  which  digestion  might 
be  arrested,  then  inquire  for  a  history  of  exposure  to  contagious  dis- 
eases and  look  for  the  earlier  evidences  of  exanthemata.  If  the  result 
of  the  examination  is  still  unsatisfactory,  examine  the  condition  of 
each  individual  organ,  particularly  bearing  in  mind  meningitis,  pneu- 
monia, peritonitis,  nephritis,  and  general  infections. 

Mycotic  and  diphtheritic  gastritis  occur  secondarily  to  typhoid  fever, 
pneumonia,  pyaemia,  smallpox,  and  sometimes  diphtheria.  The  mucous 
membrane  may  be  covered  with  patches  in  areas  or  throughout  its 
whole  extent. 

Some  special  micro-organisms  irritate  the  gastric  mucosa,  as  the 
anthrax  bacillus  and  the  sarcinse  and  yeast  fungi  in  cancer  and  dilata- 
tion of  the  stomach.  Rarely  tuberculous  inflammation  with  ulceration 
takes  place,  and  other  micro-organisms  have  been  described.  Klebs 
found  the  bacillus  gastricus  with  numerous  spores  in  the  tubules,  as 
a  consequence  of  which  a  gastritis  was  set  up. 

The  mucous  membrane  itself  escapes  infection  from  micro-organisms, 
because  of  the  character  of  its  secretion.  The  acid  gastric  juice  is 
antagonistic  to  and  causes  the  death  of  micro-organisms.  Tuberculo- 
sis, for  instance,  rarely  attacks  the  stomach  for  this  reason. 

Phlegmonous  Gasteitis.  This  is  a  very  rare  affection,  in  which 
the  inflammation  is  seated  in  the  submucosa  and  leads  to  perforation. 
The  onset  is  sudden.  The  chief  local  symptom  is  intense  pain  in  the 
epigastrium,  with  a  burning  sensation.  There  are  great  acidity,  dry 
tongue,  and  absolute  anorexia.  The  fever  is  high  and  characterized 
by  delirium.  Chills  usually  accompany  it.  The  pulse  is  small,  rapid, 
and  irregular.  The  matters  vomited  are  first  mucus,  then  pus.  The 
patient  is  extremely  restless  and  anxious,  even  delirious,  and  early 
passes  into  coma.  Death  takes  place  from  collapse.  It  is  impossible 
to  make  an  absolute  diagnosis,  as  local  peritonitis  and  abscess  of  the 
liver  are  characterized  by  the  same  symptoms.  In  abscess  a  tumor 
may  form  in  the  epigastrium.  It  may  occur  idiopathically,  but  it  fre- 
quently occurs  in  septicaemia,  and  follows  trauma. 

Toxic  Gasteitis.  This  form  of  gastritis  is  allied  to  the  former  in 
the  severity  of  general  symptoms.  It  is  the  result  of  the  swallowing  of 
irritating  poisons,  of  which  phosphorus,  arsenic,  bichloride  of  mercury, 
and  caustic  acids  and  alkalies  are  the  most  common.  It  is  attended  by 
inflammation  of  the  mouth,  oesophagus,  and  stomach.  There  are  sali- 
vation and  dysphagia,  and  constant  vomiting  of  blood,  often  with  shreds 
of  mucous  membrane.  The  patient  is  restless,  and  may  have  convul- 
sions ;  collapse  readily  develops.  In  mild  cases,  in  which  the  local 
effects  of  the  corrosive  substance  have  been  mitigated  by  proper  anti- 
dotes, sloughs  occur,  leaving  behind  ulcers  on  the  mucous  membrane, 
which,  after  healing,  result  in  deformity  or  stenosis  of  the  oesophagus. 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     797 

Some  cases  are  attended  by  other  symptoms  peculiar  to  the  special 
poison.  Thus  with  arsenic  there  are  choleraic  symptoms  ;  in  phos- 
phorus-poisoning the  symptoms  come  on  late  after  its  ingestion,  and 
are  attended  by  jaundice  and  symptoms  of  acute  yellow  atrophy. 

Diseases  of  the  Stomach  Characterized  by  Indigestion. 

Functional  Disorders  of  the  Stomach.  The  Neuroses.  Func- 
tional disturbances  of  the  stomach  are  due  to  impairment  of  the  motor 
power  of  the  stomach,  impairment  of  the  secretory  function  and  of  the 
sensory  function.  The  following  table  of  Ewald,  as  given  by  that 
distinguished  authority,  is  a  classification  of  the  various  neuroses  mid- 
way between  the  symptomatic  and  the  etiological  : 

The  Neuroses  of  the  Stomach. 

1.  Conditions  of  Irritation. 

a.  Sensory.  b.   Secretory.                        c.   Motor. 

Hyperesthesia.  Hyperacidity.           Eructation. 

Nausea.  Hypersecretion.        Pyrosis. 

Hyperorexia.  Vomiting. 

Anorexia  ex  hyperesthesia.  Colic. 

Parorexia.  Tormina  ventriculi. 
Gastralgia. 

2.  Conditions  of  Depression. 

Polyphagia.  Anacidity.  Atony. 

Anaesthesia.  Insufficiency  of  the  pylorus  and 

cardia. 
3.  Mixed  Form. 
Gastro -intestinal  neurasthenia  (dyspepsia  nervosa). 
4.  Keflexes  from  Other  Organs  upon  the  Gastric  Nerves. 

Reflexes  from  the  brain,  eyes,  spinal  cord,  kidneys,  liver,  sexual  organs,  and 
intestines  manifest  themselves  in  the  forms  mentioned  in  1  and  2. 

It  must  not  be  supposed  that  each  of  the  above-named  symptoms 
occur  in  an  individual,  or  that  functional  disturbances  may  be  limited 
to  alterations  of  the  sensory  and  secretory  or  the  motor  apparatus,  re- 
spectively. They  do  not  occur,  as  Ewald  states,  as  distinct  indepen- 
dent diseases,  but  usually  in  groups,  "  either  appearing  simultaneously 
or  closely  following  one  another  during  the  course  of  the  malady,  pass- 
ing before  us  like  an  ever-changing  scene."  They  may  arise  directly 
from  disease  of  the  stomach,  or  reflexly  from  disease  of  other  organs, 
as  the  brain,  the  spinal  cord,  uterus,  kidneys,  liver,  eyes,  and  nose. 

Etiology.  Gastric  neuroses  are  of  most  frequent  occurrence  in 
women,  especially  during  the  years  from  puberty  to  the  menopause. 
The  accidents  of  childbirth  are  predisposing  factors.  In  both  sexes 
they  are  of  most  frequent  occurrence  after  the  age  of  twenty  years, 
because  individuals  are  subjected  to  causes  which  lead  to  neuroses  at 
this  period  of  life.  The  gastric  neuroses  occur  in  all  conditions  of 
patients.  They  are  more  likely  to  occur  in  those  who  are  poorly  nourished 
or  anaemic ;  although  persons  who  are  distinctly  robust  may  also  suffer. 
While  more  common  in  the  residents  of  cities,  they  may  occur  in 
farmers  and  others  accustomed  to  an  open-air  life.     Although  we  are 


798  SPECIAL  DIAGNOSIS. 

oftenest  called  upon  to  treat  them  among  the  better  classes,  neverthe- 
less a  large  number  of  cases  are  seen  among  the  poor.  To  analyze 
more  closely  the  predisposing  causes,  we  have  to  study  individually 
all  conditions  and  circumstances  in  life  which  lead  to  wear  and  tear, 
as  in  business  or  social  affairs.  The  causes  which  Beard  and  others 
have  forcibly  pointed  out  as  factors  in  the  production  of  neurasthenia 
are  especially  prevalent  in  this  country. 

In  men,  excessive  devotion  to  business,  or  dissipation  ;  in  women, 
excesses  in  social  life,  or  the  restraint  of  home  cares,  with,  unhappily, 
too  often,  the  irritation  of  marital  relations,  are  the  predisposing 
factors  which  lead  to  the  development  of  this  class  of  cases.  Often 
patients  in  the  large  cities  are  subject  to  the  neuroses  in  the  spring 
after  the  dissipations  of  the  winter.  Behind  this  excess  there  is,  no 
doubt,  in  the  majority  of  cases,  a  nervous  temperament  that  is  respon- 
sible for  the  bringing  out  of  the  symptoms,  particularly  if,  combined 
with  this  temperament,  the  patients  live  in  an  unhygienic  way  in 
regard  to  exercise,  ventilation  of  their  dwelling-places,  and  drainage, 
combined  with  improper  diet. 

Symptoms.  With  the  gastric  neuroses  other  symptoms  of  neurasthe- 
nia are  present,  and  the  patient  may  seek  advice  for  these  symptoms, 
such  as  headaches  of  various  kinds,  changes  in  the  mental  condition, 
vertigo,  insomnia,  neuralgias,  and  all  forms  of  paresthesia.  Intimately 
connected  with  the  neurasthenic  state  is  that  of  hysteria,  and  therefore 
in  gastric  neuroses  hysterical  manifestations  are  most  common.  It  may 
be  impossible  completely  to  define  the  border-line  between  neurasthe- 
nia and  hysteria,  and  the  gastric  symptoms  of  the  former  are  the  gas- 
tric symptoms  of  the  latter.  While,  therefore,  general  neurasthenic 
symptoms  are  prominent,  in  order  to  reach  a  diagnosis  upon  which 
proper  lines  of  treatment  can  be  based,  the  condition  of  the  individual 
must  be  viewed  as  a  whole,  and  no  one  symptom  or  group  of  symptoms 
exaggerated  in  our  minds. 

Varieties.  Ewald  has  divided  the  neuroses  into  those  which  arise 
from  («)  irritation,  those  which  arise  from  (b)  depression,  and  (c)  those 
in  which  both  are  combined — mixed  neuroses. 

(a)  1.  Sensory  Neuroses  of  Irritation.  Hypek.esthesia.  The 
first  result  of  irritation  is  hyperesthesia  of  the  stomach,  which  is  indi- 
cated by  a  feeling  of  fulness  and  tension,  and  of  nausea.  The  sensation 
is  allied  to  the  normal,  and  is  also  seen  in  chronic  gastritis,  as  well  as 
in  hysteria,  meningeal  irritation,  cerebral  tumors,  and  other  diseases 
of  the  nervous  system.  The  increased  irritability  is  such  that  the 
gentlest  irritant  excites  discomfort  or  a  painful  sensation.  There  is  a 
continuous  sensation  of  heat  or  cold,  of  gnawing,  or  pulling,  or  burning 
in  the  organ.  The  local  sensation  reflexly  influences  the  physical  life 
of  the  patient,  so  that  hypochondriasis  in  some  form  attends  it.  The 
sensations  may  be  relieved  by  food,  to  become  worse  if  the  stomach  is 
emptied,  although  in  the  larger  number  of  cases  the  trouble  is  aggra- 
vated during  digestion.  The  sensations  are  likely  to  be  aggravated  by 
fasting  a  longer  period  than  usual,  or  by  restriction  of  the  diet.  Ex- 
cesses may  aggravate  them,  and,  on  the  other  hand,  they  are  said  to 
follow  debilitating  states.     Some  foods,  such  as  shell-fish,  crabs  and 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     799 

lobsters,  or  oysters,  and  strawberries,  are  likely  to  increase  the  peculiar 
sensations  in  the  epigastrium,  exciting  mild  depression,  or  burning,  or 
even  nausea.  The  excitation  from  these  foods  is  usually  due  to  pecu- 
liar idiosyncrasies  of  the  individual.  On  account  of  the  same  idiosyn- 
crasies, pruritus,  erythema,  and  urticaria  occur,  with  headache  and 
some  fever. 

Deviations  from  the  Sense  of  Hunger.  Hyperorexia. 
When  hunger  is  exaggerated  it  is  known  as  boulimia,  or  hyperorexia. 
It  may  be  temporary  or  permanent.  When  permanent  it  is  obstinate, 
weakening,  and  exceedingly  unpleasant.  It  may  occur  alone  or  be  a 
symptom  of  various  diseases  of  the  nervous  system,  as  manifest  disease 
of  the  brain,  neurasthenia,  hysteria,  and  psychoses.  It  complicates 
such  disorders  as  diabetes,  and  may  be  of  temporary  duration  in  con- 
valescence from  acute  disease.  The  disorder  accompanies  migraine,  or 
hypochondriasis,  and  exophthalmic  goitre.  Analogous  to  it  is  perver- 
sion of  the  appetite,  as  seen  in  pregnancy,  in  children,  and  in  mental 
disorders. 

Anorexia.  Loss  of  appetite,  or  repugnance  to  food.  In  the  first 
instance,  there  is  simply  loss  of  appetite  ;  in  the  second,  there  is  repug- 
nance toward  food,  or  nausea  at  the  sight  of  it.  Loss  of  appetite 
accompanies  dyspepsia  in  all  forms.  In  the  gastric  neuroses  it  occurs 
spontaneously,  or  is  due  to  hyperesthesia  of  the  stomach,  and  therefore 
may  arise  from  central  or  peripheral  conditions  of  irritation.  It  is 
•commonly  seen  following  central  nerve  perturbation.  The  patient  is 
hungry,  and  sits  down  to  the  meal  fully  prepared  to  satisfy  himself. 
The  first  mouthful  is  at  once  followed  by  anorexia,  which  may  almost 
amount  to  nausea.  On  account  of  these  symptoms  the  patient  eats  less 
and  less  of  solid  food,  which  soon  results  in  disturbance  of  nutrition 
affecting  the  higher  centres.  On  the  other  hand,  profound  mental  dis- 
turbance may  be  an  exciting  cause,  so  that  after  the  death  of  a  friend, 
or  shock  of  any  kind,  the  patient  is  unable  to  take  food.  Loss  of  appe- 
tite may  be  the  only  manifestation  of  the  gastric  neurosis,  but  because 
nutrition  is  so  seriously  interfered  with,  it  soon  results  in  other  local 
or  general  symptoms.  Fen  wick  points  out  that  its  relationship  to  ema- 
ciation and  enfeeble rnent  is  such  that  grave  organic  diseases  may  be 
simulated.  Thus  it  may  be  mistaken  for  phthisis,  and  a  general  ex- 
amination alone  is  sufficient  to  distinguish  it. 

Gastralgia.  Pain  in  the  stomach  occurs  in  organic  disease,  as  in 
ulcer  or  cancer,  or  forms  of  gastritis.  It  also  attends  a  gastric  neurosis, 
and  may  be  the  only  symptom  of  this  neurasthenic  state.  Such  pain 
is  functional,  and  is  found  in  anaemic,  neurotic  women.  It  may,  how- 
ever, occur  in  all  classes.  It  is  characterized  by  sudden  pain  in  the 
epigastrium,  usually  without  regularity,  though  at  times  it  may  be  dis- 
tinctly periodic.  There  may  not  be  any  definite  relationship  between 
the  attack  of  pain  and  the  taking  of  food,  though  it  is  most  apt  to 
occur  when  the  stomach  is  empty.  Some  kinds  of  food  may  aggravate 
it,  though,  in  general,  eating  relieves  the  pain.  If  the  epigastrium  is 
examined,  it  will  be  found  to  be  free  from  tenderness,  and  indeed 
pressure  with  the  palm  of  the  hand  may  give  relief.  The  pain  is  of 
an  agonizing  character,  sometimes  sharply  localized,  or  again  diffuse. 


800     •  SPECIAL  DIAGNOSIS. 

It  may  even  resemble  the  girdle-sensation.  On  account  of  the  severity 
of  the  pain  the  patient  may  be  compelled  to  double  himself  up  to  relax 
the  abdominal  muscles.  The  breath  is  short,  and  speaking  is  done  in 
a  whisper.  The  attack  is  attended  by  more  or  less  collapse,  and  the 
patient  may  complain  of  the  sensation  of  impending  death.  There  is 
pallor  of  the  face,  which  is  distorted  with  pain,  and  the  brow  is  covered 
with  perspiration.  The  pain  may  radiate  along  the  spinal  nerves  in 
close  situation  to  the  stomach,  and  there  is  often  vigorous  pulsation  of 
the  abdominal  aorta. 

The  attack  may  last  but  a  few  minutes  or  continue  for  hours.  It 
sometimes  terminates  suddenly  with  vomiting,  or  is  relieved  as  soon 
as  food  is  taken.  After  the  attack  the  patient  is  exhausted  and  re- 
laxed, and  passes  an  abundance  of  urine  of  low  specific  gravity. 

The  gastralgias  that  are  due  to  disease  of  the  central  nervous  system 
are  often  most  puzzling.  Rosenthal  has  written  exhaustively  on  this 
subject.  Types  of  gastralgia  of  this  character  are  seen  in  the  gastrie 
crises  of  tabes,  first  described  by  Charcot.  Recent  observers  have 
found  that  it  is  due  to  sclerotic  degeneration  of  the  vagus  nucleus. 
The  patient  is  suddenly  seized  with  severe  pains,  which  may  begin  in 
the  groin  and  ascend  along  both  sides  of  the  abdomen  to  the  epigas- 
trium, to  which  point  they  are  fixed.  Pain  in  the  shoulders  occurs  at 
the  same  time.  The  pains  are  characteristic  of  lumbar  ataxia  in  their 
lightning-like  rapidity.  With  the  pain  the  heart's  action  is  increased 
in  rapidity  and  force.  There  is  no  rise  in  temperature.  At  the  same 
time  there  is  uninterrupted  and  painful  vomiting,  which  is  attended  by 
nausea  and  vertigo.  The  gastric  pain  may  continue  uninterruptedly 
for  two  or  three  days.  It  belongs  to  the  pre-ataxic  period,  so-called, 
but  is  almost  sure  to  continue  throughout  the  whole  course  of  the  dis- 
ease. The  nature  of  the  stomach-contents  bears  no  relation  to  the 
pain.  The  frequency  of  the  attacks  is  variable.  They  may  recur  at  long 
periods,  or  as  frequently  as  once  a  month  or  once  a  week.  Another 
special  characteristic  is  the  sudden  relief  that  is  given  without  cause. 

Neurasthenic  Gastralg-ia.  Neurasthenic  gastralgia  occurs  in 
patients  who  are  suffering  from  neurasthenia,  and  is  divided  by  Rosen- 
thal into  two  forms,  the  one  irritative,  the  other  depressant ;  these  are 
related  by  transitional  forms.  The  early  symptoms  of  neurasthenia 
(q.  v.),  particularly  in  the  irritative  form,  with  painful  points  in  the 
nape  of  the  neck  and  between  the  scapulas,  or  often  lower  down  on  the 
vertebras,  with  neuralgias  and  paresthesia  in  the  upper  and  lower  ex- 
tremities, are  attended  by  periodical  gastralgia.  The  gastralgia  is 
characterized  by  a  boring  sensation  which,  during  the  attack,  radiates 
over  the  lower  ribs  to  the  median  line.  It  is  accompanied  by  vaso- 
motor symptoms  and  symptoms  of  cerebral  anamiia.  In  the  depressant 
form  the  patient  complains  of  weight  and  fulness,  or  a  dragging  sensa- 
tion after  eating,  which  is  constant  instead  of  paroxysmal.  The  neu- 
ralgic pains  are  not  so  marked,  motor  exhaustion  is  not  so  prominent, 
and  the  pain  in  the  back  is  not  so  intense  as  in  other  varieties.  In 
both  instances  on  deep  pressure  over  the  region  of  the  nerve-plexuses 
which  follow  the  bloodvessels  in  the  abdomen,  there  is  sharp  and  un- 
pleasant pain  radiating  to  the  epigastrium.     Burkart  considers  these 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     801 

painful  points  to  be  present  in  all  cases,  Avhile  Richter  believes  that 
pressure  over  the  stomach  and  abdomen  is  not  painful.  With  such 
pain  there  is  usually  increased  pulsation  of  the  abdominal  aorta,  partic- 
ularly during  the  time  of  the  paroxysm.  In  neurasthenic  gastralgias 
there  is  increased  sensitiveness  to  the  electrical  current  and  increased 
irritability  of  the  sensory  nerves  of  the  trunk,  which  may  also  be  ex- 
tended to  the  limbs. 

Neurasthenic  gastralgia  must  be  distinguished  from  the  gastralgia 
of  organic  disease  and  the  gastralgia  of  hysteria.  The  gastralgia  of 
organic  disease  is  recognized  by  observing  the  condition  of  the  stomach 
when  fasting  and  by  studying  the  secretion.  In  organic  disease  there 
is  retarded  digestion  ;  in  gastric  neuroses  digestion  is  completed  in  the 
normal  limit  of  time — seven  hours.  Hysterical  gastralgias  are  recog- 
nized by  the  presence  of  the  usual  symptoms  of  hysteria,  in  which  the 
psychical  factors  occupy  a  prominent  place,  associated  with  convul- 
sions, paralyses,  pupillary  inequalities,  hemianesthesia,  and  electrical 
sensibility.  Most  characteristic,  however,  is  the  alternation  of  hysteri- 
cal gastralgias  with  neuralgia,  or  neuroses  in  other  organs. 

(a)  2.  Secretory  Neuroses  of  Irritation.  Hyperacidity  and 
Hypersecretion.  Hyperacidity  is  the  increase  of  the  normal 
amount  of  hydrochloric  acid  secreted,  due  to  a  neurosis  of  the  secretory 
function.  Hyperacidity  begins  when  the  amount  of  acid  in  the  fluid 
withdrawn  from  the  stomach  in  the  usual  way  is  between  60  and  70 
per  cent.  It  must  not  be  forgotten  that  it  is  a  symptom  of  gastric 
ulcer,  but  it  exists  as  a  neurosis  independent  of  any  organic  lesion  of 
the  stomach.  It  has  been  observed  in  nervous  diseases,  as  hysteria 
and  melancholia,  and  as  a  reflex  symptom  in  gallstones  and  renal 
calculus. 

Hypersecretion  occurs  in  two  forms,  the  periodical  and  constant. 
The  acid  is  not  necessarily  increased.  The  periodical  occurs  after  eat- 
ing ;  it  has  no  direct  connection  with  food.  It  is  seen  in  neurasthenia 
and  locomotor  ataxia.  In  chronic  hypersecretion  the  gastric  juice, 
which  is  usually  hyperacid,  is  in  excess,  so  that  the  fasting  stomach 
may  contain  large  quantities,  even  to  a  pint  and  a,  half,  without  food 
and  only  slightly  tinged  by  bile.  In  chronic  hypersecretion  the  diges- 
tion of  starches  is  delayed,  but  that  of  albuminoids  is  very  prompt. 
After  an  abundant  meal  consisting  of  meat  and  starches  the  meat  dis- 
appears entirely.  Hypersecretion  occurs  in  about  half  of  all  the  stom- 
ach disorders,  according  to  Riegel.  It  is  more  common  in  men  than 
in  women.  The  acid  fluid  causes  the  hyperresthetic  conditions  in  the 
gastric  region  previously  described.  Pain  and  eructation,  heartburn 
or  gastralgia,  vomiting  of  sour  masses,  occur  with  the  digestive  dis- 
turbances of  chronic  gastritis.  The  tongue  is  usually  clean  and  the 
appetite  increased  rather  than  diminished.  As  a  result,  atony  of  the 
muscular  coat  takes  place,  followed  by  gastrectasia.  The  neurosis  is 
then  converted  into  an  organic  lesion,  and  the  symptoms  <>f  dilatation 
arise. 

Reickman's  disease  is  a  hypersecretion  of  the  gastric  juice,  and  there 
are  two  forms — the  acute,  which  is  generally  of  nervous  origin,  and 
the  chronic.     The  latter  is  seen  in  emaciated  persons  ;  the  stomach  is 

.11 


802  SPECIAL  DIAGNOSIS. 

dilated,  and  succussion-splash  is  readily  obtained.  The  diagnosis  is 
made  in  part  by  examination  of  the  gastric  contents,  which  are  re- 
moved five  to  six  hours  after  the  meal.  The  quantity  will  be  found 
large.  On  standing,  the  material  becomes  separated  into  three  layers 
— an  upper,  frothy  layer  ;  a  middle,  turbid,  yellowish  layer,  and  a 
lower,  consisting  of  starchy  matter.  In  order  to  determine  that  hyper- 
secretion exists,  the  stomach-contents  are  removed  in  the  evening,  and 
the  viscus  washed  out  thoroughly  until  the  water  is  no  longer  acid  in 
reaction.  The  patient  receives  no  food  until  the  next  morning,  when, 
after  the  proper  interval,  the  contents  of  the  stomach  are  again  evacu- 
ated. From  30  to  600  c.c.  (1  to  19  ounces)  of  fluid  will  now  be 
obtained,  which,  on  examination,  proves  to  be  active  gastric  juice.  ' 
The  disease  is  chronic. 

In  order  to  make  a  diagnosis  the  secretions  must  be  secured  while 
fasting.  The  patients  usually  improve  on  albuminous  food,  which 
differentiates  it  from  gastralgia  and  pyrosis  of  acid  fermentation. 
Alkalies  give  temporary  relief. 

Gastroxynsis  is  a  gastric  neurosis  in  which,  after  mental  overexertion 
or  profound  emotional  disturbance,  there  is  sudden  vomiting  of  acid 
fluid,  continuing  for  a  considerable  time.  It  is  closely  allied  to 
migraine. 

(a)  3.  Motor  Neuroses  of  Irritation.  Eructations.  Eructations 
and  belching  are  phenomena  of  the  gastric  neuroses  of  motor  origin. 
They  usually  occur  in  hysterical  subjects  rather  than  in  neurasthenics. 
In  the  latter  they  are  associated  with  other  sensations,  particularly  op- 
pression and  tension  in  the  epigastrium.  In  hysteria  they  occur  alone. 
There  is  increase  in  the  contractility  of  the  stomach,  the  pyloric 
sphincter  contracts  powerfully,  and  the  stomach  is  distended  ;  gas  is 
expelled  at  the  cardiac  end  of  the  stomach.  They  may  be  due  to 
paralysis  of  the  cardiac  end  of  the  stomach  rather  than  to  contraction 
of  the  pyloric  end.  They  occur  involuntarily  generally.  They  must 
not  be  confounded  with  the  pseudohysterical  vomiting  which  Bristowe 
has  described.  In  the  latter  instance  the  gas  is  raised  from  the  oesoph- 
agus by  contraction  of  the  muscles  of  the  neck.  Hysterical  eructation 
is  very  frequently  of  oesophageal  origin.  The  belching  is  loud  and 
may  occur  in  paroxysms.  The  gas  is  odorless,  and  hence  is  distin- 
guished from  the  gas  of  dyspepsia  and  fermentation  ;  it  is  in  all  proba- 
bility the  result  of  the  swallowing  of  air. 

Pyrosis.  Pyrosis,  or  heartburn,  is  the  raising  of  sour  masses  from 
the  stomach.  The  stomach-contents  are  not  necessarily  hyperacid. 
If  acid,  as  in  the  normal  gastric  juice,  or  hyperacid,  the  regurgitation 
causes  severe  acrid  and  burning  sensations.  It  is  probably  due  to 
heightened  contractility  of  the  muscular  coat  of  the  stomach  with 
pyloric  contraction,  which  overcomes  the  weaker  cardia. 

Pneumatosis.  Excess  of  gas  in  the  stomach.  When  the  stomach 
is  overdistended  the  diaphragm  is  pushed  up,  pressing  on  the  heart. 
The  patients  are  seized  with  severe  dyspnoea.  At  first  inspiration  is 
difficult,  and  finally  both  inspiration  and  expiration  become  difficult. 
Palpitation  of  the  heart  and  pulsation  of  the  peripheral  arteries  take 
place.     There  is  fulness  of  the  head  and  a  sensation  of  impending 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     803 

death.  The  patient  may  become  unconscious.  Relief  can  only  be 
afforded  by  belching,  when  the  attack  rapidly  subsides.  Introducing 
a  stomach  tube  gives  immediate  relief. 

Nervous  Vomiting.  (See  Subjective  Symptoms  and  Gastroxyn- 
sis). 

Tormina  Ventriculi.  Peristaltic  Unrest.  Characterized  by 
borborygmi  and  gurgling,  which  begin  immediately  after  eating,  are 
heard  at  a  considerable  distance,  and  are  a  source  of  great  annoyance. 
It  is  a  common  symptom  of  the  gastric  neuroses. 

Rumination  {Merycismus).  Rumination  is  a  rare  condition  in 
which  the  patients  regurgitate  and  chew  the  cud  like  ruminants. 

(6)  1.  Secretory  Neuroses  of  Depression.  An  acidity.  An- 
acidity  of  the  gastric  juice  as  a  neurosis  is  found  in  hysterical  persons 
and  in  neurasthenics.  (See  chemical  examination  Absence  of  Hydro- 
chloric Acid). 

(b)  2.  Sensory  Neuroses  of  Depression.  Anaesthesia.  In  con- 
ditions of  depression  polyphagia,  or  the  want  of  a  feeling  of  satiation 
occurs ;  if  gluttony  is  excluded,  it  is  a  morbid  condition  of  extreme 
rarity. 

(b)  3.  Motor  Neuroses  of  Depression.  Atony,  or  Atonic  Dys- 
pepsia. It  accompanies  gastritis  ;  it  also  occurs  as  a  primary  neurosis. 
The  innervation  of  the  nerve-centres  regulating  peristalsis  is  disor- 
dered. The  primary  disorder  may  be  local  or  central.  The  movement 
of  the  chyme  is  tardy  or  insufficient.  Atony  should  be  applied  to  the 
disease  of  the  motor  function  only,  or,  as  Rosenbach  states  it,  to  insuf- 
ficiency of  the  stomach.  The  symptoms  develop  gradually.  At  first 
oppression  during  digestion  occurs,  with  swelling  and  fulness  of  the 
stomach. 

There  is  mental  and  physical  torpor  during  the  time  of  the  digestive 
act.  The  symptoms  become  aggravated,  and  eructations  occur,  vomit- 
ing begins,  and  gradually  the  fermentative  symptoms  become  most 
pronounced.  At  this  period  it  is  putrid,  or  fermentative  dyspepsia. 
By  the  usual  tests  the  motor  power  of  the  stomach  is  found  to  be 
diminished.     The  secretions  are  also  scanty. 

Relaxation  at  Orifices.  Relaxation  of  the  Cardiac  and  Pyloric 
Ends  of  the  Stomach  from,  Conditions  Resembling  Paralysis.  When 
the  cardiac  end  is  relaxed  eructations  and  regurgitations  occur.  If 
large  quantities  of  the  material  from  the  stomach  are  regurgitated  and 
expectorated,  the  condition  is  pathological.  It  may  lead  to  serious 
changes  in  nutrition.  It  may  exist  for  years  without  bad  results.  It 
must  not  be  confounded  with  the  regurgitation  from  diverticula  of  the 
oesophagus.     In  the  latter  regurgitation  is  produced  at  will. 

(c)  Mixed  Neuroses.  Nervous  Dyspepsia.  According  to  Ewald, 
this  is  the  true  gastric  neurasthenia,  which  combines  all  forms  of  gas- 
tric neuroses.  The  clinical  picture  is  made  up  of  a  combination  of 
various  neurosal  symptoms.  Leube  considers  nervous  dyspepsia  a 
group  of  symptoms  of  a  cerebral  nature  due  to  abnormal  irritability 
of  the  sensory  nerves  of  the  stomach  during  the  normal  digestive 
processes,  the  symptoms  of  which  are  hyperesthesia  and  nausea,  hy- 
jjerorexia,  anorexia,  parorexia,  and  gastralgia.     He  thinks  the  true 


804  SPECIAL  DIAGNOSIS. 

peptic  activity  of  the  stomach  is  unchanged.  Although  the  anatomical 
or  physiological  explanation  of  the  condition  is  difficult,  the  clinical 
symptoms  are  those  of  irritation  of  paralysis,  the  manifestations  of 
which  are  intermingled,  sometimes  one  and  sometimes  the  other  being 
most  prominent.     (See  table,  page  797.) 

The  one  characteristic  feature  is  that  the  symptoms  are  mild.  With 
severe  forms  of  gastralgia  nervous  vomiting  and  boulimia  do  not  occur. 
Symptoms  of  intestinal  indigestion  are  usually  associated  in  a  mild 
degree.  Constipation  is  of  the  most  common  occurrence,  although  in 
some  cases  there  is  diarrhoea.  In  other  cases  the  intestinal  iu  digestion 
is  much  aggravated,  with  mild  gastric  disturbances  and  anorexia,  repug- 
nance toward  taking  food,  furred  tongue  and  mild  nausea,  constipation 
and  colicky  paiu,  either  diffuse  or  in  separate  painful  spots.  .  The 
abdomen  is  distended  and  tympanitic,  sometimes  to  a  marked  degree. 
It  is  called  flatulent  dyspepsia.  Along  with  the  gastric  and  intestinal 
symptoms,  the  general  nervous  symptoms  to  which  the  term  neuras- 
thenia is  applied  are  present.  These  nervous  manifestations  sometimes 
precede  the  local  gastric  symptoms,  but  as  the  latter  develop  the  former 
become  more  aggravated.  The  dyspeptic  conditions,  as  Ewald  puts 
it,  are  on  a  neurotic  basis,  or  are  such  as  may  occur  in  the  form  of  reflex 
neuroses  in  chlorosis,  menstrual  disorders,  uterine  and  ovarian  disease, 
and  intense  physical  or  psychical  excitement.  As  far  as  Ave  know  there 
are  no  great  alterations  in  the  chemical  fimctions  when  anatomical  and 
pathological  changes  are  absent.  An  indigestion  of  short  duration,  a 
mild  catarrh,  recurring  hyperemia,  have  been  the  primary  cause  of 
nervous  symptoms  in  the  digestive  organs. 

Diagnosis.  There  are  no  characteristic  symptoms,  and  the  student 
must  bear  in  mind  that  it  may  be  necessary  to  make  several  examina- 
tions and  listen  to  the  story  of  the  subjective  symptoms  frequently 
before  a  conclusion  can  be  arrived  at.  This  is  all  the  more  necessary 
because  of  the  frequency  in  which  organic  lesions  and  neurasthenic  con- 
ditions are  present  at  the  same  time.  The  course  of  the  disease  must 
be  observed  for  a  long  time,  all  possible  causal  factors  investigated,  and 
all  the  general  signs  of  neurasthenia  carefully  considered.  In  addition, 
it  may  be  necessary  to  use  therapeutic  tests.  If  the  possible  organic 
diseases  are  not  relieved  by  such  measures,  there  must  be  a  deeper  basis 
for  the  gastric  symptoms.  Just  as  in  neurasthenia  and  in  neurasthenic 
states  elsewhere,  the  peculiarities,  idiosyncrasies,  and  all  the  associations 
in  the  life  of  the  individual  must  be  considered  in  connection  with  the 
general  and  local  symptoms  of  the  neurasthenic  state.  Great  stress  must 
be  placed  upon  the  study  of  individual  symptoms,  their  mutual  rela- 
tionship, and  their  changeable  occurrence.  In  gastric  neurasthenia 
gastralgia  is  more  diffuse  than  the  pain  of  ulcer  or  cancer  of  the  stom- 
achy It  is  not  so  much  dependent  upon  food  as  either  of  the  others, 
particularly  ulceration.  In  gastric  neurasthenia  vomiting  is  rare.  The 
v. uniting  is  composed  of  mucus  mixed  with  bile  and  food  in  various 
stages  of  digestion.  It  is  never  bloody,  nor  does  it  contain  decomposed 
masses.  Hysterical  vomiting  occurs  with  ease  and  regularity  compared 
with  the  vomiting  of  neurasthenia.  The  vomiting  in  neurasthenia  is 
bitter,  due  to  the  presence  of  peptones.     In  gastric  neurasthenia  the 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     805 

stools  are  changeable  in  character.  They  do  not  contain  undigested 
remnants  of  food,  or  mucus,  or  blood.    The  form  of  the  feces  is  variable. 

Differential  Diagnosis.  Neoplasms,  ulcers,  strictures,  and  dilatation  are 
distinguished  by  physical  signs  or  characteristic  symptoms.  In  gastric 
neurasthenia  the  stomach  should  be  empty  seven  hours  after  taking  a 
meal.  The  results  of  the  chemical  examination  are  not  sufficiently 
definite  for  diagnostic  purposes,  for  at  times  the  same  chemical  changes 
are  present,  as  in  ulcer,  carcinoma,  and  chronic  catarrh.  The  diag- 
nosis must  be  based  largely,  as  previously  intimated,  upon  prolonged 
observation  and  a  carefully  taken  history,  and  upon  the  general  condi- 
tion of  the  patient.  The  cases  must  not  be  mistaken  for  costal  neural- 
gia, although  it  is  not  usually  easy  to  be  led  astray.  Keflex  gastric 
neuroses  are  seen,  as  indigestion,  gastralgia,  or  vomiting.  The  types 
are  interchangeable,  although  vomiting  occurs  in  the  more  acute  reflexes, 
indigestion  in  the  more  chronic.  The  cerebral  disorders  which  give 
rise  to  vomiting  are  meningitis,  abscess,  and  tumor.  The  vomiting 
may  be  transitory,  or  may  be  persistent.  There  is  usually  hypersecre- 
tion of  the  gastric  juice.  The  vomiting  may  usher  in  the  disease  or 
develop  during  its  course.  If  vomiting  is  of  long  standing  its  possibly 
reflex  origin  should  always  be  investigated.     (See  Vomiting.) 

Gastralgia  is  sometimes  a  reflex  from  lesions  in  the  cervical  and 
dorsal  portions  of  the  cord  ;  not  only  in  the  posterior  columns,  but  also 
in  disseminated  sclerosis.  Vomiting  occurs,  and  the  attack  is  known 
as  a  gastric  crisis. 

Chronic  dyspepsia  is  a  frequent  reflex  disorder  of  diseases  of  the 
sexual  organs,  as  amenorrhoea  and  dysmenorrhea,  in  the  climacteric 
period,  and  in  chronic  inflammations  of  the  uterus.  In  malpositions 
and  tumors,  and  in  pelvic  exudations  with  traction,  in  ulcers,  in  ova- 
rian tumors,  the  so-called  dyspepsia  uterina  of  Kisch  is  common. 

Chronic  Gastritis.      Causes.     1.  Previous  attacks  of  acute  gastritis. 

2.  The  local  irritation  of  badly  cooked  or  poorly  masticated  food, 
and  of  alcoholic  and  other  beverages. 

3.  The  local  irritation  of  urea  in  chronic  Bright' s  disease,  and  of 
products  of  putrefaction  in  constipation. 

4.  In  anaemia  chronic  gastritis  is  of  frequent  occurrence,  and  in 
venous  congestions  from  any  cause,  but  particularly  from  disease  of 
the  heart  or  diseases  which  interfere  with  the  portal  circulation.  It 
occurs  secondarily  to  diabetes,  gout,  rheumatism,  nephritis,  and  tuber- 
culosis. 

5.  It  is  a  constant  attendant  upon  local  disease  of  the  stomach,  as 
cancer,  dilatation,  and  ulcer,  and  of  local  disturbance  of  the  circulation. 

The  symptoms  are  those  of  chronic  indigestion.  There  is  a  dry, 
pasty,  or  salty  taste  in  the  mouth,  especially  in  the  morning.  The 
tongue  is  coated  over  its  entire  surface,  or  has  red  patches  at  the  base ; 
its  papilla?  arc  always  swollen  and  its  edges  marked  by  the  teeth. 
Aphtha?  recur  frequently.  The  lips  are  dry  and  often  chapped. 
The  appetite  is  poor  or  capricious.  Although  there  is  no  great 
thirst,  the  patients  crave  fluids  with  their  meals,  and  acid  drinks  are 
grateful.  After  eating  there  is  a  feeling  of  oppression  and  disten- 
tion in  the  epigastrium,  frequently  followed  by  belching.     The  gaseous 


806  SPECIAL  DIAGNOSIS. 

eructations  are  odorless  or  foul,  and  rancid  regurgitation  with  pyrosis 
is  frequent.  The  acidity  is  due  to  fatty  acids  and  not  to  hydrochloric 
acid,  as  in  hypersecretion.  Vomiting  is  invariably  present,  but  occurs 
irregularly.  It  is  usually  preceded  by  nausea.  The  most  character- 
istic form  is  that  in  which  mucus  is  vomited  in  the  morning  on  rising. 
Constipation  usually  exists  ;  it  may  alternate  with  diarrhoea.  There 
are  flatulency  and  rumbling  in  the  intestines. 

General  Symptoms.  The  nervous  symptoms  are  the  most  pronounced. 
The  mental  activity  is  diminished,  there  is  a  feeling  of  languor  or 
torpor,  especially  after  eating.  Headache  is  frequent  after  eating,  and 
the  patient  may  become  morose  and  hypochondriacal.  Attacks  of  ver- 
tigo are  common.  Itching  of  the  skin  and  coldness  of  the  extremities 
are  not  rare.  Sleep  is  deeper  and  longer  than  is  natural,  but  is  dis- 
turbed by  dreams,  and  is  not  refreshing.  Yawning  is  frequent.  Phar- 
yngitis usually  attends  the  attack,  with  hacking  cough  and  expectora- 
tion, or  hawking  of  mucus. 

The  pulse  may  be  weak  and  irregular,  and  at  times  there  is  an  even- 
ing rise  of  temperature.  The  urine  is  scanty,  high-colored,  and  usually 
loaded  with  urates. 

Three  forms  are  seen  :  (1)  Simple  chronic  gastritis;  (2)  chronic 
mucous  gastritis  ;  the  term  "  chronic  catarrh  of  the  stomach  "  is  applied 
to  both  conditions.  If  the  condition  lasts  a  long  time,  it  results  in  (3) 
atony,  with  dilatation  of  the  stomach,  or  with  atrophy.  Atrophy,  or 
atrophic  gastritis,  is  secondary  to  the  chronic  form,  or  to  stenosis  of  the 
oesophagus,  or  to  cancer.  The  symptoms  are  those  of  pernicious  anae- 
mia. Cirrhosis  of  the  stomach  is  also  a  sequence  of  gastritis.  It  is 
rare,  and  the  symptoms  are  not  characteristic  of  a  spinal  lesion.  They 
are  those  of  the  primary  disease. 

Examination  of  the  Stomach-contents.  In  simple  gastritis  the  stom- 
ach, after  digestion  is  completed,  contains  a  small  amount  of  slimy 
fluid.  Hydrochloric  acid  is  diminished  in  quantity  after  a  test-break- 
fast ;  lactic  acid  and  the  fatty  acids  are  present,  as  previously  noted. 
Pepsin  and  the  milk-curdling  ferment  are  absent  or  diminished.  In 
mucous  gastritis  there  is  subacidity.  It  differs  from  the  simple  form 
in  the  excess  of  mucus  only.  In  atrophy  the  hydrochloric  acid  and 
pepsin  are  diminished,  or  absent  altogether  after  the  test-breakfast. 
The  fasting  stomach  is  empty.  There  are  no  fermentation  acids. 
Atrophy  must  be  distinguished  from  cancer  and  subacid  neuroses. 
The  latter  occur  in  younger  individuals  than  those  subject  to  atrophy. 
A  bloody  tinge  in  the  stomach-contents,  or  hemorrhage,  may  be  the 
only  distinguishing  mark  of  cancer.  It  is  often  impossible  to  make 
a  diagnosis. 

Diagnosis.  The  diagnostic  features  of  chronic  gastritis  are  :  First, 
long  duration  ;  second,  persistence  of  local  symptoms  ;  third,  recur- 
rence of  local  symptoms  after  food,  the  symptoms  being  aggravated  by 
stimulants,  or  stimulating  food  ;  fourth,  moderate  pain  ;  fifth,  absence 
of  cachexia  ;  sixth,  absence  of  tumor  ;  seventh,  flatulency.  Hemor- 
rhage is  rare,  and  there  may  or  may  not  be  vomiting,  while  the  quan- 
tity of  hydrochloric  acid  is  variable.  Finally,  the  cause  is  usually 
definite. 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     807 

Dilatation  of  the  Stomach  (Gastr ectasia).  (See  Plate  XXXVIII., 
Fig\  1.)  It  is  caused  by  obstruction  at  the  pyloric  orifice,  either  from 
cancer,  the  cicatrix  of  an  ulcer,  or  fibrous  stricture.  It  follows  atony 
and  degeneration  of  the  walls  of  the  stomach  which  occur  in  the  course 
of  chronic  gastritis.  It  may  attend  paralysis  of  the  stomach.  Excessive 
eating  or  drinking  are  the  only  probable  causes  independent  of  organic 
disease.     Hence,  we  have  (1)  obstructive  and  (2)  atonic  dilatation. 

The  dilatation  may  be  acute.  The  term  acute  paralytic  distention  is 
also  applied  to  this  condition.  The  cases  are  extremely  rare.  There 
is  sudden  enlargement  of  the  upper  portion  of  the  abdomen,  with 
pressure  upon  the  surrounding  structures.  The  heart  is  dislocated  and 
its  action  much  interfered  with ;  collapse  follows  and  may  end  in 
death.  At  first  there  may  be  some  belching,  but  the  patient  is  soon 
unable  to  remove  the  gas,  and  suffers  from  extreme  discomfort,  palpi- 
tation, and  dyspnoea.  The  vomiting  may  occur  at  once  or  later.  It 
is  persistent  and  excessive.  On  physical  examination  the  stomach 
yields  the  same  physical  signs  as  in  chronic  dilatation. 

Chronic  dilatation  develops  slowly.  The  symptoms  of  it  are  super- 
imposed upon  the  causal  disease.  There  is  marked  dyspepsia,  with 
flatulency,  pyrosis,  and  other  symptoms  of  fermentation.  The  tongue 
is  pale  and  furred,  or  red,  smooth,  and  shiny ;  or  it  may  be  soft  and 
flabby.  If  frequent  vomiting  has  attended  the  causal  disease,  it  now 
occurs  at  longer  intervals ;  the  amount  is  excessive,  greater  than  the 
normal  stomach  would  hold,  and  is  made  up  of  partially  digested  and 
fermented  food  and  large  amounts  of  mucus.  The  stomach-contents 
contain  sarcinse,  torulse,  and  other  products  of  fermentation.  Hydro- 
chloric acid  is  usually  absent,  but  there  is  a  large  excess  of  lactic 
and  fatty  acids.  The  patient  loses  flesh  and  strength ;  becomes  irri- 
table, depressed,  and  more  or  less  melancholy.  The  patient  is  subject 
to  vertigo  and  to  attacks  of  nocturnal  asthma.  The  nervous  symptoms 
of  chronic  gastritis  are  also  present. 

Sleeplessness  is  quite  common.  In  some  cases  there  is  excessive 
thirst  because  of  the  small  amount  of  nutriment  and  fluid  absorbed. 
Cardiac  palpitation  and  irregularity  are  common,  and  dyspnoea  may 
occur  on  account  of  the  distention.  Tetany  has  been  observed  in  cases 
of  dilatation,  especially  after  lavage. 

Physical  Examination.  The  diagnosis  is  not  complete  without  physi- 
cal examination.  On  inspection  the  abdomen  is  large  and  prominent, 
and  the  outline  of  the  stomach  can  sometimes  be  seen.  Peristaltic 
movements  of  the  organ  are  often  seen.  The  movement  is  from  left 
to  right.  The  heart  is  lifted  upward.  On  palpation  the  peristalsis  can 
be  felt,  and  with  one  hand  on  the  stomach,  tapping  with  the  other,  a 
splashing  sound  can  be  detected.  Or  the  hand  may  be  placed  over  the 
stomach  (patient  standing)  and  the  body  quickly  shaken.  On  palpa- 
tion the  striking  or  pushing  hand  should  be  compressed  over  the  false 
ribs.  A  tumor  can  sometimes  be  felt  in  the  region  of  the  pylorus,  or 
below  the  umbilicus.  On  percussion,  when  the  stomach  contains  gas, 
a  tympanitic  note  is  heard.  After  drinking  water  dulness  may  be  de- 
tected between  gastric  and  intestinal  tympany  if  the  patient  stands  up. 
The  dull  note  disappears   when  he  resumes  the  recumbent  posture. 


808  SPECIAL  DIAGNOSIS. 

Before  taking  water  tympany  is  not  so  marked  in  the  upright  as  in 
the  recumbent  posture,  because  the  stomach  is  dragged  back  or  down. 
The  tympany  extends  high  up  in  the  chest  on  the  left  side,  so  that 
Traube's  half-moon  space  is  exaggerated.  It  may  extend  as  high  as 
the  fourth  interspace  on  the  left  side.  Cardiac  dulness  is  increased 
and  the  apex  of  the  heart  is  lifted  upward  and  to  the  left.  In  the 
axillary  region  the  tympany  may  extend  as  high  as  the  sixth  rib. 
There  is  usually  atrophy  of  the  spleen,  so  that  unless  very  careful 
light  percussion  is  performed  the  splenic  dulness  cannot  be  brought 
out.  The  lower  limit  extends  below  the  transverse  umbilical  line,  and 
may  even  extend  midway  to  the  pubis.  If  there  is  gastroptosis,  the 
half -moon  space  becomes  dull  on  percussion,  the  stomach  tympany  fall- 
ing to  a  lower  level.  On  auscultation  succussion  can  easily  be  elicited. 
Sometimes  the  sound  is  sizzling,  as  if  there  was  effervescence.  Heart- 
sounds  may  be  transmitted  clear  and  metallic  over  the  tympanitic 
stomach.  With  auscultatory  percussion  the  border  of  the  stomach  can 
often  be  defined  accurately.  Percussion  must  be  commenced  far  away 
from  the  stomach-limit  and  conducted  toward  it.  (See  Examination 
of  the  Abdomen.) 

Stenosis  of  the  Pylorus.  Usually,  obstruction  is  caused  by  malig- 
nant disease.  Hypertrophic  stenosis  occurs  in  rare  instances  and  leads 
to  dilatation,  as  indicated  above.  The  condition  may  be  congenital  or 
acquired. 

Acquired  stenosis  may  be  the  result  of  chronic  gastritis,  or  develop 
independently,  sometimes  as  part  of  a  general  proliferation  of  connec- 
tive tissue.  (See  case  of  author,  Path.  Soc.  Trans.,  vol.  xi.  1881-83, 
p.  216.)  If,  to  the  physical  signs  of  tumor  of  the  pylorus,  be  added 
the  signs  and  symptoms  of  dilatation,  we  have  the  clinical  picture  of 
hypertrophic  stenosis  of  the  pylorus.  It  is  extremely  rare  to  find 
complete  obstruction. 

Congenital  hypertrophic  stenosis,  as  Metzler  and  Caudley  point 
out,  has  for  its  characteristic  features  :  (1)  Vomiting,  occurring  with- 
out apparent  cause  and  persisting  in  spite  of  treatment ;  (2)  the  ab- 
sence of  bile  from  the  vomited  matter ;  (3)  obstinate  constipation ;  (4) 
marasmus  ;  (5)  the  presence  of  a  tumor  in  the  region  of  the  pylorus  ; 
(6)  the  absence  of  abdominal  distention  except  from  dilatation  of  the 
stomach  itself  in  some  instances ;  and  (7)  the  absence  of  signs  or 
symptoms  of  gastritis  and  of  the  more  common  forms  of  intestinal 
obstruction.  Diagnosis  depends  entirely  on  the  characteristic  symp- 
toms arising  during  the  first  few  weeks  of  life  and  the  presence  of  a 
tumor. 

Diseases  of  the  Stomach  Characterized  by  Pain  and  Vomiting. 

Cancer  of  the  Stomach.  The  clinical  symptoms  are  varied.  Gas- 
tric cancer  may  occur  without  any  symptoms  whatever,  and  be  discov- 
ered after  death  from  other  causes.  On  the  other  hand,  general  maras- 
mus and  cachexia  may  be  present,  without  local  symptoms.  In  some 
cases  the  gastric  symptoms  are  slight,  and  obscured  by  the  symptoms 
of  secondary  growth  in  the  liver  or  peritoneum. 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     809 

Typical  cases  are  those  which  occur  late  in  life,  with  symptoms  of 
chronic  gastritis.  These  symptoms  may  continue  for  months  before 
anything-  further  is  observed.  Gradually  the  uneasiness  and  discom- 
fort after  eating  increase  to  actual  pain.  Loss  of  appetite  is  marked, 
and  in  spite  of  careful  treatment  there  is  loss  of  flesh  and  strength. 
The  usual  vomiting  of  chronic  gastritis  gradually  becomes  more  fre- 
quent. The  general  appearance  of  the  vomitus  is  at  first  like  that  of 
chronic  gastritis.  Soon  it  becomes  streaked  with  blood,  or  a  moder- 
ately large  hemorrhage  may  take  place.  The  vomited  matter  is  dark 
in  color,  like  coffee-grounds  in  appearance.  The  relation  of  vomiting 
to  the  time  of  taking  meals  depends  upon  the  seat  of  the  disease.  If 
at  the  cardiac  end  of  the  stomach,  the  vomiting  may  take  place  at 
once.  If  in  the  greater  curvature,  within  twenty  minutes  or  one 
hour  and  a  half  after  taking  food.  If  at  the  pyloric  orifice,  the  vomit- 
ing is  delayed  several  hours.  ■  As  the  disease  advances,  and  obstruc- 
tion becomes  more  complete  at  the  cardiac  orifice,  food  is  immediately 
regurgitated,  unless  secondary  dilatation  of  the  oesophagus  takes  place. 
When  there  is  gastric  dilatation  the  vomiting  may  take  place  at  longer 
intervals  and  be  characteristic  of  the  vomitus  of  dilatation.  Constipa- 
tion is  the  rule. 

Tumor.  After  the  symptoms  of  chronic  gastritis  have  continued  for 
some  time  without  relief  a  tumor  may  be  detected,  depending  upon  its 
situation  and  size.  (See  Tumors  of  Abdomen.)  If  the  growth  is  situ- 
ated at  the  cardiac  orifice  of  the  stomach,  it  is  often  impossible  to 
detect  it.  If  at  the  pyloric  orifice,  the  tumor  is  found  to  the  right  of 
the  median  line  above  the  umbilicus,  but  may  be  forced  down  by 
the  weight  of  the  stomach  and  felt  at  the  umbilicus.  (See  Plate 
XXXVIII.,  Fig.  2.)  When  dilatation  follows  pyloric  tumor  it  may 
be  still  lower  down,  as  in  a  case  of  the  writer's,  in  which  it  was  found  two 
inches  below  and  to  the  right  of  the  umbilicus.  In  tumor  of  the  greater 
curvature  the  mass  is  detected  below  the  margin  of  the  ribs  on  the  left 
side,  and  may  be  as  low  down  as  the  umbilicus.  If  the  greater  curvature 
is  involved,  the  organ  usually  atrophies,  and  hence  the  physical  signs 
indicating  the  lower  border  of  the  stomach  are  higher  up  than  in  health. 

It  is  necessary  to  exclude  tumors  due  to  other  causes.  This  is  some- 
times difficult — indeed,  as  far  as  the  location  and  physical  characters 
are  concerned,  often  impossible.  The  most  pronounced  diagnostic 
feature  of  tumor  of  the  pylorus  is  the  occurrence  of  secondary  dilata- 
tion of  the  stomach.  For  a  differential  diagnosis  of  tumors  in  this 
region,  see  Palpation  of  Abdomen. 

Symptoms  due  to  Metastasis.  The  liver  is  the  most  frequent  seat  of 
secondary  growths.  The  organ  enlarges,  and  its  surface  is  covered 
over  with  nodules.  (See  Plate  XXXVIII. ,  Fig.  2.)  Jaundice  occurs 
in  rare  instances.  The  enlarged  liver  may  cover  the  stomach  and  hide 
the  local  mass.  The  inguinal  glands  enlarge.  At  times  there  is  en- 
largement of  the  supraclavicular  glands,  suggestive  also  of  intra-abdom- 
inal carcinoma,  from  other  causes. 

The  general  symptoms  are  those  of  emaciation  and  cachexia.  The 
emaciation  is  extreme,  and  in  some  cases  may  be  out  of  proportion  to 
the  local  symptoms. 


810  SPECIAL  DIAGNOSIS. 

The  symptoms  of  cachexia  are  those  of  emaciation  and  anaemia. 
The  ancemia  becomes  profound.  The  pallor  of  the  face  is  striking, 
often  it  is  of  a  yellowish  and  straw-colored  hue.  It  must  not  be  con- 
founded with  jaundice — examination  of  the  conjunctiva?  is  usually 
sufficient  to  distinguish  the  two.  The  skin  is  flabby,  and  the  subcu- 
taneous fat  is  entirely  lost ;  the  emaciation  is  not  so  marked  as  in  cancer 
of  the  oesophagus,  except  when  there  is  complete  cardiac  stricture. 
The  nutrition  of  the  skin  suffers,  boils  are  common,  and  ulcers  may 
occur.  Subcutaneous  hemorrhages  are  seen  in  the  terminal  stages  on 
the  backs  of  the  hands,  on  the  dorsum  of  the  feet,  on  the  legs  and 
arms.     There  is  slight  cedenia  of  the  ankles. 

General  atrophy  of  the  internal  organs  takes  place,  so  that  the  heart 
becomes  small ;  it  loses  its  strength,  the  patient  becomes  weaker  and 
weaker,  the  pulse  rapid  and  feeble. 

If  fever  occurs  in  the  course  of  the  disease,  it  is  usually  due  to  sec- 
ondary accidents,  as  suppuration  in  a  tumor,  or  perforation  with  septic 
peritonitis.  The  usual  course  of  the  temperature  is  normal  until  the 
later  stages,  when  it  is  subnormal. 

Examination  of  the  Stomach-contents.  Hydrochloric  acid  may  or 
may  not  be  absent,  depending  upon  the  amount  of  gastric  catarrh. 
Lactic  acid,  on  the  other  hand,  is  commonly  present  even  in  the  earli- 
est stages,  and  when  associated  with  absent  HC1  is  very  diagnostic. 
Boas'  test-breakfast  must  be  given.  For  an  accurate  diagnosis  re- 
peated examinations  must  be  made.  Other  general  and  local  condi- 
tions, as  fevers  on  the  one  hand,  or  dilatation  on  the  other,  are  attended 
by  absence  of  hydrochloric  acid  at  times.  In  carcinoma  it  is  the  per- 
sistence of  the  absence  which  is  diagnostic.  Pepsin  and  the  milk- 
curdling  ferment  are  not  changed. 

The  Urine.  Indican  in  increased  amount,  acetone  and  diacetic  acids 
may  be  present  in  the  urine ;  otherwise  there  is  no  change. 

Diagnosis.  In  the  diagnosis  of  gastric  cancer  the  following  must  be 
borne  in  mind  :  1.  The  age  of  the  patient.  2.  The  occurrence  of 
causeless  dyspepsia  without  relief.  3.  Rapid  loss  of  flesh  and  strength, 
with  cachexia.  4.  The  occurrence  of  pain  in  the  epigastrium,  contin- 
uous, increased  by  food,  but  not  relieved  by  vomiting,  as  in  ulcer, 
and  not  distinctly  localized.  5.  Tumor — hard,  circumscribed,  fol- 
lowed by  the  physical  signs  of  dilatation,  if  in  the  pylorus.  6.  Vom- 
iting is  necessarilv  associated  with  the  taking  of  food,  in  which  frag;- 
ments  of  cancer  may  be  found  ;  blood-cells  are  common  ;  they  may  be 
detected  on  microscopical  examination,  or  by  the  test  for  heemin.  7. 
Examination  of  stomach-contents.  («■)  Except  in  dilatation  the  fasting 
stomach  is  empty  ;  (6)  hydrochloric  acid  is  often  absent,  whereas  lactic 
acid  is  present ;  (c)  delayed  absorption  is  present,  indicated  by  motor 
tests.  8.  Hemorrhage.  In  small  amounts,  usually  of  characteristic, 
coffee-ground  appearance.  9.  Metastases— above  the  left  clavicle  ;  in 
the  liver  ;  in  the  inguinal  glands  ;  rarely  in  the  lungs  and  peritoneum. 
10.  Eichhorst  speaks  of  persistent  itching  of  the  skin  and  insomnia  as 
characteristic  symptoms.  11.  Finally,  the  comparatively  short  dura- 
tion of  the  case.     Rarely  does  it  extend  over  a  period  of  two  years. 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     811 


Differential  Diagnosis  of  Gastric  Cancer,  Gastric  Ulcer,  and 
Chronic  Gastritis.    (Welch.) 


Gastric  Cancer. 

1.  Tumor  is  present  in  three- 
fourths  of  the  cases. 

2.  Rare  under  forty  years  of 


Gastric  Ulcer. 


Tumor  rare. 


Chronic  Catarrhal  Gastritis. 
No  tumor. 


May  occur  at  any  age  after 
childhood.  Over  one-half  of 
the  cases  under  forty  years 
of  age. 


May  occur  at  any  age. 


3.  Average  duration  about  one    Duration  indefinite;  may  he    Duration  indefinite, 
year,  rarely  over  two  years.  ;    for  several  years. 


4.  Gastric  hemorrhage  fre- 
quent, but  rarely  profuse ; 
most  common  in  the  ca- 
chectic stage. 


Gastric  hemorrhage  less  fre- 
quent than  in  cancer,  but 
oftener  profuse  ;  not  uncom- 
mon when  the  general 
health  is  but  little  im- 
paired. 


Gastric  hemorrhage  rare. 


5.  Vomiting  often  has  the  pe-    Vomiting  rarely  referable  to    Vomiting    may   or   may    not   be 
culiarities  of  that  of  dila-      dilatation  of  the  stomach,      present, 
tation  of  the  stomach.  and  then  only  in  a  late  stage 

I    of  the  disease. 


Free  hydrochloric  acid  usu- 
ally absent  from  the  gastric 
contents  in  cancerous  dila- 
tation of  the  stomach  ;  lac- 
tic acid  much  increased. 


Free  hydrochloric  acid  usu- 
ally present  in  the  gastric 
contents. 


7.  Cancerous  fragments  may    Absent. 
be  found  in  the  washings 

from  the  stomach  or  in  the 
vomit  (rare). 

8.  Secondary  cancers  may  be    Absent, 
recognized  in  the  liver,  the 
peritoneum,  the  lymphatic 
glands. and, rarely, in  other 
parts  of  the  body. 


9.  Loss  of  flesh  and  strength 
and  development  of  ca- 
chexia usually  more  mark- 
ed and  more  rapid  than  in 
ulcer  or  in  gastritis,  and 
less  explicable  by  the  gas- 
tric symptoms. 

10.  Epigastric  pain  is  often 
more  continuous,  less  de- 
pendent upon  taking  food, 
less  relieved  by  vomiting, 
and  less  localized  than  in 
ulcer. 

11.  Causation  not  known. 


Cachectic  appearance  usually 
less  marked  and  of  later 
occurrence  than  in  cancer, 
and  more  manifestly  depen- 
dent upon  the  gastric  dis- 
orders. 


Pain  is  often  paroxysmal, 
more  influenced  by  taking 
food,  oftener  relieved  by 
vomiting,  and  more  sharply 
localized  than  in  cancer. 


Causation  not  known. 


Free   hydrochloric   acid  may  be 
present  or  absent. 


Absent. 


Absent. 


When  uncomplicated,  usually  no 
appearance  of  cachexia. 


The  pain  or  distress  induced  by 
taking  food  is  usually  less  severe 
than  in  cancer  or  ulcer.  Fixed 
points  of  tenderness  usually  ab- 
sent. 


Often  referable  to  some  known 
cause,  such  as  abuse  of  alcohol, 
gormandizing,  and  certain  dis- 
eases, as  phthisis,  Bright's  dis- 
ease, cirrhosis  of  the  liver,  etc. 

May  be  a  history  of  previous  simi- 
lar attacks.  More  amenable  to 
regulation  of  diet  than  is  cancer. 


12.  No  improvement,  or  only  Sometimes  a  history  of  one  or 
temporary  improvement,  more  previous  similar  at- 
in  the  course  of  the  dis-  tacks.  The  course  may  be 
ease.  irregular  and  intermittent. 

]    Usually    marked    improve- 
ment by  regulation  of  diet. 

Cases  of  cancer  of  the  stomach  may  present  only  symptoms  of  anae- 
mia. In  this  manner  the  disease  has  been  confounded  with  pernicious 
ancemia.  The  blood  is  never  reduced  in  cancer  to  the  degree  it  is  in 
pernicious  anamiia,  nor  does  it  present  the  characteristics  found  in 
anaemia. 

Ulcer  of  the  Stomach.  Simple  round  ulcer  of  the  stomach  may 
occur  at  any  age,  but  is  most  common  in  young  anaemic  women.     It 


812  SPECIAL  DIAGNOSIS. 

may  be  the  result  of  an  erosion  of  hemorrhagic  infarcts  by  the  gastric 
juice.     Stockton  believes  it  to  be  a  neuropathic  change. 

The  Symptoms.  The  symptoms  are  variable.  The  cases  have 
been  divided  by  Welch  into  four  classes  :  (1)  Those  in  which  there  are 
no  symptoms  whatever,  the  ulcer  having  been  found  after  death  from 
other  diseases  ;  (2)  no  symptoms  until  the  sudden  occurrence  of  hemor- 
rhage, or  perforation  ;  (3)  the  symptoms  of  chronic  gastritis  or  gastral- 
gia  only  ;  (4)  typical  cases,  with  the  characteristic  symptoms,  pain, 
hemorrhage,  and  vomiting.  The  symptoms  of  gastric  ulcer  may  develop 
suddenly. 

Pain,  The  pain  is  localized  ;  it  is  usually  confined  to  a  small  area 
in  the  epigastrium.  It  may  be  seated  behind  the  cartilage  of  the  sixth 
and  seventh  ribs,  or  may  be  complained  of  in  the  back,  between  the 
eighth  and  ninth  dorsal  vertebra?,  extending  as  low  down  as  the  first 
and  second  lumbar.  It  is  of  a  burning  or  gnawing  character,  is  in- 
creased by  food,  and  comes  on  in  from  two  to  ten  minutes  after  the 
ingestion  of  food.  It  is  relieved  by  vomiting,  or  after  the  act  of  diges- 
tion is  completed  ;  but  a  persistent,  dull  pain  or  a  feeling  of  soreness 
remains.  In  addition  to  the  ordinary  pains,  there  may  be  attacks  of 
gastralgia.  The  pain  is  increased  by  pressure.  It  may  be  modified 
by  the  position  of  the  patient.  It  may  be  relieved  by  lying  on  the 
back  when  the  ulcer  is  in  the  anterior  wall ;  or  relieved  by  lying  on 
the  abdomen  when  in  the  posterior  wall. 

Vomiting.  Vomiting  occurs  shortly  after  the  ingestion  of  food.  It 
is  not  attended  by  retching.     The  vomited  matter  may  contain  blood. 

The  vomited  matter  and  the  contents  of  the  stomach  contain  hydro- 
chloric acid,  which  may  be  in  excess.  Eichhorst  thinks  it  is  always  in 
excess. 

Hemorrhage.  Blood  in  the  vomitus  gives  it  a  brown  or  reddish 
color.  It  may  be  detected  by  the  usual  methods.  Hemorrhage  may 
occur,  however,  independently  of  the  act  of  vomiting.  It  varies  in 
amount  from  half  a  pint  to  a  quart.  It  may  be  so  severe  as  to  cause 
collapse.  Sometimes,  instead  of  being  discharged  as  a  profuse  hemor- 
rhage, the  blood  may  gradually  ooze  from  the  ulcer  and  collect  in  the 
stomach  before  being  vomited.  It  is  then  altered  by  the  acid  gastric 
juice.  Sometimes  the  blood  is  not  vomited,  but  passed  by  stool,  which 
is  then  tarry.  Tarry  stools  also  follow  the  vomiting  of  blood.  In  the 
course  of  ulcer  a  hemorrhage  may  be  so  severe  that  death  takes  place 
before  vomiting  occurs.  The  stomach  is  then  found  to  be  filled  with 
blood. 

The  stomach  bougie  should  not  be  used  ;  the  nature  of  the  contents 
must  be  determined  by  an  examination  of  the  vomited  matter. 

The  General  Symptoms.  If  the  cases  are  of  long  standing,  the 
face  is  anxious  and  the  lines  are  sharpened.  If  there  is  much  hemor- 
rhage, anaemia  ensues.  There  is  not  much  wasting  and  no  fever. 
Chronic  dyspepsia  and  constipation  may  be  present  during  the  intervals 
in  which  the  severe  symptoms  are  in  abeyance.  The  period  of  abey- 
ance varies,  and  the  symptoms  may  come  on  without  cause,  as  in  gas- 
tric crises,  during  which  time  the  vomiting  may  persist  for  two  or  three 
days.     I  saw  a  young  girl  of  twenty  years  with   most  severe  gastric 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     813 

hemorrhage  and  classical  symptoms  of  ulcer.  With  careful  treatment 
she  improved.  After  marriage  she  remained  well  until  pregnancy. 
During  the  first  periods  of  this  condition  vomiting  was  extreme  ;  it 
then  subsided,  whereupon,  without  warning,  a  gastric  crisis  took  place. 
The  vomiting  of  blood  continued  for  many  days,  and  the  symptoms  of 
gastric  ulcer  remained  for  a  month. 

One  of  the  characteristic  features  of  the  disease  is  the  recurrence  of 
symptoms  after  a  long  period  of  abeyance.  A  patient  under  my  care 
during  the  last  ten  years  has  had  three  undoubted  attacks.  It  is  pos- 
sible that  during  each  period  ulcers  healed,  to  be  followed  after  a  time 
by  the  occurrence  of  new  ulcers. 

Diagnosis.  The  diagnostic  features  are  :  1.  The  age.  2.  The  long 
duration.  3.  The  occurrence  of  emaciation  up  to  a  certain  point  only  ; 
most  of  the  patients  are  under-weight  and  have  a  gaunt  look,  particu- 
larly males.  4.  The  characteristic  pain.  5.  The  vomiting.  6.  The 
hemorrhage.  7.  The  periods  of  relief  from  symptoms.  8.  The  absence 
of  marked  nervous  symptoms  which  attend  gastric  neuroses.  9.  The 
absence  of  dilatation  of  the  stomach.  10.  The  hyperacidity  of  the 
gastric  juice. 

The  Accidents  of  Ulcer  of  the  Stomach.  1.  The  occurrence  of  perfo- 
ration. Sudden  severe  pain,  with  collapse.  The  pain  is  usually  in 
the  epigastrium,  but  may  be  in  the  back  as  high  as  the  seventh  or 
eighth  dorsal  vertebra. 

2.  Hemorrhage,  which  may  cause  death  immediately,  with  either 
vomiting  of  blood  or  retention  in  the  stomach. 

3.  With  healing  of  the  ulcer,  stenosis  at  the  pyloric  orifice  may  take 
place,  with  subsequent  dilatation  of  the  stomach. 

Diseases  of  the  Intestines. 

The  intestine  is  a  canal  of  varying  dimensions,  the  physiological 
office  of  which  is  to  propel  material  received  from  the  stomach,  and  to 
permit  of  the  digestion  and  absorption  of  that  which  is  to  serve  for  the 
nutrition  of  the  body.  The  canal  is  richly  supplied  with  bloodvessels 
and  lymphatics.  It  is  made  up  of  mucous  membrane,  muscle,  and 
peritoneum.  For  the  purpose  of  digestion,  fluids  are  secreted,  either 
from  the  intestinal  glands  or  large  neighboring  glands  which  discharge 
into  the  canal. 

Diseases  which  affect  the  canal  impair  or  cause  an  abeyance  of  the 
physiological  offices.  As  these  offices — absorption  and  digestion — are 
essential  to  nutrition,  it  is  not  surprising  that  the  body-weight  and 
strength  are  impaired.  We  know  too  little  about  the  function  of  diges- 
tion to  utilize  such  knowledge  in  diagnosis.  Intestinal  digestion  is 
also  dependent  upon  the  healthy  performance  of  the  functions  of  the 
liver  and  pancreas.  It  is  difficult  to  draw  fine  lines  of  distinction  even 
in  health,  and  intestinal  pathology  is  closely  interwoven  with  hepatic 
and  pancreatic  pathology. 

Alterations  of  the  function  of  the  intestine  as  a  canal  give  rise  to  dis- 
tinctive symptoms.  Either  its  movements  are  too  frequent  and  rapid, 
causing  diarrhoea,  or  too  sluggish,  causing  constijjiition.    Obstruction  of 


814  SPECIAL  DIAGNOSIS. 

the  canal  leads  to  symptoms  common  to  such  a  condition  (see  Morbid 
Process),  modified  by  the  physiological  duties  and  the  anatomical 
structure  of  the  canal. 

The  morbid  processes  are  hyperemias,  inflammations,  degenera- 
tions, and  new  growths.  The  symptoms  that  attend  these  processes 
are  not  different  from  the  symptoms  that  attend  such  processes  in 
similar  structures  elsewhere.  It  must  not  be  forgotten  that  the  function 
of  the  canal  is  influenced  by  each  process.  On  account  of  the  process 
we  may  have  pain  and  fever ;  on  account  of  the  impaired  function, 
pain,  flatulency,  diarrhoea,  or  constipation,  change  in  the  character  of 
the  stools,  and  impaired  nutrition.  Some  of  the  above  morbid  processes 
may  lead  to  the  mechanical  condition,  obstruction. 

The  morbid  alterations  of  the  intestinal  tract  are  ascertained  by 
data  obtained  by  inquiry  and  by  observation.  The  data  obtained  by 
inquiry  include  the  subjective  symptoms — pain,  and  discomfort  from 
flatulency.  By  observation  the  general  condition  of  the  patient,  the 
presence  of  tenderness,  alterations  in  the  size  and  shape  of  the  abdo- 
men, and  other  physical  phenomena  are  observed.  The  feces  are  care- 
fully studied,  with  the  object  of  determining  modifications  of  the 
function  of  the  bowel,  the  presence  of  ingredients  due  to  some  morbid 
process,  as  serum,  blood,  pus,  or  mucus,  or  of  extraneous  matter,  as 
worms  or  foreign  substances.  The  feces  are  studied  by  the  naked  eye, 
by  the  microscope,  and  by  bacteriological  methods. 

One  symptom  may  be  the  chief  manifestation  of  a  disease,  as  pain 
of  lead-colic,  diarrhoea  of  several  morbid  disorders,  constipation  of 
others.  In  the  discussion  of  the  special  symptoms  a  consideration  of 
the  diseases  of  which  the  symptom  is  the  main  expression  will  be 
taken  up. 

Parasites.  The  intestine  is  the  recipient  of  material  for  nutrition. 
Parasitic  forms  of  animal  life,  or  their  ova  or  spores,  may  enter  the  in- 
testine with  the  food.  They  either  remain  in  the  intestinal  tract  or 
wander  into  other  structures.  They  include  animal  and  vegetable 
parasites,  such  as  forms  of  protozoa,  vermes,  and  fungi.  While  the 
canal  is  open  to  infection  by  various  micro-organisms,  it  is  the  natural 
habitat  of  others,  which  may  become  deleterious  agencies  when  the 
conditions  of  their  environment  are  changed.  Thus  the  bacillus  coli 
communis  is,  in  man,  with  normal  epithelial  structure  and  normal 
secretions,  an  innocuous  parasite  which,  when  inflammation  sets  in, 
may  become  nocuous. 

The  symptoms  produced  by  the  protozoa  and  fungi,  or  by  their  prod- 
ucts, the  ptomaines,  are  of  an  infectious  or  toxic  nature.  Inflamma- 
tion is  produced  locally. 

The  symptoms  of  worms,  if  retained  in  the  intestinal  canal,  are  :  (1) 
Reflex  in  nature  ;  (2)  symptoms  due  to  catarrhal  inflammation  ;  (3) 
symptoms  due  to  action  of  the  parasite  on  the  blood — anaemia ;  (4) 
symptoms  due  to  wandering  of  the  parasite,  as  in  trichinosis.  (See 
Feces.) 

Symptoms  of  the  Tcen'm  and  Bothriocephali.  There  may  be  no  symp- 
toms save  discharge  of  the  parasite  or  portions  of  it  by  the  rectum. 
In  others  the  symptoms  of  intestinal  dyspepsia  or  intestinal  catarrh 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     815 

are  observed.  Headache,  giddiness,  lassitude,  and  itching  at  the  nose 
and  at  the  anus  are  said  to  be  present.  The  patient  becomes  hypo- 
chondriacal. Convulsive  disorders  occur.  Hysteria,  forms  of  epilepsy, 
grinding  of  the  teeth  at  night,  and  restlessness  attend  the  habitation  of 
the  parasite  in  the  intestine.  In  all  convulsive  disorders  the  possi- 
bility of  worms  as  a  cause  must  be  remembered. 

Symptoms  of  Asearides.  (1)  Gastro-intestinal  catarrh  ;  (2)  symp- 
toms of  obstruction  (rare)  ;  (3)  symptoms  due  to  wandering — as  to  the 
hepatic  duct  to  the  stomach,  or  to  the  vagina  ;  (4)  nervous  symptoms 
of  reflex  origin  ;  (5)  the  worm  or  its  ova  in  the  feces. 

Symptoms  of  Oxyuris  Vermicular  is.  (1)  Gastro-intestinal  dyspepsia 
or  catarrh  ;  (2)  itching  or  heat  at  the  anus,  worse  in  bed  ;  (3)  vesical 
and  rectal  tenesmus  ;  (4)  erythema  about  the  anus  ;  (5)  priapism  ;  (6) 
vulvitis  and  vaginitis  ;  (7)  the  worms  in  the  feces. 

The  Strongylus.  The  symptoms  are  local,  with  the  symptoms  of 
profound  anaemia.  The  discovery  of  the  ova  in  the  feces  distinguishes 
this  form  of  anaemia  from  other  varieties. 

The  symptoms  due  to  the  presence  of  the  trichina  spiralis  and  filaria 
will  be  discussed  in  appropriate  sections.  (See  Blood  and  Infectious 
Diseases.) 

The  Intestines  in  other  Diseases.  The  relationship  of  intes- 
tinal disorders  to  affections  of  other  viscera  will  be  discussed  with  each 
symptom.  It  must  not  be  forgotten  that  derangement  of  this  tract 
may  have  its  origin  in  local  causes  or  in  causes  remote  from  the  intes- 
tinal tract,  or  in  some  general  condition  of  the  individual.  Thus  diar- 
rhoea may  be  due  to  inflammation  which  is  primarily  local,  or  which 
may  be  secondary  to  infection.  Nothing  is  more  common  than  to  see 
diarrhoea  in  a  general  infection,  such  as  septicaemia.  In  exophthalmic 
goitre  the  diarrhoea  is  not  due  to  a  local  cause,  but  to  some  as  yet  un- 
known nerve  disorder.  Constipation  may  be  due  to  central  brain  dis- 
ease, to  a  general  condition  like  diabetes,  or  be  of  local  origin. 

It  must  be  remembered  that  the  diagnosis  of  an  intestinal  lesion 
is  never  complete  without  determining  its  causes.  Thus  enteritis  and 
ulceration  occur  in  typhoid  fever,  in  cholera,  and  in  other  infectious 
disorders,  all  of  which  are  to  be  passed  in  review  in  making  up  a  diag- 
nosis. Diarrhoea  is  a  symptom  in  Bright' s  disease,  and  the  causal  rela- 
tionship must  always  be  borne  in  mind. 

Differential  Diagnosis.  Intestinal  disease  or  disorders  are  not  usually 
confounded  with  disease  of  other  structures.  It  is  worthy  of  remark, 
as  a  fact  which  is  sometimes  overlooked,  that  symptoms  of  intestinal 
obstruction  are  frequently  due  to  peritonitis.  Tumors  of  the  intestine 
must  be  distinguished  from  tumors  of  the  peritoneum,  the  stomach, 
pancreas,  and  liver,  and  the  uterus  and  ovaries.  The  history,  the  seat 
and  physical  character  of  the  tumor,  and  the  associate  symptoms  point 
to  the  true  condition. 

Arteries  of  the  Intestine.  The  intestines  are  supplied  by  the  mesen- 
teric arteries.  Its  branches  may  become  the  seat  of  emboli.'  The 
symptoms  are  sudden  pain,  intestinal  hemorrhage,  and  discharge  of  a 
portion  of  intestine.  The  patients  are  the  subjects  of  atheroma  or  heart 
disease. 


816  SPECIAL  DIAGNOSIS. 

The  Subjective  Symptoms. 

The  Data  Obtained  by  Inquiry.  Pain.  Colic.  Colic  is  the  term 
applied  to  paroxysmal  pain  in  the  abdomen.  It  is  characterized  by 
suddenness  of  onset  and  by  alteration  of  intestinal  function.  It  attends 
all  forms  of  inflammation  of  the  intestinal  tract.  It  is  applied  to  a 
peculiar  affection  known  as  lead-colic,  due  to  local  effects  of  lead.  The 
term  colic  is  also  applied  to  painful  affections  of  the  hepatic  ducts, 
pancreatic  ducts,  the  ureters,  and  the  uterus.  Intestinal  colic  is  the 
form  at  present  referred  to.  In  addition  to  the  inflammation  of  the 
intestinal  tract,  it  may  be  due  to  indigestion  with  flatulency.  AVhen  it 
occurs  suddenly  without  local  cause  it  is  known  as  enter algia. 

Ixtestinal  Colic.  The  colic  of  intestinal  indigestion  occurs  sud- 
denly, or  it  may  be  preceded  by  signs  of  intestinal  indigestion.  The 
pain  is  chiefly  in  the  umbilical  region  and  radiates  from  that  point. 
It  is  relieved  by  moderate  pressure  or  warmth.  The  patient  is  rest- 
less and  irritable.  The  face  is  anxious.  The  pain  causes  him  to 
roll  about  and  double  up.  There  is  a  cold  sweat,  and  the  pulse  is 
small  and  hard.  Prostration  or  collapse  rapidly  ensues.  Nausea  and 
vomiting  follow  the  pain,  and  there  are  gaseous  eructations.  Disten- 
tion. The  abdomen  is  distended  and  tympanitic  on  percussion.  The 
pain  may  be  relieved  by  the  passing  of  flatus.  Cramps.  Spasm  of 
the  muscles  of  the  calves  is  common.  The  cramps  are  very  painful ; 
the  muscles  become  knotted.  The  hands  and  feet  are  also  cramped. 
The  pain  is  said  to  be  due  to  spasm  of  the  intestine,  and  is  known  also 
as  spasmodic  colic.     It  is  certainly  due  to  distention  or  to  irritation. 

If  the  intestinal  colic  is  due  to  indigestible  food,  it  may  have  been  pre- 
ceded by  an  attack  of  acute  indigestion,  and  the  griping  pains  may 
have  developed  at  long  intervals,  with  gastric  and  intestinal  flatulency. 
Vomiting  may  precede  or  attend  the  attack,  and  diarrhoea  follow.  If 
the  colic  is  due  to  gas  alone,  there  is  great  tympanites.  If  it  is  due 
to  feces,  it  has  been  preceded  by  a  history  of  constipation,  and  there 
may  be  fecal  masses  detected  in  the  rectum  or  along  the  colon. 

Fever.  The  presence  of  fever  is  against  intestinal  colic,  and  points 
to  inflammation  in  some  portion  of  the  abdomen  ;  moreover,  in  inflam- 
mation the  pain  is  constant,  but  localized  and  aggravated  by  pressure. 
The  skin  is  hot  and  dry. 

Diagnosis.  The  sudden  severe  pain,  often  relieved  on  the  discharge 
of  gas,  with  gastro-intestinal  disorder,  tympanites,  the  occurrence  of 
cramps  in  the  extremities,  and  the  localization  of  pain  to  the  umbili- 
cus, all  point  to  the  true  nature  of  the  affection.  A  history  of  indis- 
cretion in  diet,  or  exposure,  aids  in  the  diagnosis.  In  colic  the  pain 
may  come  on  suddenly,  or  increase  gradually  from  a  sense  of  discom- 
fort or  soreness.  The  pain  at  its  height  is  described  as  agonizing,  and 
of  a  boring  or  shooting  character,  abating  for  a  time  and  then  in- 
creasing, until  the  patient  rolls  and  twists  in  agony  and  breaks  out  into 
a  cold  sweat.  The  pain  may  shoot  from  the  seat  of  greatest  intensity 
to  the  shoulders,  back,  chest,  or  iliac  region. 

It  must  be  distinguished  from  enteralgia.  The  latter  comes  on 
slowly  and  lasts  for  hours  or  days.     The  pain  is  situated  around  the 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     817 

umbilicus,  and  is  relieved  by  deep  pressure,  although  the  skin  may  be 
hyperaesthetic.  Sometimes  the  abdomen  is  retracted ;  there  are  no 
signs  of  indigestion,  and  flatulency  and  borborygmi  are  absent. 

Lead  Colic.  If  the  enteralgia  is  due  to  lead,  there  is  a  history  of 
exposure  to  that  metal.  The  blue-line  on  the  gums,  with  obstinate 
constipation  but  no  vomiting,  and  the  occurrence  of  neuritis  due  to 
saturnine-poisoning,  point  to  the  true  nature  of  the  case. 

Hepatic  Colic.  In  hepatic  colic  the  pain  is  situated  in  the  region 
of  the  liver,  and  may  radiate  to  the  shoulder  or  back.  It  is  sometimes 
fixed  in  the  right  parasternal  line  about  the  cartilages  of  the  sixth  and 
seventh  ribs.  The  attack  is  attended  by  vomiting,  usually  of  bilious 
fluid.  It  occurs  in  women  most  frequently  ;  the  patients  are  almost 
always  over  forty  years  of  age.  It  may  be  followed  by  jaundice.  There 
is  local  tenderness,  and  there  may  be  some  swelling  in  the  region  pre- 
viously mentioned.  The  bowels  are  constipated,  and  after  the  attack 
may  contain  gallstones. 

Renal  Colic.  In  renal  colic  pain  begins  in  the  kidney  and  then 
extends  along  the  ureter.  It  is  always  more  localized  to  the  right  or 
left  of  the  median  line  in  the  abdomen.  It  is  more  frequently  in  the 
lower  portion  of  either  of  the  upper  quadrants,  three  inches  to  either 
side  of  the  median  line,  depending  upon  the  kidney  affected.  From 
this  region  the  point  of  maximum  intensity  and  of  local  tenderness 
moves  to  the  lower  quadrant  toward  the  median  line  in  the  oblique 
direction,  rarely  getting  an  inch  below  the  transverse  umbilical  line. 
The  pain  then  extends  to  the  region  above  the  pubes  and  down  the 
thighs.  From  the  first  there  is  increased  frequency  of  micturition. 
The  urine  is  scanty,  high-colored,  and  may  contain  blood.  With  the 
free  micturition  relief  follows. 

Local  Peritonitis.  Pain  over  the  liver,  spleen,  and  kidneys  is  gener- 
ally due  to  involvement  of  the  peritoneal  coverings  of  these  organs, 
and  partakes  of  the  character  of  local  peritonitis.  It  may,  however, 
be  due  to  malignant,  ulcerative,  or  inflammatory  disease,  and  the  diag- 
nosis must  be  made  by  noting  the  character  of  the  pain,  its  intensity, 
duration,  seat,  and  the  other  general  and  local  symptoms  with  which 
it  is  associated. 

Rectal  Pain.  Pain  in  defecation  may  be  due  to  piles,  internal  or 
external,  or  to  fissure,  or  may  be  the  result  simply  of  the  passage  of 
an  unusually  large,  hard  mass.  Pain  from  fissure  is  most  acute  and 
spasmodic,  and  persists  for  some  time  after  defecation.  Fibroid  stric- 
ture of  the  rectum  causes  more  pressure  and  straining  at  stool  than 
real  pain  ;  but  cancer  is  apt  to  be  extremely  painful. 

Uterine  Colic.  In  uterine  colic  the  pain  is  situated  in  the  pelvis. 
There  is  some  abnormality  of  discharge,  and  a  history  of  uterine  dis- 
ease. Care  must  be  taken  not  to  confound  the  sudden  pain  of  extra- 
uterine pregnancy  with  intestinal  colic  or  other  forms  of  abdominal 
pain.  In  extra-uterine  pregnancy  the  pain  is  in  the  lower  quadrants  of 
the  abdomen  to  the  right  or  left  of  the  median  line.  It  is  sudden  and 
intense,  attended  by  more  or  less  collapse.  It  may  be  attended  by 
all  the  symptoms  of  internal  hemorrhage.  It  may  cause  vomiting. 
The  history  of  cessation  of  menses,  or  other  signs  of  pregnancy,  of 

52 


818  SPECIAL  DIAGNOSIS. 

discharge  of  decidua,  with  the  local  signs  on  physical  examination? 
indicate  the  true  nature  of  the  pain. 

Pancreatic  Pain.  In  disease  of  the  pancreas,  either  from  the  passage 
of  calculi  (extremely  rare)  or  because  of  pancreatic  hemorrhage,  there 
may  be  sudden  severe  pain.  The  pain  is  localized  to  the  region  below 
the  sternum.  It  may  be  severe  in  the  back  and  extend  up  the  thorax. 
It  occurs  in  paroxysms,  and  is  attended  by  great  anxiety  and  collapse. 

Gastric  Pain.  Intestinal  colic  must  be  differentiated  from  pain 
of  gastric  ulcer,  gastric  cancer,  and  gastralgia.  The  characteristics  of 
pain  in  these  affections  have  been  discussed.  When  perforation  occurs 
in  gastric  ulcer  the  pain  is  usually  seated  in  the  epigastrium,  but  may  be 
complained  of  in  the  back  as  high  as  the  mid-scapular  region.  It  is 
sudden  and  severe,  preceded  by  a  history  of  ulcer  and  attended  by 
collapse.  There  are  no  evidences  of  indigestion.  Perforation  of  the 
biliary  passages  is  attended  by  pain  in  the  hepatic  region.  The  pain 
is  sudden  and  is  usually  preceded  by  symptoms  due  to  derangement  of 
the  biliary  passages  from  obstruction  by  gallstones. 

Appendicitis.  Intestinal  colic  must  not  be  confounded,  although 
it  frequently  has  been,  with  the  pains  that  attend  appendicitis.  This 
is  particularly  the  case  with  relapsing  appendicitis.  In  this  form  only 
mild  fever  attends  the  attack.  The  patient  is  seized  with  severe  pain, 
which  may  be  described  as  occurring  in  the  lower  right  quadrant,  but 
is  sometimes  complained  of  about  the  umbilicus.  It  frequently  follows 
indiscretion  in  diet,  and  may  be  attended  by  vomiting,  and  is  likewise 
usually  relieved  by  eructation,  but  not  by  the  passage  of  gas,  a  point 
of  great  importance  in  the  diagnosis.  The  attack  occurs  mostly  in 
young  subjects,  and  lasts  from  twelve  to  twenty -four  hours.  It  may 
be  so  severe  as  to  cause  collapse.  If  fever  attends  it,  and  there  is 
a  mass  present,  the  diagnosis  is  much  easier.  In  the  relapsing  as  well 
as  the  true  form  there  is  tenderness  at  McBurney's  point.  (See  Ap- 
pendicitis.) 

Peritonitis.  Intestinal  colic  must  not  be  confounded  with  peri- 
tonitis, which  may  follow  in  any  of  the  above  conditions,  or  develops  at 
other  points  in  the  abdomen.  The  purulent  peritonitis  that  succeeds 
pyosalpinx  may  be  attended  by  severe  pain  without  much  reaction. 
The  pain,  however,  although  complained  of  about  the  umbilicus,  can  be 
localized  by  pressure  in  the  lower  quadrant  and  in  the  pelvis.  It  may 
disappear  after  eight  or  ten  hours,  to  be  followed  by  a  recurrence. 
The  recurrence  of  pain  is  usually  attended  by  fever.  In  the  first 
twenty-four  hours  the  bowels  are  loose,  or  at  least  readily  moved.  If 
the  peritonitis  continues  beyond  this  period,  it  is  often  impossible  to 
move  the  bowels. 

Intestinal  Obstruction.  Intestinal  colic  must  not  be  confounded 
with  organic  disease  of  the  bowels  with  resulting  obstruction.  In 
these  affections  there  are  sudden  constipation  and  rapid  prostration. 
The  vomiting,  if  present,  persists  and  soon  becomes  stercoraceous.  In 
intussusception  the  stools  are  characteristic.  Strangulation,  or  ileus,  is 
associated  with  a  history  of  previous  peritonitis  or  the  presence  of  hernia. 
In  the  latter  there  may  be  signs  at  the  hernial  points.  In  the  obstruc- 
tion from  external  pressure  the  presence  of  tumors  has  been  known 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     819 

previously  or  can  be  recognized.  In  fecal  obstruction,  or  the  obstruc- 
tion by  gallstones,  the  local  signs  may  be  pronounced,  and  the  pain  is 
usually  in  the  ileo-caecal  region.  The  affection  is  acute.  Pain  that 
extends  over  a  long  period  of  time,  that  is  not  due  to  an  acute  process, 
or  attended  by  sevire  acute  symptoms,  has  been  considered  elsewhere. 
(See  Abdomen.) 

Rheumatism  and  Neuralgia.  Intestinal  colic  may  be  mistaken  for 
rheumatism  of  the  abdominal  walls.  In  the  latter  there  may  be  a 
history  of  exposure.  The  muscles  are  extremely  tender.  There  are 
no  gastro-intestinal  symptoms,  the  urine  is  loaded  with  uric  acid  and 
urates,  and  there  may  be  muscular  pain  in  other  situations,  or  a  pro- 
nounced history  of  previous  attacks  of  rheumatism.  In  lumbo-abdom- 
inal  neuralgia  the  pain  may  simulate  intestinal  colic.  Pressure-points, 
where  the  respective  nerves  have  their  exit  through  the  fascia,  are 
detected. 

Pain  in  Vertebral  Disease.  Just  here  may  be  considered  the 
pain  about  the  navel,  which  occurs  in  paroxysms,  due  to  disease  of  the 
vertebra?.  There  may  be  caries  from  tuberculous  disease  or  from 
pressure  of  an  aneurism  or  malignant  growths.  Examination  of  the 
vertebra?  may  determine  its  nature. 

Diarrhoea.  Diarrhoea  is  a  symptom  of  disorder  of  the  intestine, 
which  in  turn  is  itself  the  cause  of  symptoms,  just  as  jaundice,  a  symp- 
tom of  hepatic  disorder,  is  the  cause  of  various  symptoms.  In  diar- 
rhoea there  is  increased  frequency  of  the  movements  of  the  bowels. 
This  is  due  to  increased  peristalsis  of  the  intestine,  which  occurs  from 
a  number  of  causes.  Not  all  increased  peristalsis  results  in  diarrhoea. 
(A)  Nervous  diarrhoea.  Increased  peristalsis  may  be  due  to  some  im- 
pression upon  the  nervous  mechanism  of  the  intestine.  This  may 
explain  the  diarrhoea  of  emotion,  or  that  which  occurs  from  other 
psychical  influences.  (B)  Catarrhal  diarrhcea.  In  the  larger  number 
of  cases  the  diarrhoea  is  due  to  catarrhal  inflammation  of  the  intestinal 
tract.  The  causes  of  the  catarrhal  inflammation  are  many,  and  have 
been  divided  into  primary  and  secondary  causes.  Primary  catarrh  is 
due  to  the  direct  influence  of  causal  factors  upon  the  mucous  mem- 
brane. (1)  It  is  seen  after  cold  or  exposure ;  (2)  it  occurs  from  the 
direct  irritation  of  undigested  food,  and  (3)  from  the  action  of  irri- 
tants, as  of  bacteria  or  the  products  of  bacteria.  Catarrhal  inflamma- 
tion due  to  micro-organisms  is  the  most  frequent  form  that  occurs  in 
children. 

Secondary  catarrhs  follow  other  lesions  of  more  pronounced  charac- 
ter, as  ulcers.  The  catarrh,  and  hence  the  diarrhoea,  that  attends  the 
ulceration  of  typhoid  fever,  the  ulceration  of  dysentery,  or  that  occurs 
in  Bright's  disease,  and  the  diarrhoea  that  attends  carcinoma  or  other 
organic  disease  of  the  bowel,  is  of  this  nature.  In  addition,  a  catarrh 
of  the  bowels  arises  from  venous  stasis  in  the  mucous  membrane,  with 
chronic  congestion.  This  occurs  in  organic  heart  disease  with  conges- 
tion of  the  liver. 

Diarrhoea  is  a  symptom  of  the  action  of  certain  poisons,  such  as 
mercury,  arsenic,  and  other  corrosive  agents.     The  diarrhoea  which 


820  SPECIAL  DIAGNOSIS. 

occurs  from  the  irritant  action  of  food-products  and  in  cholera  infantum 
is  due  to  a  toxic  ptomaine. 

Diarrhoea  sometimes  fulfils  a  vicarious  office.  This  is  the  case  with 
the  diarrhoea  which  comes  on  in  cases  of  chronic  Bright' s  disease,  and 
in  acute  Bright' s  disease  before  the  supervention  of  uraemia.  When 
diarrhoea  occurs  in  a  person  with  pallor,  dimness  of  vision,  and  oedema 
the  urine  should  always  be  examined. 

The  Symptoms  of  Diarrhoea.  The  Motions.  Increased  move- 
ments of  the  bowels.  The  frequency  of  the  movements  varies  with  the 
cause.  In  the  diarrhoea  of  nervous  origin,  usually  after  five  or  six 
movements  have  occurred,  the  patient  is  relieved,  because  by  this  time 
the  cause  for  the  nervousness  has  disappeared.  In  catarrhal  diarrhoea 
the  number  varies  from  half  a  dozen  in  twenty-four  hours  to  the  same 
number  in  an  hour.  Inoleed,  in  some  severe  cases  the  evacuations 
may  be  almost  constant. 

Character  of  the  movements.  The  movements  may  be  (1)  fecal,  with 
a  small  amount  of  water.  They  are  light  in  color,  softer  than  natural, 
but  yet  retain  their  form.  They  are  the  kind  of  movements  seen  in 
simple  catarrh. 

2.  The  fecal  matter  is  mixeol  with  undigested  food.  The  feces  are 
in  scybalous  masses,  and  the  watery  element  is  increased.  They  are 
the  stools  of  the  so-called  dyspeptic  diarrhoea. 

3.  Along  with  the  feces  more  or  less  mucus  is  seen.  The  amount  of 
mucus  depends  upon  the  seat  as  well  as  the  intensity  of  the  inflamma- 
tion. Inflammations  of  the  large  intestine  are  attended  with  mucous 
discharge.  It  may  be  mixed  with  and  stained  by  feces  so  that  it  can 
be  recognized  only  by  close  inspection.  In  milder  degrees  of  catarrh 
it  is  seen  on  the  surface  of  the  fecal  masses. 

4.  The  feces  disappear  almost  entirely,  anol  instead  the  evacuations 
are  watery.  The  watery  evacuations  may  be  discolored,  as  in  the  pea- 
soup  evacuations  of  typhoid  fever,  or  they  may  be  almost  clear  water, 
as  in  the  rice-water  discharges  of  cholera. 

5.  The  evacuations  may  contain  blood.  Bloody  discharge  usually 
accompanies  the  discharge  of  mucus  ;  when  the  catarrh  is  in  the  loAver 
bowel  blood  may  occur  independently  of  the  mucus.  If  with  the 
mucus,  it  tinges  it  in  reddish  specks,  or  small  amounts  of  free  blood 
are  seen.  The  blood  may  be  bright  in  color,  and  then  usually  comes 
from  the  rectum.  It  must  be  remembered  that  the  blood  may  be  from 
hemorrhoids,  or  fissure,  which  is  unduly  irritated  by  the  diarrhoea.  It 
is  then  bright  red  and  unmixed  with  the  movement,  and  from  its 
position  can  readily  be  seen  to  have  followed  it.  On  the  other  hand, 
it  may  be  due  to  cirrhosis  of  the  liver,  with  venous  congestion.  It 
may  be  due  to  the  ulceration  of  typhoid  fever,  and  the  intense  inflam- 
mation of  enteritis.  It  is  a  symptom  of  carcinoma  of  the  bowel,  and 
is  of  frequent  occurrence,  almost  pathognomonic,  in  intussusception. 
It  must  be  remembered  that  blood  of  this  character  is  discharged  from 
the  bowel  independently  of  diseases  of  that  tube,  as  in  purpura,  scurvy, 
and  other  blood  diseases.  (See  Arteries  of  the  Intestines,  page  815.) 
If  mixed  with  the  movement,  the  blood  may  be  black,  as  in  all  forms 
of  melcena,  or  it  may  be  dark  red  in  color.     The  black  blood  usually 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     821 

comes  from  the  stomach  or  the  first  part  of  the  duodenum,  and  may 
be  the  result  of  ulceration,  or  even  from  the  swallowing  of  blood. 

Microscopical  and  Bacteriological  Examination.  (See  Feces.)  In 
simple  catarrhal  inflammation  of  the  tubules,  on  microscopical  examina- 
tion, but  little  is  found  except  an  excess  of  epithelium  from  the  mucous 
lining.  In  more  intense  inflammations,  in  addition  to  epithelium,  we 
find  pus  and  blood  and  mucus.  Micro-organisms  are  found,  the  kind 
depending  upon  the  cause  of  the  diarrhoea.  In  health,  Booker  has 
found  at  least  forty  varieties  of  micro-organisms,  many  of  which,  in 
all  probability,  are  not  pathogenic.  In  health,  the  bacillus  coli  com- 
munis and  the  bacterium  lactis  aeriformis  are  found.  In  the  diarrhoea 
of  children  both  forms  are  present  in  excessive  numbers,  because  con- 
ditions favoring  their  growth  arise,  and  in  all  probability  are  the  cause 
of  the  irritation  of  the  bowel.  In  that  form  of  inflammation  of  the 
bowel  known  as  dysentery,  in  addition  to  the  bacteria  that  attend  in- 
flammation, the  amoeba  coli  is  often  present.  It  has  been  found  that 
dysentery  may  be  due  to  a  number  of  causes,  but  that  the  so-called 
tropical  dysentery  is  due  to  the  protozoa  first  described  by  Kartulis, 
in  Egypt,  and  in  this  country  by  Osier.     (See  Feces.) 

Pain.  The  symptoms  that  attend  increased  movement  of  the  bowels 
depend  upon  the  cause  and  also  have  direct  relationship  to  the  fre- 
quency of  the  evacuation.  The  most  frequent  symptoms  are  pain, 
flatulent  distention,  with  borborygmi  and  tenesmus.  The  pain  depends 
largely  upon  the  cause.  If  the  irritant  is  a  product  of  indigestion,  or 
a  bulky  mass,  pain  is  more  or  less  severe.  It  is  situated  in  the  centre 
of  the  abdomen,  and  may  extend  all  over  it.  Pain  occurs  before  the 
evacuation  ;  it  is  sharp,  lancinating,  and  is  usually  relieved  by  the 
movement.  If  the  inflammation  is  in  the  large  intestine,  the  pain  may 
be  complained  of  in  the  course  of  the  large  bowel  or  be  more  intense 
over  the  caecum  and  the  sigmoid  flexure.  The  rectum  may  be  the 
seat  of  pain  or  of  painful  sensations.  This  has  been  described  as  a 
feeling  of  a  hot  ball  in  the  lower  pelvis. 

Flatulent  Distention.  The  flatulent  distention  is  not  very  great 
generally.  The  abdomen  is  distended,  tympanitic  on  percussion,  and 
tender  on  palpation,  both  of  which  may  be  more  marked  in  the  middle 
of  the  abdomen  if  enteritis  alone  is  present,  or  it  may  extend  along 
the  course  of  the  colon,  as  in  the  so-called  entero-colitis  of  children. 
With  the  distention  there  are  borborygmi.  The  rumbling  usually 
subsides  after  the  evacuation. 

Tenesmus  occurs  in  all  forms  of  diarrhoea  if  the  evacuations  have 
been  frequent.  After  the  discharge  of  the  contents  of  the  bowel,  par- 
ticularly if  from  the  rectum,  the  tenesmus  is  much  more  severe,  and  may 
be  of  constant  occurrence.  In  the  severe  cases  the  tenesmus  may  be 
almost  continual.    On  account  of  it  prolapse  of  the  bowel  is  apt  to  ensue. 

General  Symptoms.  The  general  symptoms  that  attend  diarrhoea 
depend  upon  the  cause.  In  simple  diarrhoea  there  might  be  slight 
feverishness  only,  with  a  little  weakness.  En  diarrhoea,  with  excessive 
movements,  with  mucus,  with  or  without  blood,  the  fever  is  marked 
and  may  rise  as  high  as  103°.  The  fever  that  attends  dysentery  is 
high,  and  usually  rises  rapidly  at  the  beginning. 


822  SPECIAL  DIAGNOSIS. 

Prostration.  More  or  less  prostration  attends  all  cases.  It  is,  how- 
ever, more  marked  when  there  are  frequent  watery  evacuations.  In 
its  most  pronounced  degree  it  is  seen  in  cholera  and  cholera  infantum. 
Collapse  rapidly  ensues  under  these  circumstances,  on  account  of  the 
depleting  effects  of  the  excessive  watery  discharge.  In  catarrh  of  the 
intestines  secondary  to  typhoid  fever  and  other  conditions  the  general 
symptoms  depend  upon  the  primary  disease. 

Chronic  Diarrhcea.  Chronic  diarrhoea  may  be  due  to  chronic 
inflammation  of  the  bowels,  as  in  chronic  intestinal  catarrh.  It  may 
be  secondary  to  the  ulceration  of  dysentery,  tuberculosis,  syphilis,  or 
cancer.  It  is  the  common  diarrhoea  of  amyloid  disease.  In  chronic 
diarrhoea  the  number  of  the  stools  varies,  but  seldom  amounts  to  more 
than  ten  to  fifteen  in  a  day.  In  chronic  intestinal  catarrh  three  or  four 
movements  occur  in  the  twenty-four  hours.  They  usually  occur  in 
the  morning,  the  first  evacuation  taking  place  immediately  on  rising 
and  the  remainder  during  the  morning  hours.  They  are  more  com- 
mon in  women  than  in  men,  and  are  readily  excited  by  exhaustion  or 
nervous  influence,  as  grief,  emotion,  or  excitement  of  any  kind.  The 
stools  are  fecal  and  watery,  and  contain  some  mucus.  The  mucus 
usually  coats  the  surface  of  the  feces.  The  color  of  the  feces  is  not 
changed.  The  patients  usually  suffer  fom  intestinal  dyspepsia,  or  they 
are  subject  to  some  gastric  neurosis.  They  are  not  under  weight,  and 
except  for  the  inconvenience  of  the  morning  hours,  could  attend  to  the 
ordinary  demands  of  life.  They  are  more  nervous  than  most  people, 
and  are  liable  to  attacks  of  hemicrania. 

Membranous  Diarrhcea.  In  a  number  of  cases  the  discharge 
from  the  bowels  resembles  membrane.  The  disease  is  also  called 
membranous  enteritis.  The  discharge  contains  much  mucus,  and  may 
be  quite  watery.  After  the  feces  have  been  passed  membrane  is  dis- 
charged. This  may  be  in  shreds  or  large  masses,  and  may  also  be 
like  a  cast  of  the  bowel.  The  patients  are  usually  women  who  are 
hysterical  and  have  some  menstrual  disorder.  Pain  may  precede  the 
discharge,  and  continue  until  there  is  complete  relief. 

Constipation.  Constipation  may  be  due  to  a  number  of  causes.  It 
may  be  due  to  alteration  or  diminution  in  the  secretions  of  the  intesti- 
nal tract,  as  is  seen  in  all  fevers,  except  when  they  are  attended  by 
specific  intestinal  catarrh,  as  in  typhoid  fever.  Such  diminution  of 
secretion  occurs  in  the  summer,  when  there  is  more  free  perspiration 
than  in  other  seasons,  and  is  present  in  affections  attended  by  excess 
of  perspiration,  or  exhaustive  diuresis.  Constipation,  therefore,  is  a 
common  symptom  of  diabetes. 

In  addition  to  alteration  of  the  secretion,  diminution  in  the  sensi- 
bility of  the  nerves  may  exist.  This  is  the  one  chief  cause  of  habitual 
constipation  that  is  so  prevalent.  On  account  of  carelessness  the 
patient  loses  the  habit  of  having  a  regular  movement  of  the  bowel 
each  day,  and  in  consequence  the  usual  stimulus  is  removed.  Consti- 
pation also  occurs  from  weakness  of  the  muscles. 

The  three  conditions — diminution  or  alterations  in  the  secretions, 
debility  of  the  muscles,  and  impairment  of  the  sensibility  of  the  ner- 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     823 

vous  mechanism — are  combined  influences,  on  account  of  which  consti- 
pation is  so  prevalent  in  persons  of  sedentary  habits  and  in  persons 
living  upon  improper  diet.  General  diseases  and  local  disorders  which 
influence  either  of  the  above  elements  cause  constipation.  Thus  in 
anaemia  and  chlorosis,  in  neurasthenia  and  hysteria,  constipation  is  a 
common  condition.  Its  occurrence  in  fevers  has  been  mentioned.  In 
the  convalescence  from  exhausting  disease  and  prolonged  confinement 
to  bed  constipation  is  apt  to  ensue. 

Local  Causes.  Atony  of  the  abdominal  muscles  or  of  the  bowel 
is  the  cause.  Atony  is  most  strikingly  seen  in  peritonitis  and  typh- 
litis, in  both  of  which  a  paretic  state  of  the  bowels  develops.  It  is 
seen  in  the  aged  and  in  cachexia  along  with  atony  of  other  muscles. 
Obstruction  of  the  bowels,  acute  or  chronic,  usually  causes  constipation 
(q.  v.).  If  the  obstruction  is  not  complete,  there  may  be  diarrhoea  on 
account  of  catarrhal  inflammation.  Constipation  often  occurs  on  ac- 
count of  pain,  particularly  pain  seated  in  the  rectum.  The  pain  is 
such  that  the  patient  shrinks  from  an  evacuation.  Frequent  postpone- 
ment soon  causes  constipation.  The  pain  may  be  due  to  fissures,  to 
hemorrhoids,  or  to  fistula.  Constipation  occurs  also  from  local  dis- 
eases in  other  portions  of  the  body,  influencing,  in  all  probability,  the 
nervous  mechanism  by  which  peristaltic  action  is  excited.  In  acute 
and  chronic  disease  of  the  brain  and  cord,  as  meningitis  and  myelitis, 
constipation  is  a  usual  attendant.  It  also  occurs  in  tetanus.  If  the 
bowel  is  deprived  of  fecal  matter,  evacuations  cease ;  constipation  is, 
therefore,  a  common  sign  of  stricture  of  the  pylorus  and  of  stricture  or 
cancer  of  the  oesophagus. 

Symptoms  of  Constipation.  Constipation  is  characterized  by  diminu- 
tion in  the  frequency  of  the  bowel-movements.  The  frequency  of  the 
movements  varies  in  health.  Some  persons  are  comfortable  with  an 
evacuation  taking  place  once  a  week,  or  at  most  every  third  or  fourth 
day.  There  are  cases  on  record  in  which  the  evacuations  took  place 
but  once  a  month.  Cases  of  this  class  are  usually  due  to  muscular 
paralysis  of  the  bowels,  with  secondary  dilatation.  The  accumulation 
of  feces  is  removed  by  a  sharp  attack  of  diarrhoea,  attended  by  much 
pain.  The  diarrhoea  sometimes  continues  for  twenty-four  hours.  When 
it  sets  in  fever  may  be  present  until  there  is  thorough  evacuation. 

Local  Symptoms.  Usually  the  symptoms  that  attend  constipation 
are  local,  being  due  to  the  discomfort  of  the  accumulation  of  feces. 
The  local  symptoms  may  be  limited  to  the  rectum  or  extend  through- 
out the  abdomen.  In  the  rectum  there  is  a  sensation  as  of  the  pres- 
ence of  a  mass,  which  may  cause  some  pain.  The  abdomen  is  dis- 
tended; there  is  considerable  rumbling,  and  sometimes  peristaltic 
waves  are  seen.  The  accumulation  of  the  fecal  mass  in  the  bowels 
may  set  up  tormina  and  tenesmus,  and  portions  of  the  mass  may  be 
discharged  from  time  to  time.  In  other  words,  a  diarrhoea  may  occur, 
the  diarrhoea  of  constipation,  or  spurious  diarrhoea.  The  stools  are 
small,  composed  of  hard  scybalous  masses,  generally  coated  with 
mucus,  and  streaked  with  blood.  The  evacuation  does  not  give  relief, 
and  the  desire  for  a  movement  may  be  more  or  less  continuous. 

On  examination  in  constipation  with  fecal  accumulations  the  outline 


824  SPECIAL  DIAGNOSIS. 

of  the  colon  may  be  marked  out  by  palpation  and  percussion  of  the 
distended  abdomen.  In  its  course  masses  are  felt  varying  in  size  from 
a  marble  to  a  base-ball,  and  in  consistence  they  may  be  soft  to  the 
palpating  finger  ;  they  are  never  indurated  like  a  calcareous  mass,  as 
gallstones  or  a  mass  due  to  malignant  disease.     (See  Fecal  Tumor.) 

General  Symptoms.  While  in  many  instances  the  general  symptoms 
are  of  no  consequence,  in  others  the  patients  are  nervous  and  may  be 
in  more  or  less  impaired  health,  on  account  of  the  secondary  effects 
upon  the  stomach.  Digestion  is  impaired  and  the  form  of  indigestion 
is  that  which  attends  neurasthenia. 

The  patients  are  of  spare  habit,  usually  of  dark  or  muddy  complex- 
ion. They  may  be  depressed.  There  is  inaptitude  for  mental  exer- 
tion ;  they  are  more  or  less  hypochondriacal.  The  tongue  is  constantly 
furred,  the  appetite  variable  ;  there  are  weight  and  fulness  after  eating, 
and  generally  some  flatulency. 

The  Secondary  Effects  of  Constipation.  The  effects  of  constipation 
upon  the  intestines  are  various  and  sometimes  disastrous.  They  are 
dilatation  and  ulceration.  The  former  may  become  enormous,  as  in 
cases  reported  by  Formad  and  Osier.  The  dilatation  may  be  so  great 
as  to  distend  the  entire  abdomen.  The  ulceration  may  be  localized  to 
the  rectum,  or  caecum,  or  extend  throughout  the  entire  large  intestine. 
On  palpation  the  course  of  the  colon  is  tender,  and  fecal  masses  may 
be  outlined  that  are  painful,  because  of  their  pressure  upon  the  ad- 
jacent ulcer.  In  the  rectum  the  ulcer  may  be  deep,  and  be  followed 
by  peri-rectal  abscess. 

Stercoral  typhlitis.  In  the  caecum  the  accumulation  may  cause  a  large 
boggy  swelling,  extending  in  the  course  of  the  csecum,  which  is  tender 
on  pressure  and  dull  on  percussion. 

Fecal  impaction,  with  secondary  ulceration,  is  of  frequent  occurrence 
in  typhoid  fever.  This  must  be  borne  in  mind,  for  often  serious  gen- 
eral and  local  symptoms  arise  because  it  is  overlooked.  Recently  I 
saw  a  case  with  diarrhoea  of  constipation,  with  some  fever,  which  per- 
sisted for  weeks  after  the  usual  course  of  typhoid  fever.  It  was 
thought  the  patient  had  tuberculosis,  or  that  the  typhoid  process  was 
abnormally  prolonged.  Examination  disclosed  ulceration  into  the 
vagina,  and  the  feces  were  constantly  discharged  from  this  orifice.  It 
had  been  thought  that  the  discharges  of  feces  were  due  to  diarrhoea. 
Of  course,  fever  attended  the  process,  and  rendered  the  case  all  the 
more  obscure. 

In  this  connection  must  be  mentioned  the  constipation  that  occurs 
on  account  of  lead-poisoning,  and  the  exhibition  of  drugs,  as  opium,  or 
astringents.  The  constipation  of  lead-poisoning  is  usually  attended 
by  colic,  and  the  blue-line  on  the  gums  is  seen,  while  wrist-drop  or 
other  manifestations  of  lead  may  be  present. 

Intestinal  Hemorrhage.  The  causes  are  general  and  local.  The 
general  causes  are  those  that  accompany  hemorrhage  in  other  localities. 
(See  Gastric  Hemorrhage.)  The  local  causes,  when  the  hemorrhage  is 
small,  are  :  inflammation  of  the  bowel ;  traumatic  injury  to  the  bowel 
from  hernia,  feces,  and  parasites,  and  foreign  bodies  swallowed,  or  from 
corrosive  poison  ;  tumors  of  the  bowel,  as  in  cancer,  invagination,  and 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     825 

ulcers.  When  the  hemorrhage  is  large  the  causes  are  the  congestion 
attending  portal  obstruction  and  liver  disease,  or  disease  of  the  heart 
with  secondary  obstruction  ;  aneurism  of  the  superior  mesenteric  artery, 
or  aneurism  rupturing  into  the  intestine,  and,  occasionally,  embolism 
of  the  artery ;  the  ulceration  from  typhoid  fever,  from  dysentery,  and 
from  syphilis.  It  may  occur  in  pyaemia  and  septicaemia,  or  the  acute 
exanthematous  diseases. 

The  symptoms  may  be  those  of  hemorrhage  alone  :  collapse,  pallor, 
failure  of  sight,  tinnitus,  vertigo,  small  pulse,  and  general  restlessness. 
The  hemorrhage  must  be  copious  under  these  circumstances,  and  is 
due  (1)  to  an  ulcer,  as  in  typhoid  fever  ;  (2)  to  portal  obstruction  ;  (3) 
to  an  aneurism  ;  (4)  to  purpura  or  haemophilia. 

A  second  group  of  symptoms  is  connected  with  the  appearance  of 
the  discharges  from  the  bowels.  The  stools  are  bloody  ;  if  the  hemor- 
rhage is  low  down,  they  are  bright  red  and  usually  mixed  with  feces. 
If  high  up,  they  are  tarry.  The  latter  condition  is  known  as  melaena. 
(See  Feces.)  The  passage  of  the  stools  is  preceded  by  colicky  pains, 
or  there  may  be  some  rumbling.  The  diagnosis  must  be  directed  to- 
ward determining  the  cause  of  the  hemorrhage,  as  well  as  its  seat ;  the 
history,  the  associate  diseases,  or  symptoms,  aid  in  determining  the 
cause.     Examination  of  the  rectum  may  afford  a  clue  to  its  origin. 

The  Objective  Symptoms. 

The  Data  Obtained  by  Observation.  Physical  Signs.  (See 
The  Abdomen.)  Inspection.  Local  and  general  enlargements  of  the 
abdomen  have  been  discussed  in  the  preceding  pages.  Movements  of 
the  intestines  are  seen  in  obstruction  due  to  increased  peristalsis.  The 
intestine  above  the  point  of  obstruction  may  swell  into  a  well-defined 
tumor  which  becomes  hard  and  dull,  and  tympanitic  on  percussion. 

Palpation.  Tenderness,  peristalsis,  peritoneal  friction,  the  bubbling 
of  gas  through  a  constriction  of  the  bowel,  and  tumors,  are  recognized 
by  palpation.  It  is  necessary  often  to  place  the  patient  on  all-fours 
or  in  a  knee-chest  position. 

Percussion.  The  normal  note  is  tympanitic.  Local  areas  of  dulness 
may  be  due  to  intestinal  tumor.  Light  percussion  should  be  employed. 
A  dull  tympany  indicates  a  solid  mass  surrounded  by  the  distended 
intestines.  The  outline  of  the  large  intestine  can  be  ascertained  by 
filling  it  with  water. 

The  Feces.  General  Considerations  and  Macroscopical 
Appearances.  The  number  of  stools  in  health  varies  chiefly  with 
the  individual  and  the  character  of  the  food  taken.  After  infancy, 
one  passage  in  twenty-four  hours  is  the  rule,  but  it  is  natural  for  some 
persons  to  have  two  or  three,  and  for  others  to  have  but  one  passage 
in  two,  three,  or  four  days.  Such  a  condition  is  termed  constipation, 
while  pathological  constipation  is  properly  called  obstipation.  The 
opposite  condition  is  known  as  diarrhoea.  The  amount  and  character 
of  food  and  drink  ingested  influence  the  number  of  stools.  Exercise 
also  plays  a  role  ;  increased  or  diminished  peristalsis,  from  whatever 
cause,  will  induce  diarrhoea  or  constipation,  respectively.     In  disease 


826  SPECIAL  DIAGNOSIS. 

the  greatest  extremes  are  met  with — from  the  non-passage  of  feces 
for  days,  as  in  obstruction,  to  an  almost  continuous  discharge,  as  in 
some  forms  of  intestinal  inflammation.  It  is  well  to  remember  that 
diarrhoea  may  be  the  symptom  of  obstipation,  as  when  impacted  feces 
in  typhoid  causes  looseness  of  the  bowels. 

The  amount  of  feces  varies  with  the  quantity  and  nature  of  food.  If 
most  of  the  food  is  digested  there  will  be  but  little  left  to  form  feces. 
In  any  disease  that  prevents  the  absorption  of  digested  food  or  causes 
an  increase  in  the  fluid  contents  of  the  intestine,  as  cholera,  the  amount 
of  feces  will  be  increased.  In  health  about  140  to  200  grammes  are 
voided  in  twenty-four  hours. 

The  form  and  consistence  of  healthy  stools  vary  somewhat.  They 
are  commonly  cylindrical  and  firm  or  mushy.  When  they  remain  long 
in  the  intestinal  canal,  and  the  water  is  extracted,  they  become  hard 
and  may  form  balls,  or  flattened  masses  known  as  scybala.  These  are 
frequently  seen  in  convalescing  typhoid  patients.  On  the  other  hand, 
the  feces  may  be  without  form,  and  are  then  liquid,  either  watery,  as 
in  cholera,  or  purulent  or  bloody.  Many  diseases  cause  such  a  con- 
dition. 

The  odor  of  feces  is  sometimes  more  or  less  characteristic  of  certain 
conditions.  Thus  the  stools  of  nursing  infants  have  a  sour  smell, 
while  in  infantile  diarrhoea,  and  when  fermentation  takes  place,  they 
have  an  odor  of  sebacic  acid.  When  urine  is  mixed  with  the  passage 
the  odor  will  be  ammoniacal ;  with  blood  present  it  often  has  a  stale 
odor. 

The  reaction  is  not  constant.  Thus  in  intestinal  catarrh,  with  acid 
fermentation,  it  will  be  acid,  or  in  alkaline  fermentation  it  will  be 
alkaline.  The  color  of  the  stool  varies  too  much  to  be  of  special  diag- 
nostic value.  In  health  it  is  light  to  dark  brown,  due  chiefly  to  the 
presence  of  hydro-bilirubin,  a  product  of  decomposition  of  bile-pig- 
ment, which  is  never  normally  found  unaltered  in  the  feces.  It  is 
influenced  greatly  by  food  and  medicines.  When  certain  berries,  as 
huckleberries,  are  eaten,  or  certain  medicines  taken — iron  and  bismuth 
— they  make  the  passages  black.  Calomel  causes  green  stools,  on 
account  of  the  biliverdin  discharged.  Green  stools  may  also  receive 
their  color  from  the  presence  of  a  bacillus  which  produces  a  green  dye. 
Santonin,  rhubarb,  and  senna  cause  yellow,  and  hsematoxylon  red 
stools.  The  last  fact  is  important,  as  parents  or  nurses  should  always 
be  warned  to  expect  red  passages  when  hsematoxylon  is  given. 

The  feces  may  be  red  or  reddish  from  the  presence  of  unaltered 
blood  ;  or  black,  when  the  blood  has  undergone  changes  ;  the  so-called 
"  tarry  stools  "  are  of  this  character.  With  a  decrease  in  the  amount 
of  bile  the  stools  become  less  colored,  and  if  the  bile  is  cut  off  they 
become  clayey.  This  color  may,  in  some  cases,  be  due  to  the  presence 
of  fat  left  undigested  because  of  the  lack  of  bile.  On  the  other  hand, 
if  from  disorders  of  the  stomach  and  intestine  the  contents  pass  through 
too  rapidly,  the  feces  may  contain  unaltered  bile,  unchanged  bile-pig- 
ment, giving  a  green  or  yellow  color,  and  showing  the  bile-reaction. 

The  constituents  of  feces  that  can  be  recognized  by  the  naked  eye  are 
numerous.     Seeds,  stones,  skins  of  fruit  and  berries,  and  the  fibres  of 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     827 

vegetables  are  often  seen  in  healthy  stools.  In  the  passages  of  chil- 
dren and  weak-minded  individuals  foreign  substances  of  all  descrip- 
tions may  be  present.  Foreign  bodies  and  partially  digested  portions 
of  food  may  be  mistaken  for  parasites.  Portions  of  tumors  from  the 
digestive  tract  may  appear  in  the  feces. 

In  certain  diseases  of  the  stomach  and  small  intestine,  and  in  those 
who  eat  very  fast  and  do  not  properly  masticate  their  food,  undigested 
and  unchanged  particles  of  food  may  be  seen  in  the  stools. 

Shreds  of  mucous  membrane  of  varying  size  are  passed  with  the 
feces.  Von  Jaksch  saw  such  a  shred  5  cm.  long  and  3  cm.  broad  in  a 
case  of  cholelithiasis.  Various  sized  pieces  of  membrane,  consisting 
of  transformed  mucus,  are  passed  in  membranous  enteritis. 

Particles  resembling  sago-grains,  perhaps  the  result  of  over-indul- 
gence in  farinaceous  food,  have  been  met  with. 

Gallstones  in  the  feces  have  great  clinical  value.  They  may  escape, 
detection  if  not  properly  sought  for.  When  suspected,  each  passage 
should  be  passed  through  a  linen  sieve,  the  fecal  masses  being  softened 
with  water.  They  may  be  found  as  small,  crumbling  masses,  composed 
chiefly  of  cholesterin  (intrahepatic  calculi),  or  as  hard,  irregular, 
smoothly  worn,  shining,  many-sided,  hard  stones,  sometimes  as  large 
as  an  egg,  usually  the  size  of  a  pea.  Enteroliths  are  occasionally  seen. 
They  are  said  to  originate  in  the  appendix. 

Blood  may  be  present  in  the  feces  in  varying  proportions  and  con- 
ditions. When  found  unaltered  on  the  surface  of  scybalous  masses,  it 
is  from  the  rectum  or  large  intestine,  and  probably  the  result  of  trau- 
matism. Hemorrhoids,  if  bleeding,  may  cause  such  an  appearance,  or 
may  cause  very  free  hemorrhage.  Severe  hemorrhage  may  come  from 
ulceration  of  the  rectum  or  colon,  due  to  malignant  disease  or  severe 
inflammation.  The  blood  may  be  intimately  mixed  with  the  feces, 
and  have  its  origin  in  the  large  intestine,  but  much  more  commonly  it 
indicates  a  source  in  the  stomach  or  small  intestine.  Under  such  cir- 
cumstances it  is  nearly  always  more  or  less  changed  by  the  intestinal 
juices,  and  is  brownish-red  or  black  (the  tarry  stool  mentioned  above), 
or  has  the  appearance  of  coffee-grounds.  The  brighter  the  color  of 
the  blood  the  nearer  is  the  source  of  hemorrhage  to  the  anus.  The 
more  retarded  the  passage  the  greater  the  change  ;  while,  if  quickly 
expelled,  blood  from  the  small  intestine  may  be  passed  unchanged,  as 
in  the  hemorrhage  of  typhoid  fever.  The  microscope  detects  blood 
when  the  naked  eye  fails  to  detect  it.  It  is  to  be  remembered  that 
certain  drugs,  as  already  stated,  may  color  the  feces  red,  and  simulate 
blood. 

Mucus  may  be  present  in  the  passages  in  health,  but  when  in  any 
marked  quantity  there  is  a  catarrh  of  the  mucous  membrane  of  the 
intestines.  When  hard  scybala  are  covered  with  mucus,  or  the  mucus 
is  seen  in  shreds,  the  large  intestine  is  the  seat  of  a  catarrh  ;  although 
mucus  may  be  mixed  with  thin  stools,  as  in  dysentery.  Usually,  how- 
ever, when  the  mucus  is  finely  divided  and  mixed  with  the  feces,  it 
comes  from  the  small  intestine.  Mucous  shreds  have  already  been 
mentioned.  In  cholera  the  particles  of  mucus  look  like  boiled  rice, 
hence  the  term  "  rice-water  stool." 


828 


SPECIAL  DIAGNOSIS. 


Fatty  stools,  to  the  naked  eye,  appear  greasy  or  even  clayey,  when 
there  is  much  fat,  even  though  bile-pigment  may  be  present. 

Pus  may  be  present  in  large  quantities  from  rupture  of  an  abscess 
into  the  intestinal  tract,  or  when  there  are  ulcerations  from  various 
conditions,  producing  pus  in  considerable  quantities. 

Microscopical  Examination  of  the  Feces.  Many  animal 
parasites  ai"e  not  microscopic,  but  it  is  convenient  to  consider  them  in 
the  following  paragraphs.  A  small  portion  of  the  solid  feces  to  be 
examined  is  placed  on  a  slide,  moistened  with  a  \  per  cent,  salt  solu- 
tion, and  a  cover-slip  applied  ;  or  if  liquid,  various  drops  are  to  be 
examined.  The  different  constituents  found  will  vary  with  the  food 
taken  as  well  as  with  disease. 

A.  Constituents  Derived  from  Food.  There  may  be  portions 
of  digested  or  undigested  food.  In  general  it  may  be  said  that  the 
presence  of  large  pieces  of  unchanged  food,  or  many  small  particles  of 
undigested  or  only  partially  digested  food,  indicates  defective  digestion 
in  the  stomach  or  small  intestine.  If  unchanged  bile  is  present,  some 
particles  wTill  be  colored  yellow,  another  indication  of  disordered  func- 
tion. 

From  the  food  we  may  see  muscle  and  elastic  fibres,  more  or  less, 
according  to  the  quantity  of  meat  eaten  by  the  patient.  The  former 
are  recognized  by  their  transverse  striation  ;  the  latter,  by  their  double 
contour  and  curling  ends.  Fat  may  be  present  as  fatty  globules  or 
in  the  form  of  needles,  fatty  crystals.  Much  fatty  food  increases 
their  number,  and  they  are  seen  plentifully  in  alcoholic  poisoning, 
in  jaundice,  in  pancreatic  diseases,  tuberculosis  of  intestines,  diseases 
of  the  mesenteric  glands,  and  enteritis.     The  crystals  may  be  trans- 

Fig.  197. 


Collective  view  of  the  feces.  (Eye-piece  III.,  objective  8A,  Reichert.)  a.  Muscle-fibres.  6.  Con- 
nective tissue,  c.  Epithelium,  d.  White  blood-corpuscles,  e.  Spiral  cells,  f-i.  Various  vegetable 
cells,  k.  Triple  phosphate  crystals  in  a  mass  of  various  micro-organisms.  I.  Diatoms.  (Von 
Jaksch.) 


formed  into  fat-drops  by  the  addition  of  acid  and  heat.  When  meat 
is  eaten  freely,  areolar  tissue  may  be  present,  but  its  presence  otherwise 
points  to  defective  digestion.  Various  forms  of  vegetable  cells  are 
commonly  seen,  in  which  granules  of  starch  may  be  contained,  or  the 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     829 

starch  particle  may  be  free.  Undigested  milk  occurs  in  the  stools  of 
children  and  when  diarrhoea  prevails  ;  a  substance,  probably  casein, 
has  been  described  by  Xothnagel  as  occurring  in  the  feces  of  persons 
who  have  intestinal  disturbances. 

In  persons  living  on  vegetables  most  of  the  above  constituents  will 
be  absent,  and  in  infants  who  partake  only  of  milk,  the  derivatives  of 
meat  are  absent,  while  there  will  be  an  excess  of  fatty  crystals  and  fat- 
globules  and  coagulated  products. 

B.  Constituents  from  the  Alimentary  Tract.  Epithelium.  In 
every  normal  stool  will  be  found  epithelium  of  the  squamous  variety. 

Occasionally  the  columnar  form  is  seen,  and  modified  epithelial  cells 
are  very  common.  In  intestinal  catarrh  their  number  is  greatly  in- 
creased. 

Red  Blood-corpuscles.  In  the  majority  of  blood-stained  stools  red 
blood-cells  are  not  found  ;  in  their  stead  will  be  seen  masses  of  free 
blood-coloring  matter  and  rhombic  crystals  of  hseniatoidin.  Red  cells 
are  seen  in  dysenteries,  in  bloody  stools  in  which  the  blood  comes  from 
near  the  anus,  as  in  hemorrhoids,  and  when  blood  is  discharged  with 
the  feces  soon  after  the  occurrence  of  the  bleeding.  If  there  is  any 
doubt  as  to  the  presence  of  blood,  when  the  corpuscle  cannot  be  found, 
a  true  decision  can  be  reached  by  examining  for  hsemiu-crystals,  ac- 
cording to  Teichmann's  method.  A  portion  of  feces  is  dried  and  pow- 
dered, placed  on  a  slide  with  a  grain  of  common  salt,  and  covered  by 
a  cover-slip.  A  few  drops  of  glacial  acetic  acid  are  directed  beneath 
the  slip,  the  slide  is  heated  just  to  boiling,  and  if  blood  has  been  pres- 
ent, reddish-brown  rhombic  crystals  of  hsemin  will  soon  be  found. 

Leucocytes.  Leucocytes  are  frequently  seen  in  healthy  stools.  ^  In  mi 
pus  is  present  or  discharged  into  the  intestinal  canal  they  are  found  in 
great  numbers,  as  in  ulceration  of  the  intestine  and  in  abscess. 

Molecular  debris,  or  detritus,  occurs  in  all  feces  as  part  of  the  waste- 
products. 

Crystals.  Fat-crystals,  are  the  most  important.  They  have  been 
quite  fully  considered  above.  There  seems  to  be  little  doubt  that  the 
crystalline  needles  found  in  the  feces  are  salts  and  fatty  acids,  and  not 
tyrosin. 

( 'harcot-Leyden  crystals,  similar  to  those  already  described  (see  Spu- 
tum), have  occasionally  been  met  with  in  the  stools  of  typhoid  fever 
patients,  in  dysentery,  intestinal  tuberculosis,  and  ankylostomiasis. 

Ha  in  of  oi'I  iii-crystals  occur  as  reddish-brown,  hard,  needle-shaped 
bodies,  usually  in  clusters,  and  free  or  enclosed  in  masses  of  mucin  or 
a  substance  resembling  it.  They  have  been  found  in  the  feces  of 
breast-fed  infants,  in  cases  of  chronic  intestinal  catarrh,  and,  by  Y<>n 
Jaksch,  in  the  stools  of  a  case  of  nephriti>. 

Crystals  of  various  salts  of  calcium,  of  triple  phosphate  and  eho/cxt'-rin 
will  often  be  recognized,  but  they  have  no  diagnostic  value.  When 
bismuth  is  being  administered,  black  rhombic  crystals  of  the  sulphide 
of  bismuth  will  be  recognized. 

C.  Parasites.  (A)  Animal  and  (B)  vegetable  parasites  flourish  in 
the  intestinal  tract,  and  the  presence  of  some  of  these  in  the  feces  is 
of  the  greatest  clinical  importance. 


830 


SPECIAL  DIAGNOSIS. 


A.  Animal  Parasites.  Following  Leuckart's  classification,  we 
will  consider  these  parasites  under  the  secondary  heads  : 

I.  Protozoa.  1.  Rhizopoda.  This  variety  is  made  important  be- 
cause the  amoeba  dysenterise  or  amoeba  coli  belongs  to  it. 

(a)  Amoeba  Dy sentence.  Amoeba  Coll.  This  protozoon  has  been 
found  so  many  times  by  various  observers  in  different  parts  of  the 
world  that  it  can  now  be  considered  to  be  the  causative  factor  of  so- 
called  tropical  dysentery.  The  subject  has  received  special  study  in 
our  own  country  by  Osier/  Stengel,2  Dock,3  and  Councilman  and 
Lafleur.4  The  work  of  Councilman  and  Lafleur  is  at  the  present  time 
the  best  that  has  been  published  in  any  country  ;  and  to  it  the  reader 
is  particularly  referred.     The  following  notes  are  based  on  this  book. 

The  amcebse  dysenterise  vary  in  size  from  0.012  to  0.035  mm.  They 
are  found  most  plentifully  in  the  small  gelatinous  masses  often  to  be 
seen  in  the  feces.  They  vary  in  number  in  different  cases,  and  in  the 
same  case  at  different  times.  The  severer  the  lesions  the  more  numer- 
ous are  the  amoeba?.  When  not  active  they  are  round  or  oblong,  and 
highly  refractive.  They  contain  one  or  more  vacuoles  of  varying  size. 
Occasionally  the  division  into  an  ectosarc  and  endosarc  is  easily  made 
out.  When  thus  inactive  they  may  be  confounded  with  swollen  con- 
nective-tissue cells  and  compound  granular  bodies  found  in  feces.  The 
active  amoebae  have,  however,  a  characteristic  movement.  This  consists 
of  progression  and  of  thrusting-out  and  retraction  of  pseudopodia.  Their 
activity  varies  greatly.  It  is  best  seen  wThen  the  body-heat  is  main- 
tained. The  stools  should  be  passed  into  a  clean  and  warm  pan,  and 
examined  immediately,  or  kept  warm  until  examined,  and  a  warm 

Fig.  198. 


Amceba  coli.    (Hallopeau.) 

stage  should  be  used  with  the  microscope.  The  division  into  ectosarc 
and  endosarc  is  usually  clear  during  activity.  The  ectosarc  is  com- 
posed of  a  hyaline  homogeneous  mass,  as  are  the  pseudopodia,  while  the 


1  Johns  Hopkins  Hospital  Bulletin,  May,  1890,  vol.  i.,  No.  5. 

2  Phila.  Med.  News,  1890.  *  Texas  Med.  Journal,  April,  1891. 
1  Johns  Hopkins  Hospital  Reports,  vol.  ii.,  Nos.  7,  8,  9. 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     831 

endosarc  is  made  up,  not  of  granular  matter,  but  of  a  dense  homo- 
geneous mass  enclosing  vacuoles  and  a  nucleus.  The  vacuoles  may 
vary  in  size  as  well  as  in  number.  There  may  be  one  or  two  large 
ones,  or  the  entire  endosarc  may  appear  as  made  up  entirely  of  small 
vacuoles.  The  nucleus  is  sometimes  plainly  seen  as  a  small  rounded 
body,  but  is  more  often  difficult  to  distinguish  from  the  vacuoles. 
Dried  cover-slip  preparations  may  be  stained  with  the  various  aniline 
dyes,  but  the  results  are  not  satisfactory. 

The  amoeba?  will  often  be  found  to  enclose  bodies  such  as  red  blood- 
corpuscles,  pus-cells,  blood-coloring  matter,  bacilli  and  micrococci. 

In  examining  the  feces  for  amoebae  dysenteriae  the  suggestion  given 
above  concerning  the  warm  bed-pan  and  warm  stage  to  the  microscope, 
and,  above  all,  the  immediate  examination  of  the  stool,  should  be  ad- 
hered to.  The  small  gelatinous  masses  should  be  selected  when  present. 
Ararious  magnifying  powers  should  be  used,  including  the  y1^  oil-immer- 
sion lens. 

(6)  Monadines,  pear-shaped,  with  a  long  slender  process,  are  seen 
alive  in  only  perfectly  fresh  stools.  They  are  not  found  constantly  in 
any  one  disease. 

2.  Sporozoa.  Under  this  head  belongs  the  coccidium  perforans  of 
Leuckart.  They  are  short,  elliptical  bodies,  which  infest  the  intesti- 
nal mucous  membrane,  and  may  damage  it  badly;  they  are  often  dis- 
charged in  large  numbers. 

3.  Infusoria,  (a)  Cercomonas  Intestinalis.  This  is  a  pear-shaped 
body,  nucleated,  with  eight  tentacles  of  varying  length.  It  is  found 
in  the  feces  of  persons  suffering  from  various  diseases,  as  cholera  and 
typhoid  fever,  and  probably  of  itself  causes  diarrhoea. 

(6)  Trichomonas  intestinalis.  Larger  than  the  cercomonas,  and  cov- 
ered with  ciliae  at  the  club  end.  It  is  not  diagnostic  and  is  not 
common. 

(c)  Paramecium  coli.  Larger  than  the  preceding,  1  mm.  long — 
oval,  covered  everywhere  with  ciliae  ;  may  be  found  in  diarrhceic  stools. 

II.  Vermes.  These  are  much  more  generally  known  and  are  of 
much  more  clinical  value  than  the  preceding. 

They  have  important  clinical  value,  as  the  presence  of  some  of  them 
in  the  intestinal  canal  gives  rise  to  many  untoward  symptoms.  They 
will  be  considered  under  (A)  Platodes  and  (B)  Annelides. 

A.  Platodes.  1.  Tapeworm — Cestodes.  These  parasites  infest 
the  small  intestine  only,  to  the  walls  of  which  they  cling  by  the  head. 
The  head  and  neck  are  small ;  the  joints  are  flat  and  form  long  ribbons. 
The  distal  joints  continually  drop  off  and  can  easily  be  recognized  in 
the  stools  by  the  naked  eye,  and  the  eggs  by  the  use  of  the  micro- 
scope. The  feces  are  best  washed  in  water  and  broken  up  to  obtain 
the  eggs.  As  the  lower  joints  are  lost  new  ones  take  their  place  from 
above.     The  more  important  are  as  follows  : 

a.  Tenia  solium  (Fig.  199)  reaches  a  length  of  two  to  three  metres. 
The  head  is  the  size  of  a  pin-head.  The  neck  is  2.5  cm.  long,  as  thick 
as  a  thread,  and  without  joints.  The  segments  forming  the  body  are 
short  and  broad  near  the  neck,  but  as  they  increase  in  size  there  is 
more  growth  in  length  than  in  width.     The  average  dimensions  are  9 


832 


SPECIAL  DIAGNOSIS. 


to  10  mm.  by  6  or  7  mm.  The  head  appears  dark,  the  body  white. 
The  joints  are  easily  detected  in  the  feces  by  the  naked  eye.  Under 
the  microscope  the  head  is  seen  to  be  spheroidal,  with  four  pigmented 
sucking-disks  surrounding  at  the  base  a  rostellum,  which  is  a  "  crown 
of  hooks  " — chitin  hooks- — about  twenty-four  in  number.  In  the  ripe 
segments,  or  proglottides,  is  seen  the  longitudinal  uterus  with  about 
twelve  horizontal  ramifications  to  a  segment.  The  eggs  are  round  or 
oval,  0.035  mm.  long,  with  a  thick,  striated  shell  when  ripe,  and  con- 
tain hooklets. 


Fig.  199. 


Fig.  200. 


Head  of  T.  solium,     x  45.    (Leuckart.) 


Ova  of  T.  solium,  a,  with  yolk,  b,  without 
yolk,  as  in  mature  segments.  The  hard  brown 
shell  is  indicated.    (Leuckart.) 


b.  Tcenia  mediocanettata,  or  saginata.  This  worm  is  four  or  five 
metres  long.  The  head  is  slightly  larger  than  that  of  the  T.  solium, 
and  more  pigmented,  and  the  segments  are  longer,  fatter,  and  darker. 
The  head  is  supplied  with  four  powerful  sucking-cups,  but  has  no 
rostellum  or  hooklets.  The  uterus  in  the  ripe  segment  is  much  more 
finely  branched  than  in  the  solium,  and  these  segments  have  indepen- 
dent movement.  The  eggs  are  very  similar  to  those  of  the  T.  solium, 
but  may  be  rather  larger. 

c.  Tcenia  nana.  In  length  the  T.  nana  is  only  10  to  15  mm.,  and 
0.5  mm.  in  breadth.  The  round  head  is  but  0.3  mm.  in  diameter. 
The  segments  are  all  short,  and  at  the  lower  end  of  the  body  are  four 
times  as  wide  as  they  are  long.  The  head  is  found  to  have  four  round 
suckers  at  the  base  of  a  rostellum  that  can  be  inverted.  At  the  base 
of  the  rostellum  are  about  twenty-two  hooklets.  The  uterus  is  oblong 
and  filled  with  eggs.     The  eggs  have  a  double  membrane. 

d.  Tcenia  cucwmerina.  This  parasite  is  found  to  be  5  to  20  cm. 
long  and  about  2  mm.  wide.  The  head  is  placed  at  the  thinner  end, 
and  under  the  microscope  are  to  be  seen  some  sixty  hooklets  regularly 
distributed  about  the  rostellum,  and  four  sucking-cups.  The  lower 
segments  are  decidedly  larger  than  the  upper — 6  by  7  mm.     "When 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     833 

ripe  they  become  reddish,  and  contain  cocoon-like  bodies,  in  which 
are  six  to  twelve  eggs. 

e.  Bothriocephalus  latus.  This  is  the  largest  of  the  worms,  meas- 
uring 7  or  8  metres.  The  head  is  somewhat  drawn  out,  and  on  either 
side  is  a  long,  narrow  sucker.  There  are  neither  hooks  nor  rostellum. 
The  proglottides  are  short  near  the  head,  but  become  square  further 
down.  The  uterus  appears  as  a  rosette,  peculiar  to  this  worm.  The 
eggs  are  oval,  and  measure  7  mm.  by  0.045  mm.,  have  a  shell  covering, 
with  an  opening  like  a  lid  at  one  end.  Ripe  segments  are  thrown  off 
in  bunches,  not  singly. 

It  will  not  be  necessary  to  describe  certain  other  varieties  that  are 
rarely  met  with. 

2.  Trematodes,  or  flukes,  a.  Distoma  hepaticum  measures  28  mm. 
by  10  mm.,  and  is  shaped  like  a  leaf.  A  short  head  is  situated  at  the 
broad  end  and  has  one  sucker  ;  on  the  under  surface  is  another  sucker, 
and  between  the  two  is  the  opening  of  the  uterus,  a  highly  convoluted 
arrangement.  The  eggs  are  brown,  oval,  about  0.12  mm.  long,  and 
have  a  lid  at  one  end.     It  is  not  often  seen. 

b.  Distoma  lanceolatum.  This  round-shaped  worm  is  about  8  mm. 
long  and  3  mm.  broad,  and  in  other  respects  resembles  the  preceding. 
The  eggs  are  more  rounded  and  contain  minute  embryos.  Like  the 
D.  hepaticum,  it  is  rarely  seeu. 

c.  Distoma  crassum  is  the  largest — 4  to  8  cm.  long.  These  flukes 
are  endemic  in  parts  of  Japan.  In  general  these  animals  occupy  the 
bile-passages  or  upper  part  of  the  small  intestine. 

B.  Axxelides.  1.  Round  Worms — Nematodes.  A.  Ascarides.  a. 
Ascaris  lumbrieoides.  This  is  the  parasite  usually  referred  to  by  the 
term  round  worm.  It  resembles  the  common  earth-worm  in  shape 
and  color.  The  male  worm  is  about  250  mm.  long,  and  the  female 
400  mm.  The  head  is  made  up  of  three  prominent  lips,  and  is  sup- 
plied with  microscopical  teeth.  The  vulva  of  the  female  is  in  the  pos- 
terior third  of  the  body.  The  eggs  are  rounded,  brownish,  0.06  mm. 
in  diameter,  and  covered,  when  fresh,  by  a  rough  albuminous  coat  over 
a  hard  shell.  This  worm  has  the  small  intestine  for  its  habitat.  It 
may  pass  with  the  stools  or  work  its  way  into  the  stomach  and  be 
vomited  (the  writer  has  had  them  thus  vomited  during  the  etherization 
of  a  child  of  ten  years).  They  have  been  the  cause  of  jaundice  by 
crawling  into  the  ductus  choledochus,  and  may  infest  the  larger  hepatic 
ducts.  Enormous  numbers  may  be  present  in  the  intestine  at  one 
time. 

b.  Oxyuris  vermicularis.  The  thread-worm,  or  seat-worm,  inhabits 
the  large  intestine,  and  is  often  present  in  the  stool  as  a  white,  thread- 
like body  ;  the  male  5  mm.  and  the  female  10  mm.  long  They  often 
wander  out  of  the  anus  and  into  the  vagina.  The  head  has  a  number 
of  small  lips,  and  is  covered  with  a  thick  skin.  The  female  has  one 
vagina  and  two  uteri.  The  eggs  are  unsymmetrical,  have  a  laminated 
shell  and  a  diameter  of  about  4  mm. 

B.  Strong y tides.  Anhylostomum  duodenatc.  This  is  a  round  worm, 
reaching  a  length  of  6  to  10  mm.  in  the  male  and  10  to  18  mm.  in 
the  female,  and  can,  therefore,  be  seen  easily,  though  the  eggs  are 

53 


834  SPECIAL  DIAGNOSIS. 

much  more  frequently  found  in  the  stool  than  is  the  worm  itself.  With 
the  eggs  there  may  be  present  in  the  stools  large  numbers  of  Charcot- 
Leyden  crystals.  The  head  is  prominent,  especially  in  the  male.  Four 
hook-like  teeth  surround  the  mouth,  and  by  these  the  animal  attaches 
itself  to  the  intestinal  wall.  The  tail  of  the  male  is  expanded  and  that 
of  the  female  pointed.  The  vulva  is  in  the  posterior  third.  The  eggs 
are  oval,  about  0.05  mm.  in  diameter,  and  contain  one  to  four  cells — 
embryonic  globules,  which  rapidly  develop  in  a  warm  place  outside 
the  body,  and  may  thus  be  recognized.  The  worm  infests  the  small 
intestine,  especially  the  jejunum.  It  often  causes  serious  symptoms — 
bloody  stools  and  intense  anseniia. 

c.  Triehotrachelides.  a.  Tricocephalus  dispar.  The  whip-worm  is 
4  to  5  cm.  in  length,  the  female  being  longer  than  the  male.  It  is 
recognized  by  the  contrasting  form  of  the  anterior  and  posterior  por- 
tions. The  former  is  thin  and  threadlike,  the  latter  expanded  and 
broad,  and  in  the  male  curled  up.  The  eggs  are  brownish,  about  0.05 
mm.  long  and  half  as  broad,  and  have  a  button-like  projection  at  either 
end  ;  they  are  to  be  recognized  in  the  stools,  where  large  ones  may  be 
present.  There  may  be  only  a  few  or  thousands  of  the  forms  present 
in  the  body.  They  live  chiefly  in  the  caecum  and  large  intestine. 
They  have  been  thought  to  cause   beri-beri  by  some  writers. 

b.  Trichina  spiralis.  It  is  the  adult  trichinae  which  exist  in  the 
intestine  and  are  found  very  infrequently  in  the  feces.  These  produce 
the  embryos,  which  become  muscle  trichinae.  The  adult  male  is  1.5 
mm.  long  and  the  female  twice  that  length.  The  former  has  two  pro- 
jections from  the  hinder  end,  between  which  are  four  papillae.  The 
female  has  a  tubular  uterus  and  a  tubular  ovary  in  the  posterior  half 
of  the  body. 

D.  Rhabdonema.  Strongylides.  Under  rhabdonema  intestinale 
we  now  include  two  small  nematodes,  which  were  termed  anguillula 
mtestinalis  and  A.  stercoralis,  and  which  are  probably  one  and  the 
same.  They  are  found  in  the  stools  of  cases  of  endemic  diarrhoea  of 
hot  countries.  Usually  the  young  embryos,  which  have  developed  in 
the  intestinal  canal,  are  dejected  with  the  stools.  These  sexually 
mature  embryos  are  0.8  to  1.2  mm  long,  male  and  female  respectively. 
They  are  round  and  have  a  cone-shaped  head.  There  are  two  jaws 
and  two  teeth  in  each.  The  adult  worm  is  about  2.2  mm.  long  and 
0.04  mm.  thick.  The  mouth  has  three  lips.  The  vulva  is  at  the  be- 
ginning of  the  posterior  third.  The  eggs  might  be  easily  confounded 
with  those  of  the  ankylostomum  duodenale,  but  are  somewhat  more 
pointed,  and  larger.  The  rhabdonema  infests  the  small  intestine,  and 
is  frequently  found  in  connection  with  ankylostoma. 

Echinococcus  hooklets  and  portions  of  the  striated  cyst-wall  have 
been  found  in  the  feces.  The  rupture  of  a  hydatid  cyst  into  the  in- 
testine may  be  discovered  when  the  above  structures  are  found,  point- 
ing to  a  cyst  in  the  abdominal  cavity. 

B.  Vegetable  Parasites.  We  find  both  (I)  pathogenic  and 
(II)  non-pathogenic  vegetable  parasites  in  the  feces.  The  latter  we 
have  classed  as  (1)  moulds,  (2)  yeasts,  and  (3)  fission-fungi. 

1.  Moulds.     The  only  mould  found   in  the   stools   is    the    thrush 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     835 

fungus,  when  children  are  the  subjects  of  thrush  in  the  mouth.     It  is 
of  very  rare  occurrence  in  the  feces,  and  has  no  special  clinical  import. 

2.  Yeasts.  In  all  feces,  in  health  or  disease,  yeast  fungi  exist. 
They  are  most  numerous  in  acid  stools.  They  are  round  or  ovoid,  and 
usually  occur  in  groups.  They  stain  dark  brown  with  a  solution  of 
iodine  and  iodide  of  potash,  while  apparently  similar  cells  become 
violet  or  blue  with  the  same  dye. 

3.  Fission-fungi.  Bacteria  are  found  in  greatest  numbers  in  the 
feces,  chiefly  as  bacilli,  micrococci,  and  spirilla.  They  may  be  grouped 
as  torulae  or  sarcinse.  They  present  active  movement,  and  may  be 
separate  or  in  colonies.  The  bacillus  coli  communis  (B.  termo)  is  the 
most  frequent  form  met  with,  both  in  health  and  disease.  It  is  not 
yet  determined  what  relations  it  holds  to  normal  and  abnormal  condi- 
tions, or  what  is  the  true  relationship  between  it  and  certain  other  bac- 
teria. B.  subtilis  is  another  bacterium  found  both  in  health  and 
disease.  As  above  stated,  there  are  various  organisms  which  stain 
brown  with  iodo-potassic-iodide  solution,  and  others  which  become 
blue  with  the  same  dye.  Von  Jaksch  has  studied  these  latter  closely. 
They  take  various  forms,  as  long  or  short  rods,  and  take  different 
shades  of  blue  or  violet.  One  of  them  is  the  Clostridium  butyricum 
of  Nothnagel.  It  occurs  as  large  round  cells,  like  yeast  fungi,  and 
stains  like  the  tubercle  bacilli  with  the  Ziehl-Neelsen  fluid.  Von 
Jaksch  finds  these  fungi  in  greater  abundance  in  intestinal  catarrh. 
They  are  present  in  both  acid  and  alkaline  stools. 

Bacillus  coli  communis  has  been  found  in  the  blood,  various 
organs,  feces  of  cholera  patients,  in  healthy  feces,  in  the  air,  and  in 
putrefying  infusions  ;  it  can  also  be  found  in  the  peritoneal  exudate 
in  most  cases  of  peritonitis. 

Morphology.  A  bacillus,  4  to  Q/m  by  2  to  3//,  with  rounded  ends, 
sometimes  in  cultures  a  short  oval.  Five  or  more  flagella  have  been 
observed  attached  to  the  organism. 

Biological  Properties.  Aerobic  ;  facultative  anaerobic  ;  non-liquefy- 
ing ;  slightly  non-motile. 

Growth.  On  gelatin  plates  the  colonies  vary  very  much.  The  deep 
colonies  are  transparent,  straw  color  to  dark  brown,  or  may  be  granu- 
lar and  opaque.  The  surface-colonies  are  large  and  spherical,  centre 
dark  brown,  edges  transparent.  In  stab-cultures  the  surface-growth 
is  thin  and  dry.  There  is  abundant  growth  along  punctures,  which 
is  white  by  reflected,  but  amber  by  transmitted  light ;  sometimes 
moss-like  tufts  are  seen.  On  potato  a  soft,  shining,  brownish-yellow 
layer  grows.  Stains  with  anilines,  but  not  by  Gram's  method.  In- 
jected in  guinea-pigs  it  produces  fever,  diarrhcea,  and  collapse.  In- 
jected into  the  abdomen  of  rabbits  it  causes  a  typical  peritonitis. 

Pathogenic  Fungi.  Spirillum  Choler.e  Asiatics.  See  page 
338. 

Spirillum  Cholera  Nostras.  Morphology.  Longer  and  thicker 
than  the  spirillum  of  Asiatic  cholera  ;  central  part  thicker  than  ends. 
Stains  as  the  true  cholera  spirillum. 

Biological  Properties.  Culture.  A  thick,  stocking-like  funnel  of 
liquefaction  instead  of  a  fine,  straight  funnel.    (See  Fig.  87,  page  340.) 


836  SPECIAL  DIAGNOSIS. 

Typhoid  Fever  Bacillus.  This  bacillus  is  present  in  the  stools 
of  typhoid  fever  patients,  but  cannot  be  directly  differentiated  by 
microscopic  examination  alone,  either  when  stamed  or  unstained.  It 
is  necessary  for  its  detection  to  make  pure  cultures  according  to  bac- 
teriological methods.  The  bacillus  is  about  as  long  as  the  tubercle 
bacillus,  but  much  thicker,  being  one-third  as  thick  as  it  is  long. 
The  ends  are  rounded.  It  is  best  stained  by  concentrated  aqueous 
solutions  of  methylene-blue,  the  dried  preparations  on  the  cover-slip 
being  prepared  as  above.  (See  Plate  III.,  Fig.  6,  b  ;  and  Typhoid 
Fever). 

Tubercle  Bacillus.  The  bacillus  of  tuberculosis  is  frequently 
found  in  the  feces  of  persons  suffering  from  intestinal  tuberculosis  and 
occasionally  in  the  feces  of  cases  of  pulmonary  tuberculosis,  when 
sputum  has  been  swallowed.  When  tubercle  bacilli  are  constantly 
found  in  the  feces,  and  in  large  quantities,  it  points  to  the  former 
condition  almost  to  a  certainty.  They  are  detected  by  methods  em- 
ployed in  the  examination  of  sputum. 

Bacilli  op  Booker.  No  less  than  nine  bacilli  have  been  described 
by  Booker.  They  have  been  found  by  him  in  cases  of  diarrhoea  in 
children.  Seven  of  them  resemble  very  closely  the  bacillus  coli  com- 
munis. Bacillus  A  is  a  bacillus  with  rounded  ends,  3-4//  by  0.7/i. 
It  is  aerobic  and  facultative  anaerobic,  liquefying,  and  motile.  Colo- 
nies on  agar  and  potato  are  dirty  brown.  On  gelatin  they  liquefy  too 
soon  to  show  characteristic  form.  The  bacillus  is  found  in  the  stools 
of  cholera  infantum. 

Chemical  Examination.  The  chemical  examination  of  the  feces 
is  of  but  slight  clinical  value.  Mucin  and  albumin  are  normally  pres- 
ent ;  peptones  in  different  diseases  (Von  Jaksch).  Among  the  acids 
to  be  found  are  bile-acids,  volatile  and  fatty  acids,  formic,  acetic, 
butyric,  and  propionic  acids  ;  while  phenol,  indol,  skatol,  cholesterin, 
and  fats  are  always  present,  according  to  the  same  author.  They  will 
not  aid  in  diagnosis. 

The  normal  coloring-matter  of  the  feces  is  urobilin  ;  its  presence  is 
shown  by  the  proper  tests.  As  before  stated,  bile-pigment  never 
occurs  in  the  feces  in  health  ;  it  is  present  when  there  is  catarrh  of  the 
small  intestine.  Blood-pigment  is  usually  in  the  form  of  hsematin. 
As  might  be  expected,  ptomaines  have  been  obtained  from  the  feces 
of  certain  diseases  caused  by  fungi. 

Diseases  Characterized  by  Pain  and  Flatulence. 

Intestinal  Indigestion.  Intestinal  indigestion  is  said  to  be  due  to 
alterations  in  or  diminution  of  the  bile,  the  pancreatic,  or  the  intestinal 
secretion.  It  is  almost  always  attended  by  gastric  indigestion,  and 
may  not  readily  be  distinguished  from  it. 

Acute  Intestinal  Indigestion.  Acute  intestinal  indigestion  is 
due  to  the  irritation  of  food  not  properly  digested  in  the  stomach.  It 
is  attended  with  colic,  flatulency,  and  borborygmi.  Some  fever  may 
develop,  and  diarrhoea  may  ensue.  In  the  mild  forms  the  tongue  is 
coated,  there  are  loss  of  appetite  and  some  general  pains.     There  is 


DTSEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     837 

epigastric  distress  or  pain  in  the  right  upper  quadrant.  Flatulency 
and  constipation  occur.  The  stools  are  often  clay-colored,  or  may 
not  be  changed.  Slight  jaundice  occurs,  and  there  is  an  abundance  of 
lithates  in  the  urine.  Accompanying  gastric  indigestion  modifies  the 
symptoms  slightly. 

The  symptoms  are  more  marked  and  pronounced  in  chronic  intestinal 
indigestion.  The  local  symptoms  are  as  follows  :  Pain  which  begins 
from  two  to  six  hours  after  eating.  It  may  be  complained  of  in  the 
region  of  the  liver  or  below  the  sternum.  It  is  usually  seated  in  the 
umbilical  region.  It  is  dull  and  continues  two  or  three  hours,  or  until 
the  next  meal  is  taken.  There  is  some  tenderness.  With  the  pain 
there  are  tympanites,  borborygmi,  and  a  sense  of  fulness  in  the  abdo- 
men ;  the  bowels  are  constipated,  and  the  stools  are  hard  and  dry. 
The  constipation  alternates  with  diarrhoea,  and  undigested  particles  of 
food  are  passed.  The  appetite  is  not  lost,  but  is  variable.  Hemor- 
rhoids are  often  present. 

The  general  symptoms  are  marked,  and  are  referred  to  the  nervous 
system  and  the  condition  of  the  blood.  There  are  great  depression  and 
hypochondriasis.  The  patients  sleep  badly,  suffer  from  bad  dreams  and 
tinnitus  aurium  ;  there  are  spots  before  the  eyes  and  more  or  less  constant 
headache.  They  complain  of  pain  in  the  back  and  limbs,  and  hyper- 
esthesia and  anaesthesia  are  present.  There  is  inaptitude  for  mental 
exertion.  Frequently  the  patient  has  sudden  attacks,  apparently  due 
to  toxins,  as  sudden  fainting  followed  by  collapse,  or  vertigo.  During 
these  attacks  there  are  great  palpitation  and  tachycardia.  The  ex- 
tremities are  cold,  and  there  are  cold  sweats  over  the  body.  Inde- 
pendently of  the  attacks,  the  patient  is  subject  to  palpitation  and  some 
dyspnoea.  The  urine  is  always  high-colored,  acid  in  reaction,  and  full 
of  urates  and  uric  acid.  Oxalate  of  lime  may  be  present,  and  the 
albuminuria  of  uric  acid  occurs,  due  to  the  irritation.  The  patient 
earl}'  becomes  anamiic,  because  of  the  auto-intoxication  and  poor 
assimilation.  There  is  some  emaciation  ;  in  some  cases  the  emaciation 
is  rapid.  The  complexion  is  sallow.  If  there  is  an  abundance  of 
oxalates,  the  patient  complains  of  weight  and  heaviness  about  the  loins. 
The  stools  may  contain  fat,  indicating  probable  pancreatic  disease,  if 
fatty  food  has  been  ingested.  On  the  other  hand,  with  loss  of  appetite, 
furred  tongue,  frontal  headache,  and  drowsiness,  the  stools  may  be 
clay-colored  and  the  bowels  costive  ;  apparently  the  bile  is  at  fault. 

Diseases  Characterized  by  Pain  and  Diarrhoea. 

Acute  Intestinal  Catarrh.  Cause.  Exposure  to  cold  or  the  direct 
irritation  of  mechanical  or  chemical  substances  within  the  intestine. 
Irritating  food  that  is  not  digested,  or  that  cannot  be  digested  because 
of  the  quantity  ;  spoiled  meats  and  unripe  fruit  usually  excite  an 
attack.  Water  saturated  with  impurities,  or  such  as  the  individual  is 
not  accustomed  to,  may  excite  an  attack.  Strangers  in  a  new  locality 
are  frequently  subject  to  a  diarrhoea  until  accustomed  to  the  drinking- 
water,  which  in  the  native  does  not  excite  catarrh.  Toxic  substances, 
as  poisons  or  drugs,  or  toxic  substances  the  result  of  putrefaction,  as 


838  SPECIAL  DIAGNOSIS. 

ptomaines,  are  frequent  exciting  causes.  Extension  of  inflammation 
from  neighboring  structures  by  infection,  as  in  peritonitis,  sets  up  a 
catarrh.  Local  diseases  of  the  intestine,  as  ileus,  intussusception,  her- 
nia, and  ulcers  of  all  forms,  are  attended  by  catarrh  of  the  intestine. 
It  also  occurs  in  cachectic  states  of  the  system,  as  cancer,  anaemia,  and 
B right's  disease.  In  disease  of  the  heart  and  bloodvessels,  or  of  the 
liver  and  spleen,  where  the  disturbance  of  the  circulation  causes  a  con- 
gestion, catarrhal  inflammation  occurs.  It  is  of  common  occurrence 
in  the  infectious  diseases,  and  particularly  in  septicaemia  and  pyaemia. 

Symptoms.  Diarrhoea  is  the  chief  symptom,  varying  with  the  cause 
and  the  extent  of  the  catarrhal  inflammation.  The  stools  differ  in  fre- 
quency and  in  color,  as  has  been  previously  indicated  in  the  various 
types.  They  contain  undigested  matter  ;  sometimes  worms.  Colicky 
pains  about  the  umbilicus,  with  borborygmi  and  frequent  desire  to  go 
to  stool,  attend  each  evacuation.  The  fever  is  of  the  remittent  type, 
and  is  attended  with  some  prostration.  The  urine  is  scanty  and  high- 
colored.  The  symptoms  vary  somewhat  with  the  location  of  the  in- 
flammation, although  the  exact  locality  cannot  be  distinctly  defined. 
The  symptoms  of  proctitis,  pain  with  tormina  and  tenesmus,  do,  how- 
ever, enable  the  localization  to  be  made  to  that  portion  of  the  bowel. 
These  are  more  common  than  in  inflammation  apparently  limited  to 
the  small  intestine,  while  in  colitis  the  violence  of  the  rectal  symptoms 
stands  between  enteritis  and  proctitis. 

The  diagnosis  of  acute  intestinal  catarrh  is  not  difficult.  It  is  more 
difficult  to  determine  the  actual  cause.  If  the  attack  occurs  suddenly 
after  the  eating  of  improper  food,  or  the  drinking  of  impure  water,  the 
irritation  is  probably  due  to  that  cause,  and  may  be  determined  by  the 
nature  of  the  feces.  If  they  contain  undigested  food,  the  diarrhoea  is 
probably  due  to  indigestion.  Catarrh  from  cold  usually  follows  ex- 
posure, and  is  generally  not  very  severe.  To  estimate  the  cause  from 
poison  or  drugs  the  condition  of  the  rest  of  the  intestinal  tract  must  be 
investigated  and  other  symptoms  of  the  effects  of  drugs  must  be  in- 
quired for.  In  arsenical  poisoning  there  is  always  vomiting  and  the 
discharges  are  of  a  choleraic  nature.  Collapse  rapidly  ensues.  The 
other  symptoms  of  arsenical  poisoning  must  be  inquired  for  and  the 
history  of  exposure,  if  possible,  ascertained.  The  intestinal  catarrh 
due  to  infectious  diseases  is  attended  by  the  symptoms  due  to  the 
respective  affections,  each  of  which  is  usually  readily  recognized.  It 
may  be  necessary  to  resort  to  a  bacteriological  examination  of  the  feces. 
The  intestinal  catarrh  which  occurs  on  account  of  local  disease  of  the 
bowel,  as  hernia,  stricture,  etc.,  is  preceded  or  attended  by  the  local 
symptoms  of  these  diseases.  In  like  manner  we  judge  of  the  nature 
of  the  diarrhoea  that  occurs  in  the  course  of  tuberculosis  or  syphilis, 
and  in  the  course  of  organic  heart  disease  or  of  liver  disease.  In  each 
instance  the  possible  influence  of  morbid  processes  present  in  other 
structures  must  be  very  carefully  estimated. 

The  Vaeieties  of  Acute  Intestinal  Catarrh.  Divisions 
have  been  made  in  accordance  with  the  symptoms  which  distinguish 
the  various  localities  of  the  intestine  in  which  the  inflammation  is  most 
marked. 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     839 

Catarrh  of  the  Duodenum.  This  partakes  of  the  nature  and  has  the 
symptoms  of  gastro-intestinal  catarrh  in  a  mild  degree,  and  is  charac- 
terized by  the  occurrence  of  jaundice  due  to  catarrhal  inflammation  of 
the  biliary  passages. 

The  Small  Intestine.  Colicky  pains  and  rumbling  are  experienced. 
There  is  usually  gastritis  at  the  same  time.  The  feces  are  mixed  with 
mucus.    Over  the  right  lower  quadrant  there  is  tenderness  on  pressure. 

Ccecum.  Pain  in  the  right  lower  quadrant  with  tumor,  dulness  on 
percussion,  and  tenderness  are  present.     (See  Typhlitis.) 

Colitis.  The  large  intestine  is  most  frequently  affected.  Pain  and 
tenderness  occur  along  the  course  of  the  bowel.  The  evacuations 
contain  mucus ;  there  is  tenesmus.  The  association  with  gastro- 
enteroptosis  and  with  neurasthenia  must  be  borne  in  mind. 

The  Rectum.  Proctitis  gives  rise  frequently  to  small  stools,  tenes- 
mus, pain  in  the  left  lower  quadrant,  with  tenderness  about  the  anus, 
and  spasms  of  the  sphincter.  There  are  considerable  mucus  and  blood 
in  the  passages. 

Cholera  Infantum.  This  affection  occurs  in  children  during  the 
hot  season.  It  is  promoted  by  bad  hygienic  surroundings,  and  is  due 
to  improper  milk  or  food.  At  first  there  is  catarrhal  diarrhoea.  This 
may  continue  for  twenty-four  hours,  then  vomiting  and  diarrhoea 
ensue.  The  stools  are  liquid  and  large  in  amount.  At  first  they  may 
contain  milk-curds.  The  vomiting  is  excited  by  anything  taken  into 
the  mouth,  or  by  odors,  or  by  movement  of  the  little  patient.  The 
watery  discharges  are  almost  constant.  They  may  be  preceded  by 
greenish  or  yellowish-green  stools  for  twenty-four  hours.  Stools  are 
acid  in  reaction,  and  their  odor  is  sour.  At  first  there  is  colicky  pain, 
but  when  the  watery  discharges  begin  there  is  only  a  little  tenesmus. 
The  stools  irritate  the  skin  and  cause  eczema.  The  rectum  may  be- 
come prolapsed.  The  abdomen  is  at  first  distended  with  gas,  but  soon 
becomes  retracted. 

In  a  short  time,  twenty-four  hours  or  even  less,  collapse  ensues. 
Previous  to  the  collapse  the  skin  is  hot  and  dry  ;  the  patient  is  restless. 
The  thirst  is  intense,  the  mouth  dry.  The  body-temperature  is  103°  to 
104°.  With  collapse  the  extremities  become  cold,  the  skin  cool.  The 
axillary  temperature  is  lowered  and  the  rectal  temperature  increased  to 
105°  to  106°.  The  restlessness  continues,  the  fontanelles  become  de- 
pressed, the  eyes  sunken,  the  face  pinched,  the  brows  drawn.  The  urine 
diminishes  in  amount  or  may  disappear  entirely.  Brain  symptoms 
ensue.  So-called  hydrocephaloid  symptoms  follow — rolling  of  the  head, 
strabismus,  turning  in  of  the  thumbs,  and,  later,  convulsions.  Stupor 
followed  by  coma  develops  in  the  fatal  cases.  If  the  patient  does  not 
die  in  collapse,  marasmus  develops ;  ulceration  of  the  cornea  may  take 
place  ;  there  are  oedema  and  blood  extravasation  under  the  skin.  The 
child  emaciates  and  withers.  On  account  of  the  weak  heart  and  ex- 
haustion pulmonary  atelectasis  or  bronchopneumonia  may  occur..  The 
age,  the  season,  the  presence  of  catarrh,  with  collapse  and  other  symp- 
toms, render  the  diagnosis  easy. 

Cholera  Morbus.  The  attack  is  characterized  by  sudden  vomiting, 
followed  in  a  short  time  by  purging.     The  vomiting  may  be  preceded 


840  SPECIAL  DIAGNOSIS. 

"by  pain,  or  both  may  occur  at  the  same  time.  At  first  the  pain  is 
seated  in  the  epigastrium  and  subsequently  about  the  navel.  It  is 
very  severe  and  paroxysmal  in  character,  compelling  the  patient  to 
double  up  if  lying  in  bed.  A  cold  perspiration  breaks  out  on  the  fore- 
head, the  extremities  become  cold,  the  face  anxious ;  the  pulse  becomes 
rapid.  At  first  the  patient  vomits  undigested  food,  then  watery, 
greenish-colored  fluid.  The  latter  is  bitter.  Purging  sets  in  at  once, 
or  within  an  hour.  The  bowel-movements  follow  an  attack  of  pain. 
The  first  passage  is  fecal,  and  may  contain  undigested  food ;  the  subse- 
quent passages  are  watery  and  profuse.  There  are  severe  attacks  of 
burning  and  tenesmus  ;  the  abdomen  is  tender  around  the  navel  and 
in  the  epigastrium.  After  an  evacuation  there  is  slight  relief,  but  soon 
another  paroxysm  of  pain  comes  on.  The  vomiting  is  excessive,  and 
retching  may  be  present  in  the  intervals.  Ice,  or  water,  or  anything 
taken  into  the  stomach  excites  pain  and  causes  the  vomiting.  The 
attack  subsides  in  twelve  to  twenty-four  hours,  and  is  followed  by  ex- 
haustion. In  rare  cases  collapse  ensues,  and  in  others  it  is  followed 
by  gastro-intestinal  catarrh. 

Cholera  Nostras.  The  symptoms  are  those  of  severe  gastro-enter- 
itis.  There  are  sudden  vomiting  and  diarrhoea.  It  usually  begins  in 
the  night.  The  vomiting  is  not  different  from  that  of  cholera  morbus. 
The  watery  and  brownish-colored  stools  become  colorless  and  have  the 
appearance  of  rice-water.  Pain  attends  the  attack,  rapid  prostration 
ensues,  the  extremities  become  cold,  and  collapse  takes  place.  With 
the  collapse  there  are  cramps  in  the  legs.  Other  muscles  of  the  body 
may  become  cramped.  The  disease  occurs  in  epidemics  during  the  hot 
season,  and  may  be  mistaken  for  cholera.  It  can  be  distinguished  from 
the  milder  forms  of  cholera  which  precede  the  occurrence  of  the  epi- 
demic only  by  the  absence  of  the  comma-bacillus.  The  bacillus  of 
cholera  nostras  is  found  in  the  stools.     (See  Feces.) 

Entero-colitis.  In  entero-colitis  the  more  intense  inflammation 
succeeds  a  mild  intestinal  catarrh.  There  are  increased  languor,  great 
fretfulness,  and  fever.  The  early  catarrh  is  attended  by  green  acid 
stools,  with  lumps  of  casein.  The  tongue  is  furred  and  moist  at  first.  It 
soon  becomes  red  and  dry  ;  vomiting  ensues.  The  stools  are  offensive 
and  increase  in  frequency,  and,  in  addition  to  the  appearance  first  indi- 
cated, contain  mucus  and  blood.  Death  may  take  place  within  the . 
first  week,  on  account  of  exhaustion  from  the  vomiting  and  diarrhoea. 

If  the  disease  is  protracted,  it  is  attended  by  great  wasting,  symp- 
toms of  hydrocephalus,  skin  eruptions,  hypostatic  pneumonia,  and  ex- 
tremely weak,  feeble  circulation. 

Chronic  Intestinal  Catarrh.  It  usually  follows  an  acute  attack,  or 
may  be  chronic  from  the  start.  It  may  follow  gastric  hyperacid- 
ity and  dilatation  of  the  stomach.  It  arises  secondarily  to  portal  con- 
gestion in  disease  of  the  liver  and  in  chronic  disease  of  the  heart  or  of 
the  lungs.     It  occur  in  malaria  and  in  the  scorbutic  cachexia. 

The  symptom  is  diarrhoea  alternating  with  constipation,  or  diarrhoea 
alone.  Stools  may  contain  undigested  food,  or  pus,  mucus,  and  blood 
in  small  amounts.  Diarrhoea  may  be  present  in  the  morning  only 
under  these  circumstances.     If  the  feces  are  examined,  the  eggs  of 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     841 

parasites,  or  infusoria  may  be  found.  The  local  abdominal  symp- 
toms of  rumbling,  flatulency,  and  tormina  are  present.  There  are 
reflex  symptoms  of  cardiac  palpitation  and  dyspnoea  (asthma).  Rush 
of  blood  to  the  head  may  occur.  Often  these  symptoms  are  relieved 
by  the  passage  of  flatus.  Chronic  catarrhal  gastritis  usually  accom- 
panies the  intestinal  catarrh.  The  general  symptoms  of  anaemia, 
emaciation,  and  neurasthenia  are  present.     Hemorrhoids  are  common. 

Amyloid  Degeneration  of  the  Intestines.  The  symptoms  are 
those  of  diarrhoea,  persistent  but  mild  in  character,  associated  with 
symptoms  of  amyloid  disease  in  other  organs.  With  enlargement  of 
the  liver  and  spleen  changes  in  the  urine  due  to  amyloid  disease  are 
present.  The  occurrence  of  these  symptoms  in  a  patient  with  syphilis, 
or  especially  in  a  child  with  bone  disease  or  tuberculosis,  points  to  the 
nature  of  the  case. 

Ulceration  of  the  Intestines.  Duodenal  Ulcee.  Ulcer  of  the 
duodenum  usually  occurs  in  young  subjects  in  whom  there  are  symp- 
toms of  chlorosis  or  anaemia.  The  causes  are  the  same  as  those  of 
gastric  ulcer.  It  may  follow  boils,  erysipelas,  or  pemphigus,  and 
differs  in  one  etiological  respect  from  ulcer  of  the  stomach,  in  that  it 
occurs  more  frequently  in  the  male  sex.  The  symptoms  are  obscure, 
and  may  be  wanting  entirely,  the  patient  probably  complaining  only 
of  intestinal  indigestion.  In  other  cases  they  are  like  those  of  gastric 
ulcer.  In  typical  cases  the  symptoms  are  those  of  pain  situated  below 
the  xiphoid  or  to  the  right  of  the  median  line  in  the  region  of  the 
pylorus.  The  pain  occurs  after  eating,  and  may  be  relieved  by  vomit- 
ing. There  is  localized  tenderness  on  pressure.  Hemorrhage  may 
take  place  from  the  stomach,  or  blood  be  found  in  the  stools  alone.  It 
differs  from  gastric  ulcer  only  in  the  possible  difference  in  location  of 
the  pain,  the  occurrence  of  intestinal  indigestion  and  hemorrhage,  and 
the  fact  that  the  pain  comes  on  one  to  two  hours  after  eating. 

Duodenal  ulcer  is  diagnosticated  by  the  occurrence  of  melaena,  which 
may  be  excessive  and  cause  syncope  and  vomiting  with  no  blood  in  the 
vomitus  ;  by  pain,  which  may  be  in  the  right  hypochondrium  or  be- 
tween the  navel  and  the  right  costal  border  ;  by  gastralgic  attacks ;  by 
dyspepsia,  with  constipation. 

General  Ulceration.  Ulceration  of  the  intestine  may  be  due 
to  a  specific  infection,  and  hence  be  symptomatic  of  typhoid  fever, 
syphilis,  and  tuberculosis.  It  is  always  present  in  the  first  mentioned, 
and  of  frequent  occurrence  in  the  latter.  Follicular  ulceration  occurs 
in  entero-colitis  in  children.  Ulcers  due  to  the  pressure  of  feces  occur 
in  typhlitis  and  chronic  constipation.  The  sacculi  of  the  colon  become 
filled  with  scybalous  masses,  the  pressure  of  which  produces  ulcers. 
Tenderness  is  experienced  along  the  course  of  the  colon,  particularly 
on  palpation  of  the  fecal  masses,  which  may  be  felt  through  the 
abdominal  wall.  A  chronic  ulcerative  colitis  is  the  form  that  succeeds 
the  diarrhoeas  which  occur  during  camp-life,  or  that  are  set  up  in  com- 
munities where  people  are  crowded  and  live  under  bad  hygienic  cir- 
cumstances. It  is  the  form  that  attends  scurvy,  and  is  frequently  seen 
in  chronic  Bright's  disease.  It  may  be  succeeded  by  dilatation  of  the 
colon,  by  hypertrophy  of  the  muscular  walls,  or  by  contraction  of  the 


842  SPECIAL  DIAGNOSIS. 

bowel.  The  persistent  diarrhoea  leads  to  profound  emaciation,  extreme 
prostration,  sallow  complexion,  with  markedly  impaired  nutrition  of 
the  skin.  Such  forms  of  diarrhoea  were  seen  during  the  late  war,  par- 
ticularly in  soldiers  held  in  captivity.  The  diarrhoea  may  first  be  of  a 
lienteric  character,  and  later  alternate  with  constipation.  Stools  con- 
tain blood  and  mucus. 

Ulcers  of  the  intestinal  tract  may  occur  from  other  causes,  and  diar- 
rhoea may  be  the  predominant  symptom.  They  may  be  due  to  cancer  ; 
the  malignant  nodules  may  ulcerate  within  the  lumen  of  the  bowel. 
The  bowel  may  be  perforated  from  the  exterior,  on  account  of  suppura- 
tion somewhere  along  its  course,  as  in  appendicitis,  pancreatitis,  or 
tuberculous  peritonitis. 

Symptoms.  The  symptoms  of  intestinal  ulcer  are  usually  those  of 
diarrhoea.  Ulceration,  however,  may  be  present  without  any  symp- 
toms whatsoever,  particularly  if  the  small  intestine  is  affected.  One 
or  two  small  ulcers,  on  the  other  hand,  in  the  lower  portion  of  the 
colon,  may  set  up  continuous  diarrhoea.  The  stools  are  composed  of 
feces,  mucus,  pus.  shreds  of  tissue,  and  blood.  If  pus  is  discharged  in 
large  amounts,  an  abscess  has  probably  opened  into  the  bowel.  Mod- 
erate discharge  of  pus  usually  follows  ulcers  in  the  colon.  Pus  may 
be  present  in  cancer.  Hemorrhage  is  of  frequent  occurrence,  and  is  an 
important  diagnostic  symptom,  especially  if  profuse  and  occurring 
without  symptoms  of  obstruction,  of  gastric  ulcer,  or  of  hemorrhoids. 
The  fragments  of  tissue  found  in  the  stools  may  point  to  the  nature  of 
the  process.  Large  amounts  attend  the  dysenteric  process.  The  frag- 
ments may  be  composed  of  the  mucosa,  connective  tissue,  and  the 
muscular  coat.  Pain  occurs  in  many  of  the  cases.  It  may  be  general 
and  colicky,  or  circumscribed  in  cases  of  ulcer  of  the  colon.  Perfora- 
tion of  the  intestine  is  followed  by  localized  or  general  peritonitis. 
The  occurrence  of  the  latter  depends  largely  upon  the  situation  and  the 
rapidity  of  the  ulceration.  If  the  perforation  is  in  the  posterior  wall 
of  the  colon,  a  circumscribed  abscess  may  develop.  AVhen  it  is  situ- 
ated in  the  upper  zone  the  pus  may  accumulate  underneath  the  dia- 
phragm, or  in  the  lesser  peritoneal  cavity.  The  signs  of  pyopneumo- 
thorax subphrenicus  occur  when  the  latter  accident  takes  place,  as  both 
pus  and  air  accumulate  in  the  abscess-cavity.  In  such  instances  the 
ulceration  usually  takes  place  at  the  splenic  flexure.  Perforation  of 
an  ulcer  of  the  caecuni  may  simulate  appendicitis. 

Tuberculosis  of  the  Intestine.  The  disease  is  usually  secondary 
to  chronic  tuberculosis,  but  may  be  primary,  especially  in  children. 
The  symptoms  are  usually  those  of  diarrhoea,  and  in  the  primary  form 
this  is  associated  with  general  emaciation,  which  advances  rapidly,  and 
with  anaemia.  Fever  of  the  intermittent  or  remittent  type  is  present. 
There  is  meteorism  ;  the  abdomen  is  much  distended,  but  eventually 
becomes  contracted.  The  mesenteric  glands  can  be  made  out  along 
the  spinal  column,  and  the  intestines  may  become  bunched  into  a  mass, 
yielding  a  dull  tympany  on  percussion  in  the  centre  of  the  abdomen. 
The  diarrhoea  is  attended  with  colicky  pains.  The  diagnosis  is  based 
upon  the  rapid  emaciation,  irregular  fever,  enlargement  of  the  mesen- 
teric glands  in  a  patient,  usually  a  child,  who  had  probably  been  ex- 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     843 

posed  to  tuberculous  infection.  In  one  of  my  cases,  the  child,  aged 
four  years,  ate  of  the  same  food,  using  the  same  utensils,  as  a  brother, 
a  young  man  of  twenty-two  years,  dying  of  pulmonary  tuberculosis. 
The  child  was  constantly  with  the  brother.  The  remainder  of  the  family, 
eight  in  number,  remained  in  perfect  health,  and  Avere  all  of  good 
physique.  The  elder  brother  became  infected  by  association  with 
tuberculous  subjects  in  improper  quarters  away  from  home. 

Intestinal  Obstruction. 

Intestinal  obstruction  may  be  acute  or  chronic.  Acute  obstruction 
may  set  in  in  the  course  of  chronic  obstruction  due  to  stricture  of  the 
bowel,  to  occlusion  due  to  external  pressure,  or  to  accumulations  within 
the  bowel. 

Causes.  Acute  intestinal  obstruction  is  due,  first,  to  constriction  by 
bands  or  strangulation  of  the  bowel  through  apertures ;  second,  to 
volvulus  of  the  colon  ;  third,  to  acute  intussusception. 

In  the  first  instance  the  type  of  the  obstruction  is  seen  in  strangu- 
lated hernia,  but  similar  strangulations  occur  in  apertures  within  the 
peritoneal  cavity.  Thus  loops  of  the  intestine  are  caught  and  con- 
stricted in.  the  duodeno-jejunal  fossa,  the  so-called  Treitz'  retro- 
peritoneal hernia,  or  in  the  foramen  of  Winslow,  also  known  as 
inter-sigmoid  hernia ;  finally,  diaphragmatic  hernia,  in  which  protru- 
sions of  the  intestine  through  the  diaphragm,  along  with  other  abdominal 
viscera,  may  take  place.  The  above-mentioned  forms  of  hernia  may 
exist  without  symptoms,  or  may  lead  to  constriction  or  twisting  of  the 
loop  of  the  intestine,  with  occurrence  of  acute  obstruction.  Moreover, 
lacerations  in  the  omentum  may  give  rise  to  internal  constrictions. 
External  constrictions,  however,  take  place,  most  commonly  in  the 
regions  of  hernias,  on  account  of  the  gut  being  constricted  by  dense 
fibrous  adhesion  ;  or  about  the  uterus  or  Fallopian  tubes,  which  had 
previously  been  the  seat  of  inflammation.  The  constricting  bands 
that  follow  the  local  peritonitis  may  gradually  occlude  the  gut,  or  be 
in  such  position  that  the  latter  becomes  twisted  about  it.  In  other 
forms  of  peritonitis  similar  constricting  bands  may  form,  which  are 
liable  to  produce  this  accident.  Disease  about  the  vermiform  ap- 
pendix, with  secondary  adhesions,  has  been  observed  to  cause  con- 
striction. A  frequent  form  of  intestinal  obstruction  is  due  to  the 
tangling  of  the  intestines  in  the  foetal  remains  of  the  omphalomesen- 
teric duct,  Meckel's  diverticulum,  which  is  situated  a  short  distance 
above  the  ileo-csecal  valve. 

Volvulus  is  a  form  of  acute  obstruction  due  to  twisting  or  knotting 
of  the  intestine.  The  condition  is  not  common.  It  occurs  most  fre- 
quently at  the  sigmoid  flexure  of  the  colon.  The  mesentery  of  the 
latter  is  often  congenitally  narrowed,  on  account  of  which  the  colon  is 
unduly  dragged  upon,  and,  if  filled  with  masses  of  feces,  cannot  restore 
itself ;  the  twisting  becomes  permanent,  and  obstruction  takes  place. 
Peristalsis  is  set  up  and  other  portions  of  the  intestine  wind  about 
the  pedicle  of  the  loops,  so  as  to  form  a  regular  knot.  Abnormal 
peristalsis,  on  account  of  diarrhoea,  often  precedes  the  appearance  of 


844  SPECIAL  DIAGNOSIS. 

the  obstruction.  External  injury  is  said  also  to  give  rise  to  the  forma- 
tion of  an  obstruction. 

Intussusception  (Plate  XXXIX.,  Fig.  1),  as  a  cause  of  intestinal 
obstruction,  occurs  most  frequently  in  children,  and  is  due  to  a  portion 
of  the  bowel  being  pushed  into  the  lumen  of  that  which  lies  next  below 
it.  A  circumscribed  portion  of  the  intestine  may  be  paralyzed.  In  the 
portion  above,  the  peristaltic  action  continues  and  the  energetic  move- 
ments push  it  into  the  paralyzed  part.  Intussusception  is  found  fre- 
quently after  death  in  the  bodies  of  children  dying  from  exhaustion. 
In  such  cases  it  occurs  just  before  death.  Intussusception  also  occurs 
when  intestinal  polypi  drag  one  portion  of  the  bowel  into  the  lower 
portion.  Large  portions  of  the  intestine  may  be  involved.  The  inva- 
gination usually  takes  place  at  the  lower  portion  of  the  ileum,  or  into 
the  caecum  ;  sometimes  the  invaginated  portion  may  reach  the  rectum 
and  project  externally.  Intense  inflammation  and  adhesion  are  set  up. 
The  internal  portion  becomes  gangrenous,  on  account  of  constriction  of 
the  afferent  vessels.  This  portion  may  slough  and  pass  with  the  dejec- 
tions, followed  by  spontaneous  cure. 

Chronic  intestinal  obstruction  may  be  due  to  occlusion  by  external 
pressure,  or  by  the  excessive  accumulation  of  material  within  the 
bowels,  or  to  stricture.     The  various  causes  are  specified  below. 

Intestinal  obstruction,  to  view  it  from  another  stand-point,  may  be 
due  to  (a)  disease  outside  of  the  intestines ;  (b)  to  disease  of  the  intes- 
tinal walls  ;  (c)  to  accumulation  within  the  intestine. 

The  obstruction  takes  place  under  the  same  circumstances  as  ob- 
struction in  other  channels. 

A.  Diseases  Outside  of  the  Intestines.  1.  Pressure  of  tumors,  chiefly 
ovarian  tumors,  uterine  tumors,  tumors  of  the  omentum,  and  pelvic 
abscess,  or  abscess  about  the  ceecum.  The  obstruction  may  be  acute 
or  chronic.  The  symptoms  of  obstruction  develop  gradually,  although 
in  some  instances  they  may  take  place  suddenly,  especially  if  aided 
by  the  accidental  occurrence  of  fecal  impaction. 

2.  Constricting  bands,  hernial  openings,  the  remains  of  foetal  struc- 
tures, cause  constriction  of  the  intestine.  In  this  class  of  cases  there 
is  usually  pain,  and  the  history  preceding  the  obstruction  is  that  of 
peritonitis,  general  or  local,  of  old  hernia,  of  appendicitis,  of  pyosal- 
pinx,  or  of  inflammation  about  the  gall-bladder  and  gall-ducts.  The 
onset  may  be  acute  or  chronic.  If  the  constriction  is  clue  to  protrusion 
into  hernial  openings,  the  onset  is  usually  sudden  and  without  previous 
symptoms. 

3.  Peritonitis  is  a  most  common  cause  of  acute  intestinal  obstruction. 
It  may  be  due  to  overdistention  by  gas  and  paresis  of  the  bowel,  or  to 
pressure  by  external  exudation. 

4.  Knots  and  twists  of  the  intestines,  usuallv  seated  about  the  sis;- 
moid  flexure,  causing  volvulus,  are  a  common  cause  of  acute  constriction. 

B.  Disease  of  the  Intestinal  Walk.  1.  Invagination,  or  intussuscep- 
tion. The  attack  is  acute,  although  the  affection  may  continue  over  a 
long  period  of  time. 

2.  Cancer  and  other  tumors  of  the  intestine  generally  lead  to  stric- 
ture and  chronic  obstruction. 


PLATE    XXXIX. 


FIG.    1. 


TumofA, 


Invagination  of  the  Ileum. 


T 


FIG.    2. 


Carcinoma  of  the  Coloi 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     845 

3.  The  healing  of  ulcers,  which  are  syphilitic  in  the  larger  number 
of  cases,  rarely  tuberculous,  will  lead  to  stricture.  The  obstruction 
belongs  to  the  chronic  variety.  It  is  seated,  in  the  larger  number  of 
instances,  in  the  rectum  or  sigmoid  flexure  of  the  colon. 

C.  Accumulations  within  the  Intestines.  1.  Feces.  The  obstruction 
takes  place  gradually,  occurs  in  weak  and  debilitated  people  in  the 
course  of  constipation,  especially  the  constipation  of  acute  disease. 

2.  Accumulations  of  improper  food  or  foreign  materials.  The  seeds 
of  fruits  or  the  husks  of  grain  accumulate  and  cause  obstruction. 
Magnesia,  iron,  and  other  articles  taken  as  medicines,  from  their  accu- 
mulation lead  to  obstruction  of  the  intestine.  In  both  of  the  above 
mentioned  varieties  obstruction  is  chronic. 

3.  Impaction  of  gallstone  within  the  intestine  is  followed  by  acute 
obstruction. 

The  Symptoms.  When  symptoms  of  intestinal  obstruction  occur 
it  is  important  to  ascertain,  in  addition,  first,  the  duration  of  the  ob- 
struction and  its  mode  of  onset ;  second,  the  possible  cause  of  the  ob- 
struction ;  third,  the  seat  of  the  obstruction. 

The  Symptoms  Common  to  Acute  Obstruction.  The  symptoms  of  intes- 
tinal obstruction  depend  upon  the  nature  and  the  seat  of  the  obstruction. 
Constipation.  The  major  symptom  is  stoppage  of  the  intestinal  contents. 
AVhen  this  takes  place  suddenly,  and  there  is  a  local  injury  to  the 
bowel,  the  symptoms,  both  local  and  general,  are  severe  and  alarming. 
"When  the  constipation  is  complete  there  is  no  escape  of  flatus.  Pain. 
The  pain  is  at  the  seat  of  obstruction  or  about  the  umbilicus.  It 
occurs  suddenly,  and  is  intense  and  colicky  or  lancinating  in  character, 
radiating  from  the  point  of  obstruction.  There  is  tenderness  over  the 
painful  part.  The  pain  is  due  to  the  injury  by  the  constricting  agent 
or  to  violent  peristalsis.  It  may  be  relieved  by  pressure.  When  inter- 
mittent, the  obstruction  is  incomplete ;  when  constant,  it  is  absolute. 
Tumor.  In  many  instances  a  tumor  can  be  outlined  due  to  single  loops 
of  intestine,  thickened  walls,  or  abnormal  contents.  This  is  particularly 
the  case  in  the  obstruction  of  invagination  and  the  obstruction  due  to 
volvulus.  Peristalsis.  The  obstruction  further  causes  increased  peri- 
stalsis. This  takes  place  above  the  point  of  constriction.  Sometimes 
the  movements  of  the  intestine  can  be  seen  through  the  abdominal 
walls.  The  extent  of  the  peristalsis  is  an  indication  of  the  site  of  the 
obstruction.  The  higher  the  obstruction,  the  less  the  peristalsis. 
Meteorism.  The  obstruction  causes  accumulation  of  gas  above  the 
point,  giving  rise  to  meteorism.  If  the  obstruction  is  low  down,  the 
distention  and  meteorismus  are  general.  If  high  up,  as  in  the  small 
intestine,  on  account  of  constriction  by  Meckel's  diverticulum  or  inter- 
nal hernia,  the  meteorism  is  in  the  upper  part  of  the  abdomen,  and 
may  be  limited  in  extent,  or  dilatation  of  the  stomach  alone  may  be 
present.  Vomiting.  Vomiting  soon  occurs  in  acute  intestinal  obstruc- 
tion, due  to  decomposition  of  intestinal  contents,  to  irritation  of  the 
stomach  by  the  intestinal  contents,  to  a  trauma  of  the  peritoneum  at 
the  seat  of  the  obstruction,  or,  finally,  to  the  occurrence  of  peritonitis. 
At  first  the  contents  of  the  stomach  are  ejected,  then  watery  fluid,  bile 
tinged  or  largely  made  up  of  bile,  and  later  feculent  matter.     Although 


846  SPECIAL  DIAGNOSIS. 

of  fecal  odor,  this  is  not  true  stercoraceous  vomiting ;  the  latter  occurs 
later  in  the  course  of  the  disease.  It  must  not  be  forgotten  that  any  ob- 
struction of  the  intestine  may  develop  with  extreme  rapidity,  so  that 
fecal  vomiting  may  occur  within  two  hours  of  the  commencement  of  an 
obstruction.  It  is  recognized  by  the  odor  of  the  matter  vomited  and 
by  its  color.  It  is  a  grave  symptom,  indicating  complete  obstruction 
of  the  intestine.  If  the  obstruction  is  high  up,  as  in  the  jejunum, 
fecal  vomiting  does  not  occur.  The  vomiting,  however,  is  more  per- 
sistent in  high  obstruction.  Eructations  of  gas  are  frequent.  The 
general  symptoms  are  those  of  extreme  'prostration  or  shock  in  its  most 
pronounced  form.  The  abdominal  fades  previously  described  develops 
very  rapidly.  The  tongue  is  not  changed  at  first,  but  soon  becomes 
dry  and  brown.  In  a  few  instances,  as  in  invagination,  there  may  be 
fever,  but  in  other  cases  usually  at  once,  or  very  soon  in  its  course,  the 
temperature  falls  to  normal  or  subnormal,  or  remains  at  this  point  if 
it  has  not  risen.  The  extremities  are  cold,  the  features  pinched,  the 
eyes  sunken,  the  expression  anxious.  The  pain  causes  the  patient  to 
double  up  in  bed.  The  pulse  becomes  rapid,  weak,  and  thready  in 
character.  The  respirations  are  proportionately  hurried,  but  are  also 
made  more  rapid  and  shallow  by  the  tympany.  The  mind  remains 
clear  until  the  supervention  of  peritonitis  and  septicaemia. 

The  Symptoms  Common  to  Chronic  Obstruction.  The  symptoms  are 
those  of  chronic  constipation,  with  local  symptoms  due  to  the  cause  of 
the  obstruction.  The  bowels  are  moved  infrequently,  and  then  in 
small  amounts.  In  obstruction  due  to  stricture  from  cancer,  or  cica- 
tricial closure,  the  feces  are  ribbon-shaped.  Reference  must  again  be 
made  to  the  occurrence  of  so-called  spurious  diarrhoea,  with  or  without 
the  passage  of  small  scybalous  masses,  on  account  of  impaction  of  feces. 
Some  credence  can  be  given  to  the  oft-repeated  expression  of  the  pa- 
tients that  they  have  a  sense  of  obstruction  in  the  bowel  and  that  they 
experience  great  relief  when  there  is  a  free  evacuation.  In  chronic 
obstruction  the  general  symptoms  are  those  of  inanition,  with  the  ner- 
vous train  of  symptoms  that  have  been  described  in  constipation  ; 
while  the  local  symptoms  depend  upon  the  cause.  When  the  local 
symptoms  are  due  to  the  pressure  of  a  tumor,  or  accumulation  of  pus 
or  fluid  within  the  abdomen,  there  is  a  history  of  local  disease,  on  ac- 
count of  which  the  tumor  developed ;  such  history  is  obtained  in 
fibroids  or  ovarian  tumor,  or  in  previous  inflammation,  which  was  fol- 
lowed by  the  occurrence  of  a  tumor  about  the  locality  of  the  inflam- 
mation, as  the  pelvis  or  the  appendix. 

If  the  obstruction  is  due  to  stricture  from  cancer  of  the  intestine,  the 
symptoms  of  that  affection  are  present.  A  tumor  can  be  made  out  at 
some  situation  in  the  course  of  the  bowel.  The  symptoms  are  (1)  the 
cachexia,  emaciation,  and  anaemia ;  (2)  pain  ;  (3)  tumor ;  (4)  constipa- 
tion with  scybalous  discharge  ;  (5)  bloody  discharge  ;  (6)  mucous  dis- 
charge. If  the  cancer  is  seated  in  the  rectum,  we  find  tormina  and 
tenesmus,  and  the  discharge  of  blood  and  scybalous  masses.  Local 
examination  reveals  the  presence  of  a  malignant  mass.  Obstruction 
due  to  stricture  from  the  healing  of  an  ulcer  is  seated  in  the  rectum  or 
sigmoid  flexure  of  the  colon.     Pain  and  a  sense  of  obstruction  are 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     847 

referred  to  that  locality.  A  history  of  syphilis  may  be  obtained,  and 
frequently  the  rectal  tube,  or  the  finger,  will  detect  the  stricture.  In 
both  instances  there  is  a  history  of  imperfect,  irregular  action  of  the 
bowels  from  time  to  time,  with  intervals  of  comparative  comfort. 
These  symptoms  precede  the  constipation.  When  feces  accumulate  in 
the  colon  the  larger  accumulations  take  place  in  the  sigmoid  flexure 
and  in  the  caecum.  Fecal  tumors,  described  under  Constipation,  are 
felt  through  the  abdominal  walls.  Obstruction  from  fecal  accumula- 
tion is  preceded  by  a  history  of  constipation  (q.  v.).  The  accumula- 
tions can  be  easily  discerned  as  a  rule.  It  must  not  be  forgotten  that 
chronic  intestinal  obstruction  may  at  any  time  become  acute. 

Chronic  intestinal  obstruction  always  occurs  in  adults.  The  onset  is 
gradual.  The  pain  that  attends  obstruction  of  this  form  is  intermit- 
tent, and  if  there  is  fecal  accumulation,  it  is  not  very  prominent. 
Vomiting  occurs  late  in  the  disease,  is  small  in  amount,  and  generally 
is  not  a  prominent  factor.  Obstruction  to  the  passage  of  feces  may  be 
constant,  or  alternate  with  diarrhoea.  In  fecal  accumulation  it  be- 
comes complete,  although  spurious  diarrhoea  may  attend  it.  The  dis- 
charges may  be  bloody,  which  points  to  cancer.  Tenesmus  is  present 
in  stricture  low  down  in  the  large  bowel.  Meteorism  is  not  marked 
when  the  obstruction  is  high  up,  as  in  acute  obstruction.  When  the 
obstruction  is  in  the  large  intestine  it  may  be  extreme,  and  in  fecal 
obstruction  gradually  increases  as  the  obstruction  becomes  more 
marked.  Coils  of  intestine  in  peristaltic  movement  are  seen  only  in 
cases  in  which  there  is  marked  emaciation. 

The  forms  of  chronic  obstruction  that  are  attended  by  tumor  have 
been  mentioned. 

The  Differential  Diagnosis.  It  is  essential  in  order  to  distin- 
guish the  form  of  acute  obstruction  to  ascertain  the  nature  of  the  ob- 
struction, and  to  determine,  if  possible,  its  site. 

The  Nature  of  the  Obstruction.  Various  factors  must  be 
considered  in  order  to  estimate  the  cause  of  the  obstruction. 

The  Age.  Obstruction  from  intussusception  occurs  early  in  life  ; 
from  bands  or  through  apertures,  in  adult  life,  usually  prior  to  forty 
years  of  age  ;  from  volvulus,  between  forty  and  sixty  years.  Obstruction 
due  to  a  gallstone  occurs  during  the  middle  or  later  period  of  life  — 
always  after  the  fortieth  year. 

The  Previous  History.  In  obstruction  by  bands  of  adhesion  there 
is  a  history  of  peritonitis,  or,  as  Treves  points  out,  previous  attacks  of 
obstruction  more  or  less  marked.  In  volvulus  the  patient  has  been 
subject  to  constipation  prior  to  the  attack,  and  in  intussusception  there 
has  been  no  previous  history,  unless  polypus  was  present,  causing  drag- 
ging, colicky  pains,  and  occasional  discharge  of  blood. 

The  Symptoms.  The  symptoms  of  the  various  forms  of  acute  obstruc- 
tion vary  somewhat.  Pain  in  strangulation,  from  bands  or  hernia,  is 
severe  and  paroxysmal  in  character,  attended  by  collapse.  It  occurs 
early  in  volvulus,  though  it  is  not  so  severe  as  in  the  former,  and 
occurs  at  long  intervals,  becoming  constant  with  exacerbations.  In 
acute  intussusception  the  pain  occurs  early,  and  is  steady.  It  in- 
creases, and  then  may  suddenly  subside.     At  first  it  is  paroxysmal. 


848  SPECIAL  DIAGNOSIS. 

attending  discharge  of  blood  and  mucus  from  the  bowels.  Local  ten- 
derness in  the  first  group  of  cases  occurs  late.  In  volvulus  it  occurs 
early,  and  may  be  noted  over  distended  coils.  In  intussusception  it  is 
usually  common  about  a  sausage-shaped  tumor.  Vomiting  is  marked 
and  occurs  in  strangulation,  soon  becomes  feculent,  and  increases  the 
severity  of  the  paroxysms  of  pain.  In  jejunal  obstruction  it  is  ex- 
cessive and  non-feculent.  In  volvulus  it  does  not  come  on  so  quickly, 
but  is  severe  and  constant  when  it  takes  place.  The  relaxation  that 
attends  vomiting  often  affords  relief  to  the  obstruction.  In  intussus- 
ception it  does  not  occur  as  early  as  in  the  other  forms,  and  is  not  so 
severe.  It  becomes  feculent  in  only  a  small  number  of  cases.  Con- 
stipation is  continuous  in  all  cases  except  intussusception.  In  the 
latter  there  is  some  constipation,  but  it  is  not  absolute ;  diarrhoea  is 
not  uncommon,  and  discharge  of  blood  in  the  stools  occurs  in  80  per 
cent,  of  the  cases,  according  to  Treves.  Prostration  is  severe  in  all 
cases,  although  probably  not  so  marked  in  volvulus.  Because  of  its 
close  proximity  to  the  rectum  tenesmus  occurs  in  volvulus.  It  is  of  fre- 
quent occurrence  in  intussusception,  often  beginning  early  in  the  attack. 

The  Physical  Signs.  (Plate  XXXIX. ,  Figs.  1  and  2.)  On  palpa- 
tion of  the  abdominal  wall  it  is  noted  to  be  soft  and  flaccid  in  most  of 
the  cases,  unless  peritonitis  has  ensued.  This  occurs  early  in  volvulus, 
hence  rigidity  is  marked.  In  a  large  number  of  cases  a  tumor  can  be 
made  out  only  in  intussusception.  It  is  seated  in  the  lower  right 
quadrant  of  the  abdomen.  Early  in  the  attack  it  is  oblong  and  of 
sausage-shape.  When  peritonitis  ensues  it  disappears,  on  account  of  the 
tympany.  A  portion  of  the  gut  may  protrude  at  the  anus,  or  be  felt 
on  rectal  examination.  Meteorism  occurs  about  the  third  day  in  a 
strangulation  ;  it  occurs  early,  is  very  rapid  and  pronounced  in  volvu- 
lus, and  is  absent  in  intussusception,  unless  constipation  or  peritonitis 
takes  place.     It  is  not  marked  in  high  obstruction. 

The  Site  of  the  Obstkuction.  The  seat  of  obstruction  is  in  a 
measure  indicated  by  (1)  the  location  of  the  pain  or  abnormal  sensa- 
tions, (2)  the  character  of  the  swelling,  (3)  the  character  of  the  stools, 
(4)  the  degree  of  meteorism,  (5)  the  results  of  a  rectal  examination,  (6) 
the  change  in  the  urine,  (7)  the  general  condition.  The  patient  is 
often  able  to  indicate  the  location  of  the  obstruction  fairly  well  by  the 
sensations  of  obstruction  or  fulness  and  by  the  great  relief  experienced 
when  a  free  evacuation  of  the  bowels  is  naturally  or  artificially  pro- 
duced. On  auscultation,  when  the  bowel  is  irrigated,  a  murmur,  like 
the  deglutition-murmur,  may  be  heard  at  the  point  of  constriction  of 
the  gut.  In  obstruction  high  up  there  is  but  little  meteorism,  the 
tumor  is  usually  not  detected,  and  pain  is  seated  about  the  umbilicus 
or  the  upper  quadrants  of  the  abdomen.  Obstruction  at  the  ileo-csecal 
valve  may  be  indicated  by  a  tumor  in  the  lower  right  quadrant  over 
the  region  of  the  valve  or  just  above  it.  It  is  usually  at  this  point 
that  invagination  takes  place,  and  hence  we  may  look  for  a  tumor  in 
this  situation.  (Plate  XXXIX.,  Fig.  1.)  On  the  other  hand,  in  vol- 
vulus of  the  colon,  or  stricture  of  the  rectum,  the  obstruction,  being 
low  down,  is  attended  by  much  meteorism  and  by  pain  in  the  left 
lower  quadrant  of   the  abdomen.     A  tumor  may  be  detected  in  this 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     849 

position.  The  position  of  the  obstruction  is  sometimes  indicated  by 
the  seat  of  peristalsis.  This  may  be  seen  to  stop  at  a  given  point, 
which  usually  indicates  the  position  of  the  obstruction.  The  seat  of 
obstruction  may  be  indicated  by  the  number  of  coils  of  intestine  that 
are  engaged  in  the  peristaltic  movement.  The  coils  of  intestine  in  front 
of  the  tumor  are  dilated  and  hypertrophied.  In  active  movement  they 
cause  prominences  which  follow  the  course  of  the  bowel.  Wyllie  has 
called  them  "  patterns  of  abdominal  tumidity."  If  the  obstruction  is 
in  the  jejunum,  peristalsis  may  not  be  observed.  If  the  lower  end  of 
the  large  intestine  is  obstructed,  the  colon  is  prominent ;  if  the  gut 
about  the  ileo-csecal  valve,  the  region  about  and  below  the  umbilicus  is 
prominent.  The  Urine.  The  position  of  the  tumor,  it  is  said,  can  be 
ascertained  by  changes  in  the  urine.  When  the  obstruction  is  in  the 
small  intestine,  indican  is  much  increased  from  the  decomposition  of 
albuminous  substances  and  products  of  putrefaction.  In  this  location 
the  urine  may  be  suppressed.  In  stenosis  of  the  large  intestine  indican 
is  not  increased  unless  there  is  cancer.  The  value  of  the  information 
derived  from  the  character  of  the  stools  and  the  results  of  rectal 
examination  are  obvious.  Obstruction  in  the  duodenum  or  jejunum  is 
followed  by  rapid  collapse  and  anuria.  In  general,  it  may  be  said  the 
more  severe  and  rapid  the  symptoms  the  more  likelihood  that  the 
obstruction  is  in  the  small  intestine. 

Intussusception  (Plate  XXXIX.,  Fig.  1),  or  invagination,  occurs 
most  frequently  in  children  prior  to  the  tenth  year.  It  is  characterized 
by  severe  colic  and  pain  in  the  abdomen,  first  complained  of  about  the 
navel.  The  severity  increases  in  paroxysms,  and  only  lessens  if  com- 
plete strangulation  has  taken  place.  With  the  onset  of  the  pain  there 
are  one  or  two  movements  of  the  bowels,  which  contain  mucus  and 
blood.  After  this  there  may  be  constipation,  or  the  stools  continue  to 
be  loose,  and  are  as  frequent  as  fifteen  or  twenty  in  a  day.  Sometimes 
they  are  quite  bloody,  and  almost  always  there  is  some  tenesmus.  In 
a  short  time  after  the  attack  vomiting  commences.  It  may  be  constant 
or  occur  only  after  taking  food.  At  first  the  abdomen  is  soft,  but 
tender  on  pressure.  A  sausage-like  tumor  can  be  felt  on  the  right  side 
below  the  transverse  umbilical  line.  On  inspection  of  the  rectum  a 
portion  of  the  intestine  may  be  seen,  dark  and  gangrenous  in  appear- 
ance, or  it  may  be  felt  by  palpation.  If  there  is  much  tenesmus,  the 
anus  often  remains  open.  In  rare  cases  the  bowel  may  slip  back  and 
the  symptoms  subside  spontaneously.  On  the  other  hand,  peritonitis 
may  rapidly  ensue,  with  high  fever,  followed  by  collapse  and  death. 

Diagnosis.  It  must  be  distinguished  from  the  entero-colitis  of  child- 
hood or  the  proctitis  due  to  a  polypus.  In  entero-colitis  there  is  no 
tumor,  and  the  collapse  and  prostration  do  not  occur  so  early  and  are 
not  so  rapid.  There  is  greater  likelihood  of  a  number  of  the  stools 
being  greenish,  like  spinach.  In  a  polypus  of  the  rectum  the  symp- 
toms are  local.  The  child  is  worn  out  and  restless,  but  great  abdominal 
tenderness,  and  the  tumor,  meteorism,  vomiting,  and  collapse  are  absent. 
The  rectum  must  be  examined. 

Intussusception  must  be  distinguished  from  peritonitis,  in  which 
symptoms  of  stenosis  of  the  bowel  from  ileus  paralytica  may  be  present. 

54 


850  SPECIAL  DIAGNOSIS. 

The  history  and  sequence  of  events  must  be  watched  carefully.  Often 
the  commencement  of  the  affection  about  hollow  viscera  which  have  pre- 
viously been  the  seat  of  disease,  or  its  onset  with  sudden  perforation, 
will  point  to  the  nature  of  the  affection.  In  peritonitis  there  is  no 
active  peristalsis  ;  there  is  general  distention  of  the  abdomen,  with 
general  tenderness  ;  the  urine  is  diminished,  but  does  not  contain  in- 
dican  in  excess.  Collapse  ensues  rapidly.  Signs  of  effusion  within 
the  abdomen  may  appear. 

It  must  be  distinguished  from  embolism  or  thrombosis  of  the  mesenteric 
artery  and  infarction  of  the  bowel.  In  the  latter  the  symptoms  take 
place  suddenly.  The  patients  have  reached  middle  or  late  life,  and  have 
atheroma  of  the  general  arterial  system.  Sudden  pain  in  the  abdomen, 
with  vomiting  and  symptoms  of  collapse,  takes  place.  Moderate  ob- 
struction occurs,  with  distention  of  the  abdomen.  After  the  pain  diar- 
rhoea with  the  passage  of  blood  follows.  The  age  and  the  absence  of 
tumor  distinguish  it  from  intussusception,  the  only  intestinal  condition 
for  which  it  may  be  mistaken. 

Hernia  and  Constriction  by  Bands.  Obstruction  due  to  these  con- 
ditions occurs  in  adults  after  the  fortieth  year  of  age,  in  both  sexes. 
In  stricture  from  pressure  of  bands  there  has  usually  been  a  history  of 
previous  attacks  of  peritonitis  or  of  inflammation  of  the  structures  in 
relation  to  the  peritoneum.  Hence,  a  cholecystitis  or  appendicitis  are 
often  found  to  precede  the  obstruction.  The  attacks  begin  suddenly, 
and  the  symptoms  may  from  the  start  be  most  pronounced.  They  are 
the  typical  symptoms  of  intestinal  obstruction.  The  local  tenderness, 
however,  may  not  be  present  as  early  as  in  other  forms  of  obstruc- 
tion. It  is  quite  characteristic  not  to  find  a  tumor  or  positive  local 
cause  for  the  obstruction,  and  also  not  to  have  meteorismus.  This  is 
due  to  the  fact  that  the  obstruction  is  usually  high  up  in  the  intestinal 
tract. 

Volvulus.  Volvulus  occurs  most  frequently  in  males.  It  occurs 
late  in  life,  and  is  usually  preceded  by  a  history  of  constipation.  Pre- 
monitory symptoms  may  have  been  present  for  a  few  days,  but  the 
symptoms  of  obstruction  develop  suddenly.  They  are  the  symptoms 
of  acute  obstruction,  but  as  the  lesion  is  in  the  lower  portion  of  the 
bowel,  meteorismus  is  present  to  a  marked  degree,  and  rectal  symp- 
toms are  found.  Tenesmus  is  present  in  a  small  proportion  of  the 
cases.  Peritonitis  is  likely  to  set  in  early,  with  increase  in  the  temper- 
ature, increased  tenderness  of  the  abdomen,  and  more  pronounced 
symptoms  of  collapse. 

Diagnosis  of  Intestinal  Obstruction  from  Other  Conditions.  Intestinal 
obstruction  must  be  distinguished  from  peritonitis  and  appendicitis. 
This  is  sometimes  very  difficult.  Careful  attention  must  be  paid  to  the 
evolution  of  the  case  and  the  history  of  previous  abdominal  disease,  or 
of  lesions  on  account  of  which,  on  the  one  hand,  peritonitis  may  occur, 
or,  on  the  other,  obstruction  of  the  bowel.  In  peritonitis  the  attack 
follows  disease  in  the  uterine  appendages,  the  vermiform  appendix,  or 
the  gall-bladder,  or  perforation  in  some  portion  of  the  gastro-intestinal 
tract.  Fever  usually  attends  the  inflammation,  with  or  without  chill. 
I  omiting  will  probably  occur  at  the  onset,  and  then  subside  until  the 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     851 

peritonitis  becomes  general.  The  first  paroxysms  of  vomiting  are  appar- 
ently due  to  shock.  The  vomiting  that  occurs  rarely  becomes  feculent. 
As  the  peritonitis  advances  the  vomiting  becomes  passive ;  a  simple 
constant  regurgitation  of  a  large  amount  of  fluid,  greenish  or  grayish- 
yellow,  or  watery,  takes  place.  It  pours  into  the  mouth,  and  is  simply 
discharg-ed  without  the  occurrence  of  retching.  The  abdomen  is  swollen 
and  tympanitic.  The  symptoms  due  to  excessive  tympany  are  more 
marked  than  in  intestinal  obstruction.  As  the  diaphragm  is  interfered 
with,  breathing  is  harried.  The  abdomen  is  tender  on  pressure  and  is 
the  seat  of  general  pain.  The  general  pain  and  tenderness,  however, 
can  usually  be  found  to  be  more  marked  at  the  possible  primary  focus 
of  the  disease.  Further,  on  local  examination,  in  these  positions  ful- 
ness or  undue  prominence  or  swelling  may  be  observed.  On  palpation 
over  the  point  of  origin  there  may  be  localized  asdema.  The  symptoms 
of  collapse  do  not  differ  from  those  of  intestinal  obstruction  in  marked 
degree,  although  the  peculiar  appearance  of  the  face  and  other  nervous 
features  occur  more  rapidly  in  peritonitis  than  in  obstruction.  It  must 
be  remembered  that  peritonitis  in  a  large  majority  of  cases  attends  ob- 
struction. 

In  appendicitis  the  symptoms  are  somewhat  like  those  of  intestinal 
obstruction.  There  may  be  constipation  and  vomiting.  The  former 
is  not  pronounced,  and  can  usually  be  relieved.  Vomiting  subsides 
after  the  first  twenty-four  hours,  unless  peritonitis  supervenes  ;  it  is 
never  stercoraceous.  The  local  physical  signs  are  characteristic.  In 
appendicitis  there  is  fixed  tenderness  on  pressure  at  McBurney's  point. 
Some  swelling  can  almost  always  be  observed.  On  light  or  deep  per- 
cussion there  is  change  in  the  note  as  compared  with  the  other  side. 
Fluctuation  can  often  be  detected  in  from  two  to  four  or  five  days. 
Both  the  tumor  and  fluctuation  can  be  detected  by  bimanual  examina- 
tion of  the  abdomen  and  flank.  Examination  by  the  rectum  may 
reveal  a  tumor  at  the  brim  of  the  pelvis  in  the  right  side.  Fever 
attends  the  attack  throughout.  When  peritonitis  supervenes  there  is 
rigidity  of  the  entire  abdomen,  which  at  first  was  localized  to  the  right 
lower  quadrant. 

Intestinal  obstruction  must  not  be  confounded  with  enteritis.  In  all 
forms  there  is  diarrhoea,  in  many  vomiting.  Pain  of  a  colicky  nature, 
spreading  from  the  neighborhood  of  the  umbilicus,  is  marked  when- 
ever obstruction  to  the  passage  of  feces  or  gas  takes  place.  Vomiting 
is  not  stercoraceous,  and  the  general  symptoms,  collapse,  etc.,  do  not 
occur.  Acute  hemorrhagic  pancreatitis  is  also  attended  by  symptoms 
similar  to  those  of  intestinal  obstruction.  There  is  sudden  severe  pain 
in  the  upper  half  of  the  abdomen,  with  vomiting  and  the  rapid  develop- 
ment of  collapse  ;  there  may  be  constipation  ;  the  situation  of  the  pain  is 
of  some  significance.  Vomiting  never  becomes  stercoraceous  ;  flatus  can 
usually  be  passed  and  the  bowels  opened  by  an  enema.  Meteoi  ismus  does 
not  take  place,  although  the  epigastrium  is  tympanitic.  If  the  symp- 
toms are  not  so  severe,  there  may  be  increased  dulness,  and  possibly  a 
tumor  on  deep  palpation  in  the  left  upper  quadrant  of  the  abdomen 
along  the  margins  of  the  ribs,  which  should  be  dull  on  percussion,  or, 
on  account  of  its  relation  to  the  stomach,  give  a  dull  tympanitic  note. 


852  SPECIAL  DIAGNOSIS. 

The  symptoms  of  internal  hemorrhage  are  present,  pallor  of  the  face 
and  extremities,  syncope,  and,  in  addition,  prostration  and  other  symp- 
toms of  collapse. 

Cancer  of  the  Intestines.  (Plate  XXXIX.,  Fig.  2.)  Obstruc- 
tion must  not  be  confounded  with  carcinoma  of  the  intestines.  The 
disease  usually  occurs  late  in  life,  and  is  associated  with  progressive 
emaciation  and  cachexia.  There  may  not  be  any  symptoms  save  general 
failure  of  health  until  the  sudden  occurrence  of  obstruction  of  the  bowel. 
The  symptoms  vary  with  the  position  of  the  carcinoma  and  the  direc- 
tion of  growth  of  the  tumor.  In  some  instances  with  the  general  symp- 
toms there  may  be  irregular  pain  in  the  abdomen,  with  irregularity  of 
stools.  The  tumor  may  be  detected  if  the  small  intestine  is  involved 
Its  detection  is  facilitated  by  having  the  patient  get  on  the  hands  and 
knees  and  palpating  the  abdomen  in  this  position,  and  by  clearing  out 
the  colon  by  a  large  enema.  On  auscultation  the  water  may  be  heard 
to  enter  the  dilated  colon  beyond  the  tumor,  the  sound  resembling  the 
deglutition-murmur  at  the  cardiac  end  of  the  stomach.  If  the  tumor  is 
situated  in  the  lower  colon,  pain  in  the  sacral  region,  resembling  sciatica, 
may  be  complained  of ;  if  the  caecuni  or  the  sigmoid  flexure  is  the  seat 
of  disease,  a  tumor  is  usually  detected.  Wherever  the  situation,  the 
tumor  found  is  tender,  usually  lying  in  the  axis  of  the  intestine — 
movable  if  in  the  small  intestine,  fixed  if  in  the  csecurn  or  the  sigmoid 
flexure.  In  the  latter  location  the  tumor  may  be  felt  per  rectum.  One 
notable  characteristic  is  that  it  may  be  palpable  some  days  and  not  be 
present  at  other  times.  The  position  and  size  may  vary  from  day  to 
day,  although  it  is  always  hard  and  knotty,  not  doughy.  By  means  of 
the  proctoscope,  with  the  patient  in  the  knee-chest  position,  as  described 
by  Kelly,  the  presence  of  tumors  of  the  descending  colon  will  be  dis- 
closed. Constipation  is  characteristic  of  most  of  the  cases.  It  may 
alternate  with  diarrhoea.  Paralysis  of  the  sphincter  ani  may  take  place, 
with  incontinence.  The  stools  are  frequently  ribbon-shaped,  or  they 
may  pass  in  scybalous  masses,  and  large  or  oftener  small  amounts  of 
blood,  chiefly  the  latter,  are  passed  with  pus  or  mucus ;  sometimes 
masses  resembling  cancer  can  be  found  in  the  stools.  If  the  tumor  is 
in  the  rectum,  there  is  great  difficulty  in  defecation  ;  the  act  is  attended 
by  pain.  Later  the  pain  becomes  constant,  and  may  radiate  to  the 
hip  or  the  genitalia.  Sometimes  this  pain  is  the  only  symptom  com- 
plained of. 

The  diagnostic  symptoms  are  :  (1)  The  general  symptoms  of  cancer. 
(2)  The  tumor.  (3)  The  occurrence  of  constipation  which  leads  to 
complete  obstruction,  or  obstipation,  alternating  with  diarrhoea.  Blood 
in  the  stools,  with  alteration  in  the  shape  of  the  feces,  is  significant.1 

Diseases  of  the  Rectum. 

Consideration  of  rectal  lesions  belongs  to  the  surgeon.  It  is  proper, 
however,  to  insist  upon  the  very  frequent  deleterious  effect  of  such 
lesions  in  neurasthenic  subjects.     Indeed,  the  bleeding  which  attends 

1  Musser:   "Carcinoma  of  the  Descending  Colon."     Univ.  Med.  Mag.,  1896. 


DISEASES  OF  STOMACH,  INTESTINES  AND  PERITONEUM.     853 

hemorrhoids  may  be  sufficient  to  lead  to  profound  anaemia,  upon  which 
neurasthenia  may  readily  develop.  The  local  suffering  due  to  rectal 
fissure,  or  prolapse,  may  aggravate  any  tendency  to  the  state  of  neuras- 
thenia, or  aid  materially,  with  other  conditions,  to  fasten  it  more 
firmly  upon  the  system.  In  cases  of  anaemia,  of  neurasthenia,  of  the 
gastric  neuroses,  of  debility,  or  prostration,  the  cause  of  which  cannot 
be  ascertained,  the  rectum  should  be  examined.  The  appearance  of 
hemorrhoids  and  other  rectal  affections  is  described  in  works  on  surgery. 
Hemorrhoids,  ulcers,  fistula,  and  carcinoma  are  to  be  sought  for  in 
abdominal  affections. 

Inspection  and  palpation  are  necessary.  The  symptoms  are  those  of 
local  pain,  tenesmus,  and  frequently  hemorrhage.  The  pain  follows  a 
movement  of  the  bowels.  There  may  be  a  feeling  as  of  a  foreign  body 
in  the  rectum,  with  some  itching  and  burning  about  the  anus.  The 
pain  may  be  so  severe  as  to  inhibit  defecation.  The  timid  subjects 
will  not  endure  the  act ;  in  consequence  they  suffer  from  vertigo,  head- 
ache, tympanites,  and  symptoms  of  gastro-intestinal  disorder.  In 
some  instances  there  is  chronic  catarrh  of  the  rectum,  with  discharge 
of  small  stools  containing  mucus  or  pus  streaked  with  blood.  Cases 
occur  in  which  hemorrhage  is  the  only  symptom,  the  constant  recur- 
rence of  which  leads  to  grave  constitutional  results.  Hemorrhoids  are 
the  lesions  for  which  the  rectum  is  most  frequently  examined.  They, 
as  well  as  other  lesions,  are  of  diagnostic  significance  in  affections 
beyond  the  rectum.  Thus  in  all  forms  of  portal  congestion  internal 
hemorrhoids  are  of  constant  occurrence,  and  when  found  in  a  toper 
may  be  one  of  the  first  indications  of  cirrhosis  of  the  liver.  Rectal 
fissure  is  not  of  much  diagnostic  significance.  The  finding  of  a  small 
cancer,  the  symptoms  of  which  may  be  those  of  hemorrhoids,  may  ex- 
plain emaciation  and  the  development  of  cachexia.  Ulcer  of  the 
rectum  may  be  due  to  syphilis,  cancer,  or  tuberculosis.  A  fistula  is 
often  tuberculous.  The  rectum  must  be  examined  in  cases  of  pyaemia, 
particularly  of  the  portal  variety,  when  jaundice,  enlargement  of  the 
liver,  and  hectic  fever  are  present,  for  local  rectal  disease  may  cause 
pylephlebitis. 


CHAPTER    VI. 

DISEASES  OF  THE  LIVER,  SPLEEN,  AND  PAXCREAS. 

The  symptoms  of  disease  of  the  liver  are  due  to  the  morbid  pro- 
cesses, to  disturbance  of  the  functions  of  the  hepatic  cells,  or  to  obstruc- 
tion of  the  channels  for  the  flow  of  blood  and  of  bile.  As  these  channels 
extend  beyond  the  glandular  structure  of  the  liver  they  may  be  affected 
by  disease  outside  of  the  organ.  Hepatic  symptoms  may,  therefore,  be 
due  to  diseases  other  than  those  of  the  liver. 

The  morbid  process  may,  in  time,  cause  alterations  in  function,  ob- 
struction of  channels,  or  physical  alterations  in  the  size  and  shape  of 
the  liver.  But  the  channels  may  be  obstructed  and  the  size  and  shape 
of  the  liver  changed  by  disease  outside  of  the  liver. 

Symptoms  due  to  the  Morbid  Process.  The  morbid  processes 
are  the  congestions,  the  inflammations,  the  degenerations,  the  morbid 
growths,  and  gross  parasites. 

In  congestion  of  the  liver  the  symptoms  are  (1)  the  symptoms  of  the 
cause,  (2)  enlargement  of  the  organ  from  the  increased  amount  of 
blood,  (3)  functional  disturbance  from  the  same  cause.  The  conges- 
tion is  not  limited  to  the  vessels  in  relation  with  the  liver-cells,  but 
involves  the  vessels  of  the  mucous  membrane  also,  hence  the  latter 
swell,  obstruct  the  ducts,  and  produce  jaundice  in  moderate  degree. 
The  inflammations  are  toxic  and  infectious.  The  symptoms  are  due 
to  the  cause  (intoxication  or  infection),  to  the  degree  of  obstruction  of 
the  vessels  and  ducts,  to  the  shape  and  size  of  the  liver,  and  to  the 
alteration  of  its  function.  AVhen  the  inflammation  is  diffused,  as  in 
the  cirrhoses,  the  hepatic  symptoms  are  more  marked  ;  when  local,  as 
in  abscess,  the  infectious  symptoms  are  in  preponderance.  If  the 
ducts  are  the  seat  of  infection,  the  bile  chanuels  are  obstructed — jaun- 
dice arising ;  if  the  vessels,  ascites.  In  morbid  growths  of  the  liver 
the  symptoms  are  those  of  malignant  disease  in  general,  to  which  are 
added  symptoms  due  to  change  in  the  size  of  the  liver,  and,  more  fre- 
quently than  in  inflammation,  symptoms  due  to  obstruction  of  the 
channels.  The  degenerations  are  so  frequently  secondary  to  and 
masked  by  the  symptoms  of  their  primary  cause  that,  save  in  regard 
to  change  of  size,  there  are  no  hepatic  symptoms  worth  mentioning. 

Symptoms  due  to  Functional  Disturbance  of  the  Liver. 
The  functions  of  the  liver  are  to  secrete  bile  ;  to  destroy  the  haemoglobin 
of  the  blood ;  to  destroy,  modify  or  neutralize  poisons  entering,  or  to 
modify  and  render  available  for  nutrition  the  peptones  absorbed  by,  the 
portal  circulation ;  the  elaboration  of  glycogen.  Bile  is  not  secreted 
when  the  liver-cells  are  destroyed,  as  in  acute  yellow  atrophy.  The 
liver  does  not  destroy  the  usual  amount  of  haemoglobin.  On  the  other 
hand,  haemoglobin  may  be  so  much  in  excess  that  the  liver  cannot 


DISEASES  OF  LIVER,  SPLEEN  AND  PANCREAS.  855 

destroy  it ;  jaundice  then  results.  (See  Hematogenous  Jaundice.)  Func- 
tional disturbances  of  the  liver  are  manifested  clinically  by  symptoms 
due  to  the  entrance  into  the  circulation  of  imperfect  products  of  diges- 
tion, or  poisons  not  destroyed  by  the  liver. 

Lithcemia  is  a  common  toxic  condition,  and  is  believed  to  be  due  to 
functional  liver-disturbance.  There  is  an  excess  of  uric  acid  and 
urates,  or  of  other  metabolic  compounds  in  the  blood.  It  may  be  a 
convenient  term  for  the  auto-intoxication  which  takes  place  in  disease 
of  the  gastro-intestinal  tract.  The  symptoms  are,  first,  symptoms  of 
excess  of  lithic  acid  in  the  system  ;  second,  the  effects  of  the  lithic 
acid  upon  the  nervous  system.     Lithsemia  may  be  acute  or  chronic. 

Acute  Lithcemia  ;  Biliousness.  When  acute  the  local  disturb- 
ances are  :  furred  tongue,  a  bitter  taste  in  the  mouth,  anorexia,  nausea, 
disgust  at  the  sight  of  food,  with  possible  morning  vomiting.  There 
is  some  tenderness  in  the  upper  mid-abdomen,  and,  after  eating,  weight, 
and  fulness  and  distress  in  that  region.  Flatulency  occurs.  Symp- 
toms of  intestinal  dyspepsia  may  arise  secondarily.  Slight  fever  or 
feverishness  may  attend  the  attack.  The  skin  is  hot  and  burning  ;  or 
cold  perspirations  may  break  out  at  irregular  times,  alternating  with 
flashes  of  heat.  The  bowels  are  constipated,  the  stools  are  clay-col- 
ored. The  symptoms  may  be  attended  by  slight  obstruction  to  the 
ducts,  causing  a  moderate  degree  of  jaundice.  In  some  instances  the 
liver  is  slightly  enlarged.  The  urine  is  loaded  with  urates  and  uric 
acid.  It  is  scanty  and  high-colored,  and  there  may  be  painful  mictu- 
rition. The  nervous  symptoms  are  usually  those  of  depression,  as  head- 
ache, some  dulness,  or  stupor  ;  the  patient  may  be  unusually  drowsy. 
The  headaches  may  be  the  most  prominent  feature  of  the  attack.  They 
are  frontal,  attended  by  slight  vertigo,  flashes  of  light  or  spots  before 
the  eyes,  and  ringing  in  the  ears. 

The  same  group  of  symptoms  is  seen  in  acute  gastro-duodenal  catarrh. 

Chronic  Lithcemia.  In  chronic  lithcemia  the  symptoms  are  varia- 
ble, and  are  characterized  by  disturbance  of  function  in  nearly  all  the 
organs  of  the  body.  They  have  been  classically  described  by  Murchi- 
son,  Da  Costa,  and  others,  and  while  the  theory  is  fairly  satisfactory 
to  work  upon  for  lines  of  treatment,  the  same  group  of  symptoms  may 
be  met  with  in  forms  of  chronic  indigestion,  particularly  the  forms  in 
which  there  is  inability  to  digest  sugars  and  starches.  The  symptoms 
are  attributed  by  some  to  chronic  intestinal  catarrh. 

Symptoms.  The  patients  are  in  ill  health  and  subject  to  chronic 
indigestion.  They  may  be  under  weight  or  corpulent.  The  skin  is 
harsh  and  dry,  its  nutrition  poor.  It  is  subject  to  erythema  ;  or  local 
inflammations,  as  eczema,  may  arise.  Irregular  sweats  occur,  alter- 
nating with  intervals  when  the  skin  is  hot  and  dry.  The  extremities 
are  cold  and  clammy,  and  tingling  and  numbness  are  often  com- 
plained of. 

Gastro-intestinal  Symptoms.  The  symptoms  are  those  of  chronic 
indigestion.  There  is  constantly  a  furred  tongue  with  local  dyspeptic 
symptoms.  The  bowels  are  irregular  or  constipated ;  sometimes 
mucus  is  passed.  Flatulency  is  excessive,  both  gastric  and  intestinal. 
An  icteric  tinge  may  be  seen  on  account  of  a  slight  local  catarrh  of  the 


856  SPECIAL  DIAGNOSIS. 

ducts,  or  of  hepatic  congestion.  It  recurs  at  frequent  periods,  while  a 
sallow  complexion  is  more  or  less  constant. 

Respiratory  Symptoms.  The  patient  is  liable  to  attacks  of  catarrh 
of  the  upper  air-passages,  and  especially  to  pharyngitis.  In  lithaemic 
states  tonsillitis  is  not  uncommon.  Chronic  pharyngitis  is  present. 
On  the  other  hand,  some  persons,  particularly  those  over  fifty  years, 
have  chronic  bronchitis,  and  attacks  of  asthma  are  common.  The 
bronchitis  cannot  be  distinguished  from  that  due  to  other  causes,  except 
by  the  fact  that  the  subject  is  lithaemic.  Emphysema  of  the  lungs 
develops  on  account  of  bronchitis  and  tissue  degeneration. 

Cardiac  Symptoms.  Palpitation  is  a  constant  accompaniment  of 
many  forms  of  lithaemia  ;  in  others  there  may  be  unduly  rapid  action 
of  the  heart,  or,  during  exacerbations,  slowness  of  the  heart's  action. 
In  the  later  stages  pseudo-angina  pectoris  is  of  common  occurrence. 
In  the  earlier  stages  pain  about  the  heart  or  in  the  left  side  is  fre- 
quently complained  of. 

Nervous  Symptoms.  Constant  headache,  worse  in  the  morning,  re- 
lieved toward  the  end  of  the  day.  Some  vertigo  may  be  present. 
Depression  of  spirits  and  inaptitude  for  mental  exertion  exist.  The 
memory  is  dull,  the  faculties  blunted.  The  patient  is  subject  to  back- 
ache, chiefly  in  the  loins.  Pain  in  the  right  shoulder  is  of  frequent 
occurrence.  In  addition,  pains  along  the  course  of  the  nerves  (neuritis), 
and  myalgias,  are  of  common  occurrence.  The  nerve-trunks  may  be 
tender.  There  is  tenderness  in  the  sheaths  of  the  muscles,  or  at  the 
insertions  of  fasciae  and  tendons.  Peripheral  nerve-sensations  are 
common.  Xumbness  and  tingling  are  frequently  complained  of. 
Paraesthesiae  of  all  forms,  variously  distributed,  are  a  source  of  annoy- 
ance. Local  sensations  of  heat  or  burning  alternate  with  areas  of 
coldness.  Tingling,  pricking  of  needles,  and  other  forms  of  pares- 
thesia occur. 

The  Urine.  The  urine  is  high-colored  and  contains  an  abundance 
of  uric  acid  and  urates.  The  amount  is  scanty,  the  specific  gravity 
high.  There  may  be  albumin,  small  in  amount,  depending  upon  the 
irritation  of  the  urates  in  their  passage  through  the  kidneys.  Cylin- 
droids  are  present ;  casts  are  not  common,  although  at  times,  when 
the  uric  acid  is  passed  in  excess,  there  may  be  a  secondary  nephritis, 
with  albumin,  blood,  and  casts.  As  an  ultimate  result  of  such  condi- 
tion we  may  have  gallstones,  or  calculi  in  the  kidneys  and  bladder. 
Lithaemic  patients  are  subject  to  attacks  of  hepatic  or  renal  colic. 

As  part  of  the  same  process  or  an  accompaniment  we  may  have 
gout  or  rheumatism.  Acute  inflammatory  rheumatism  (rheumatic  fever) 
does  not  belong  to  this  category,  but  muscular  rheumatism,  subacute 
inflammation  of  the  joints  with  moderate  fever,  true  gout,  and  gout 
with  its  modifications  when  seated  in  the  various  joints,  are  the  ultimate 
results  of  this  process  in  the  patient.  Attacks  of  gout  may  occur  in 
a  patient  who  has  not  shown  any  symptoms  of  lithaemia,  but  those 
who  have  symptoms  of  lithaemia  are  more  susceptible  to  causes  which 
produce  attacks  of  gout.  The  gouty  and  rheumatic  manifestations  are 
due  to  the  deposition  of  uric  acid  and  urates  in  tissues  which  are  not 
highly  vitalized,  and  in  which,  therefore,  the  circulation  is  sluggish. 


DISEASES  OF  LIVER,  SPLEEN  AND  PANCREAS.  857 

Lithseniia  later  assumes  the  gouty  aspect  Tophi  are  seen  in  the 
situations  natural  to  them.  The  appearance  of  the  face  is  character- 
istic, with  capillary  congestions  and  stases.  The  patients  usually  be- 
come more  or  less  obese  and  are  subject  to  attacks  of  glycosuria. 
Early  in  their  life  degenerations  of  vessels  take  place.  The  kidneys 
are  always  under  an  excessive  strain.  A  good  deal  of  material  is  not 
discharged ;  its  effects  upon  peripheral  vessels  are  such  as  to  cause 
vasomotor  spasm  and  heightened  tension,  leading  to  low-grade  inflam- 
mations, with  the  development  of  atheroma.  For  the  same  reason 
chronic  interstitial  nephritis  is  set  up,  and,  because  of  heightened  strain 
in  the  vascular  system,  chronic  sclerotic  valvulitis. 

Functional  symptoms  from  disorder  of  the  liver  are  otherwise  not 
marked,  unless  we  include  a  group  of  cases  in  which  sudden  coma  and 
convulsions  take  place,  presumably  because  material  has  been  absorbed 
from  the  gastro-intestinal  tract  and  enters  the  general  circulation 
through  the  temporary  cessation  of  the  function  of  the  liver,  the  office 
of  which  is  to  destroy  the  material.  Such  symptoms  may  arise  in 
organic  disease  of  the  liver,  as  cirrhosis. 

Symptoms  due  to  Obstruction  of  the  Channels.  (1)  Obstruc- 
tion of  the  bile-duds,  either  from  disease  or  external  pressure,  causes 
jaundice,  pain,  and  fever.  The  three  symptoms  may  occur  singly  or 
combined.  Jaundice  may  occur  alone  in  obstruction  by  gallstones ; 
pain  may  occur  with  it ;  or  jaundice,  pain,  and  fever  may  occur 
together  ;  rarely,  pain  or  fever  may  be  present  alone.  Each  symptom 
will  be  described  later.  (2)  Obstruction  of  the  blood-channels  causes 
congestion  of  the  liver,  which  may  be  active  or  passive,  or  ported  ob- 
struction. The  symptoms  of  each  will  be  discussed  ;  suffice  it  to  say 
that  here  again  the  symptoms  are  modified  by  the  process.  Thus  in 
portal  obstruction  from  pressure  the  symptoms  are  quite  different  from 
those  in  portal  obstruction  due  to  suppurative  inflammation  of  the  vein. 

Congestion  of  the  Liver.  In  the  congestions  the  liver  is  enlarged. 
If  the  hyperemia  is  active,  painful  distention  may  be  complained  of, 
and  the  organ  may  be  the  seat  of  some  tenderness.  There  may  be,  in 
addition,  weight  and  fulness  in  the  liver-region.  Active  hyperemia 
may  follow  a  chill  or  suppression  of  the  menses,  but  more  frequently 
occurs  after  indiscretions  of  diet,  the  free  use  of  alcohol,  or  stimulating 
food,  followed  by  an  attack  of  acute  gastro-intestinal  catarrh.  It  is 
more  common  in  the  tropics,  and  is  due  in  that  climate  to  suppression 
of  the  perspiration.  It  is  recognized  by  the  occurrence  of  symptoms 
of  acute  gastritis  with  enlargement,  pain,  and  tenderness  of  the  liver. 
Slight  jaundice  may  attend  the  attack. 

Passive  congestion  is  also  attended  by  enlargement  of  the  liver.  The 
enlargement  may  cause  a  sense  of  weight  or  fulness,  but  pain  is  not 
complained  of.  The  organ  is  not  tender,  the  edges  are  smooth  and 
indurated.  The  liver  may  pulsate.  This  is  detected  by  placing  the 
hand  over  the  surface  of  the  liver,  when,  with  each  impulse  of  the  heart, 
the  organ  can  be  felt  to  expand.  The  symptoms  of  the  cause  of  the 
passive  congestion  combine  with  those  just  enumerated  as  due  to  en- 
largement of  the  organ.  In  addition  we  have  symptoms  due  to  obstruc- 
tion of  the  flow  of  blood  in  the  portal  circuit. 


858  SPECIAL  DIAGNOSIS. 

Passive  congestion  occurs  in  organic  heart  disease  after  compensa- 
tion has  failed  and  the  right  heart  is  dilated.  The  organ  rapidly  be- 
comes congested  because  of  its  close  proximity  to  this  chamber.  In 
emphysema  of  the  lungs,  in  fibroid  phthisis,  in  intrathoracic  tumors 
pressing  upon  the  vena  cava,  mechanical  congestion  also  takes  place. 
The  recognition  of  passive  congestion  is  not  difficult.  The  symptoms 
due  to  enlargement  (see  Objective  Symptoms)  and  the  symptoms  due 
to  portal  obstruction  point  to  the  true  nature  of  the  morbid  process. 

Portal  Obstruction.  Disease  of  the  portal  vein  or  occlusion  of  its 
branches  in  the  liver,  obstructs  the  flow  of  blood.  The  diseases  of  the 
portal  vein  are  thrombosis,  and  adhesive  and  suppurative  inflammation. 
Obstruction  of  the  terminal  venous  radicles  in  the  liver  is  caused  by 
cirrhosis. 

Thrombosis  of  the  portal  vein  attends  cirrhosis  of  the  liver,  or  may 
occur  secondarily  to  pressure  upon  the  vein  by  a  tumor.  Disease  of 
the  pancreas  was  the  cause  of  the  pressure  in  a  patient  under  my 
observation.  As  a  result  of  thrombosis  adhesive  inflammation  of  the 
vein  takes  place,  with  or  without  the  establishment  of  a  collateral  cir- 
culation to  replace  its  function. 

The  symptoms  of  disease  of  the  trunk  of  the  portal  vein  are  the  same 
as  those  of  obstruction  of  the  terminal  branches,  and  are  known  as  the 
symptoms  of  portal  congestion.  (See  below.)  In  one  respect  only  do 
they  differ.  While  we  have  ascites  in  both,  in  thrombosis  of  the 
portal  vein  it  occurs  suddenly,  and  is  characterized  by  rapid  recurrence 
after  tapping. 

Suppurative  inflammation  of  the  portal  vein  is  attended  by  symptoms 
resembling  pyaemia,  and  is  also  called  portal  pyaemia.  The  inflamma- 
tion is  secondary,  and  depends  upon  inflammation  in  the  portal  area. 
It  may  follow  appendicitis,  infectious  inflammation  of  the  hemorrhoidal 
veins,  or  of  the  veins  anywhere  in  the  gastro-intestinal  tract.  Pus  is 
carried  into  the  liver  by  the  portal  current.  In  consequence  thereof, 
multiple  hepatic  abscesses  arise.  Three  pathological  affections  are 
therefore  seen  :  (1)  Suppuration  in  the  portal  area  ;  (2)  inflammation 
of  the  vein  ;  (3)  multiple  abscesses  of  the  liver  (for  the  symptoms  of 
which  see  Abscess). 

Occlusion  or  overfilling  of  the  branches  in  the  liver  occurs  in  passive 
congestion,  and  most  typically  in  cirrhosis  of  the  liver.  The  circula- 
tion in  the  liver  is  interfered  with  ;  the  blood  is  thrown  back  into  the 
portal  vein,  and  overfills  the  vessels  of  the  portal  area.  As  a  result 
we  have  (1)  congestion  of  the  mucous  membrane  of  the  stomach  and 
bowels,  with  the  symptoms  of  gastro-intestinal  catarrh.  (2)  Dilatation 
of  the  veins,  chiefly  the  hemorrhoidal,  giving  rise  to  hemorrhoids.  (3) 
Ascites.  (4)  Hemorrhages.  The  hemorrhages  may  occur  in  any  part 
of  the  gastro-intestinal  tract.  Hsematemesis  and  intestinal  hemor- 
rhage are  seen  singly  or  combined.  The  vomited  blood  may  be  small  in 
amount,  often  with  mucus.  In  some  cases  large,  sometimes  fatal,  hemor- 
rhages take  place  either  from  the  mucous  membrane  of  the  stomach  or 
from  the  veins  about  the  oesophagus,  which  often  become  varicosed  in 
cirrhosis.  Hemorrhages  from  the  intestine  may  be  from  enlarged 
hemorrhoidal  veins,  from  an  intestinal  ulcer,  or  from  the  intact  mucous 


DISEASES  OF  LIVER,  SPLEEN  AND  PANCREAS.  859 

membrane.  (5)  Enlargement  of  the  spleen.  (6)  Changes  due  to  the 
collateral  circulation.  If  complete  collateral  circulation  is  established, 
the  above  symptoms  may  not  ensue.  The  collateral  circulation  may 
be  through  deep-seated  or  through  superficial  veins.  If  the  latter, 
the  external  veins  of  the  abdomen  are  enlarged.  The  epigastric  and 
mammary  veins  become  prominent.  The  veins  about  the  umbilicus 
may  become  so  enlarged  and  prominent  as  to  form  a  swelling,  to 
which  the  term  caput  Medusce  has  been  applied.  The  venules  along 
the  line  of  attachment  of  the  diaphragm  in  the  lower  thoracic  zone 
are  overdistended.     They  may  be  the  seat  of  pulsation.' 

In  consequence  of  the  portal  overfilling  the  enlarged  terminal 
branches  of  the  vein  press  upon  contiguous  structures,  interfere  with 
the  circulation  of  blood  in  the  major  vascular  system  of  the  liver,  and 
invite  catarrh  of  the  terminal  ducts,  with  obstruction,  and  hence  jaun- 
dice. This  is  seen  quite  frequently  in  passive  congestion  of  the  liver, 
rarely  in  cirrhosis. 

Symptoms  due  to  the  Changes  in  Shape  and  Size.  The  liver 
may  be  enlarged,  contracted,  or  irregular.     (See  Objective  Symptoms.) 

When  the  liver  is  contracted  symptoms  of  portal  obstruction  usually 
occur  ;  when  enlarged  they  occur  occasionally. 

The  Data  Obtained  by  Inquiry. 

A  knowledge  of  etiological  factors  is  of  aid  in  the  diagnosis  of 
hepatic  affections.  In  disease  of  the  liver  more  than  in  any  other 
organ  of  the  body  we  find  the  affection  secondary  to  disease  elsewhere. 
Moreover,  diseases  of  the  liver  are  almost  always  associated  with  defi- 
nite causes,  the  presence  or  absence  of  which  is  of  great  diagnostic  sig- 
nificance. In  the  study  of  hepatic  disease  we  consider,  therefore, 
among  etiological  factors,  the  age,  the  sex,  the  habits  of  life,  the 
climate,  and  the  presence  or  absence  of  disease  in  other  portions  of  the 
body.  Primary  liver  disease  is  comparatively  rare.  Secondary  liver 
disease,  on  the  other  hand,  is  of  common  occurrence.  There  are  but 
few  general  diseases  or  states  of  the  system  that  do  not  in  some  way 
influence  the  liver.  The  above  remarks  refer  to  organic  disease.  Func- 
tional disorders  of  the  liver,  as  previously  remarked,  are  so  difficult 
to  separate  from  functional  disorders  of  the  stomach  and  intestines, 
that,  practically,  from  an  etiological  and  clinical  stand-point,  they  go 
hand-in-hand 

The  Social  History.  The  Age.  Diseases  of  the  liver  usually 
occur  late  in  life,  because  the  causes  upon  which  they  depend  are  oper- 
ative only  at  that  period.  In  a  case,  therefore,  of  ill  health  in  a  young 
subject,  when  the  cause  cannot  well  be  determined,  the  liver  is  not  so 
likely  to  be  the  seat  of  disease  as  in  older  subjects.  Late  in  life  we 
have  gallstones  with  their  multiple  consequences,  inflammation,  cir- 
rhosis, and  cancer.  We  may,  however,  have  the  congestions  and  the 
degenerations  in  early  life,  although  not  so  frequently. 

The  Sex.  The  sex  is  not  of  much  significance  from  a  diagnostic 
stand-point.     Cancer  may  be  more  frequent  in  the  female  sex,  because 

1  Musser:  Trans.  Phil.  Path.  Soc,  vol.  xi.  p.  20. 


860  SPECIAL  DIAGNOSIS. 

cancer  of  the  uterus  and  other  organs  is  more  common.  Cancer  of 
the  biliary  passages  is  more  frequent  in  females,  because  in  that  sex 
gallstones,  which  are  etiological  factors  in  cancer,  are  more  common. 
Cirrhosis,  also,  is  said  to  be  relatively  more  frequent  in  females. 

The  Habits.  It  is  always  necessary  to  inquire  into  the  habits.  Alco- 
holism points  to  cirrhosis  ;  the  excessive  use  of  stimulating  foods  to 
hypersemia  ;  sedentary  habits  and  the  use  of  starches  and  fats  to  gall- 
stones. The  occupation  has  but  little  influence  in'  the  development  of 
hepatic  disease.  With  regard  to  the  climate,  it  may  be  said  that  in 
tropical  countries  hyperemias  and  abscess  of  the  liver  are  more  fre- 
quent. 

The  Family  History.  But  little  avails  in  the  study  of  the  family 
history  for  diagnosis,  as  most  of  the  morbid  processes  are  secondary 
to  disease  elsewhere.  This  does  not  apply  to  biliary  calculi,  the 
formation  of  which  appears  to  be  confined  to  members  of  special 
families. 

Previous  Disease.  It  is  absolutely  essential  to  inquire  into  this 
to  establish  a  diagnosis,  as  liver  disease  is  usually  secondary.  The 
occurrence  of  heart  disease  or  obstructive  lung  disease  points  to  a  con- 
gestion ;  infectious  diseases  to  cirrhosis  when  that  is  not  otherwise 
accounted  for  ;  dysentery  to  abscess  ;  ulceration  or  suppuration  in  the 
portal  area  to  multiple  abscess  ;  syphilis  to  syphilitic  diseases  ;  tuber- 
culosis, suppurations,  bone  disease,  and  syphilis  to  amyloid  disease  ; 
pyaemia  to  multiple  abscesses  ;  tuberculosis  to  fatty  liver. 

The  Subjective  Symptoms. 

The  subjective  symptoms  are  such  as  belong  to  functional  disorder 
of  the  liver,  conspicuous  among  which  are  gastro-intestinal  symptoms 
and  toxaemia.     (See  Functional  Disturbance  and  Lithaemia.) 

Pain  is  a  frequent  symptom  of  liver  disease.  When  sudden  in 
onset,  acute,  and  increased  by  pressure  or  movement,  it  is  due  to  peri- 
hepatitis. Acute  paroxysmal  pain  below  the  ribs  or  in  the  epigastrium 
points  to  gallstones.  It  may  be  in  the  seventh  or  eighth  interspace. 
Pain  with  distention  occurs  in  congestion.  Stabbing  or  darting  pains 
belong  to  cancer.     The  pain  of  perihepatitis  may  attend  abscess. 

Pain  in  the  liver  must  not  be  confounded  with  pleurisy.  In  pneu- 
monia there  is  often  congestion  of  the  liver  and  perhaps  perihepatitis. 
The  associated  pain  has  been  mistaken  for  the  pain  of  hepatic  colic. 

The  Data  Obtained  by  Observation.     The  Objective  Symptoms. 

Topographical  Anatomy.    (See  Plates  XIII.,  XIV.,  and  XXXV.) 

The  right  lobe  of  the  liver  is  applied  to  the  concavity  formed  by  the 
lower  lobe  of  the  right  lung,  being  separated  from  it  by  the  diaphragm. 
The  thin  lower  edge  of  the  right  lung  overlaps  the  liver  at  its  upper 
part,  but  the  greater  portion  of  the  anterior  surface  of  the  right  lobe  of 
the  liver  is  in  contact  with  the  ribs.  The  under  surface  of  the  liver 
is  in  relation  with  the  stomach,  transverse  colon,  duodenum,  right 
kidney,  and  right  suprarenal  capsule.     "  The  highest  part  of  its  con- 


DISEASES  OF  LIVER,  SPLEEN  AND  PANCREAS,  861 

vexity  on  the  right  side  is  about  one  inch  below  the  nipple,  or  nearly 
on  a  level  with  the  external  and  inferior  angle  of  the  pectoralis  major. 
Posteriorly  the  liver  comes  to  the  surface  below  the  base  of  the  right 
lung,  about  the  level  of  the  tenth  dorsal  spine."     (Holden.) 

A  needle  thrust  into  the  right  side,  between  the  sixth  and  seventh 
ribs,  would  traverse  the  lung,  and  then  go  through  the  diaphragm  at 
its  central  attachment,  into  the  liver.  The  lower  border  of  the  liver 
extends  in  the  median  line,  one-third  of  the  distance  from  the  tip  of 
the  xiphoid  cartilage  to  the  umbilicus.  In  the  right  mammary  line  it 
extends  to  the  lower  border  of  the  ribs  ;  and  in  the  mid-axillary  line 
to  the  tenth  rib.  The  upper  border  is  opposite  the  upper  border  of 
the  sixth  rib  in  the  mammary  line,  and  extends  horizontally  in  the 
axilla  to  the  ninth  rib  behind. 

The  attachments  of  the  liver  permit  of  a  certain  amount  of  move- 
ment. Hence,  the  liver  can  be  depressed  by  deep  inspiration,  emphy- 
sema of  the  lungs,  or  right  pleural  effusion.  If  the  patient  lie  upon 
his  left  side,  the  left  lobe  of  the  liver  rises  higher  and  the  right  ex- 
tends lower,  and  vice  versa  if  the  patient  lie  upon  the  right  side,  the 
liver  turning  upon  the  suspensory  ligament  as  an  axis.     (Gerhardt.) 

Inspection.  Inspection  is  not  of  very  great  assistance  in  the  diag- 
nosis of  diseases  of  the  liver.  Frequently  there  is  a  swelling  or  tumor 
in  the  right  upper  quadrant,  which  may  or  may  not  be  produced  by 
an  enlargement  of  the  liver,  but  which  should  direct  attention  to  that 
organ.  The  lower  right  zone  of  the  thorax  may  also  be  distinctly 
prominent.  Such  a  swelling  may  be  observed  in  amyloid  disease, 
hydatid  tumor,  cancer,  abscess,  and,  less  frequently,  in  fatty  liver. 
In  amyloid  and  fatty  livers  the  projection  hi  the  right  upper  quadrant, 
which  may  extend  to  the  left  beyond  the  median  line,  presents  a 
smooth  surface,  whereas  in  hydatid  tumor  there  is  frequently  a  rounded 
projection  at  some  part  of  the  prominent  area,  and,  in  cancer,  several 
nodules  may  be  large  enough  to  cause  slight  rounded  projections,  which 
the  eye  is  more  apt  to  detect  after  the  sense  of  touch  has  first  directed 
attention  to  their  presence. 

Enlargement  and  occasionally  pulsation  of  the  superficial  abdominal 
veins  are  accompaniments  of  cirrhosis. 

Jaundice.  The  Symptoms.  The  color  of  the  skin  and  of  the  mucous 
membranes  in  jaundice  has  been  described.  (See  page  121.)  In 
addition  to  the  yellow  discoloration  we  find  :  1.  Irritations  of  the 
skin.  Pruritus  is  common  and  intense,  and  may  cause  great  dis- 
tress. An  attack  of  jaundice  may  be  preceded  by  general  itching. 
It  occurs  in  all  forms,  but  is  more  marked  in  obstructive  jaundice 
of  long  duration.  Scratch-marks  are  seen  on  the  surface  of  the  skin, 
and  erythematous  eruptions  and  boils  frequently  occur.  Xanthelasma 
is  a  peculiar  affection  occurring  on  the  tongue,  on  the  skin  of  the 
eyelids,  and  about  the  ears.  (See  page  92.)  2.  Discoloration  of  the 
secretions.  All  the  secretions  of  the  body  are  changed  in  color,  as 
previously  described.  3.  Bile  absent  in  the  feces.  The  stools  are  ashy 
or  gray  in  color.  4.  Sloicness  of  the  pulse.  The  heart's  action  falls  to 
40  or  30  to  the  minute,  or  even  lower.     5.  Hemorrhages.     In  the  later 


862  SPECIAL  DIAGNOSIS. 

stages  of  all  forms  of  jaundice  hemorrhages  are  of  common  occurrence. 
In  acute  malignant  jaundice  they  are  seen  underneath  the  skin,  and 
come  from  the  mucous  membranes.  6.  Cerebral  symptoms.  Irrita- 
bility and  depression  of  spirits  are  marked.  As  the  disease  advances 
the  mind  grows  sluggish  ;  the  patient  is  dull,  and  sleeping  most  of  the 
time.  Gradually  the  symptoms  of  the  typhoid  state  develop.  In  the 
acute  febrile  forms  coma  and  convulsions  are  of  common  occurrence. 
In  the  affection  known  as  acute  yellow  atrophy  the  cerebral  symptoms 
are  marked,  and  occur  soon  after  the  onset  of  the  disease.  Within 
the  first  twenty-four  hours  there  may  be  convulsions,  with  delirium 
in  the  intervals,  and  subsequently  coma. 

Causes.  Jaundice  is  of  two  varieties,  the  hepatogenous  and  the 
hsematogenous. 

Hepatogenous  Jaundice.  Jaundice  is  hepatogenous  when  there 
is  obstruction  of  the  ducts.  The  obstruction  may  take  place  in  the 
large  ducts  or  in  the  smaller  terminal  ducts.  The  obstruction  may  be 
due  to  disease  outside  of  the  ducts  ;  to  disease  of  the  ducts,  or  to  ob- 
struction within  the  ducts. 

1.  Jaundice  from  disease  outside  of  the  ducts.  External  pressure. 
External  pressure  by  tumors  of  the  stomach,  kidney,  pancreas,  or 
omentum  ;  by  tumors  of  the  liver  itself,  or  enlarged  glands  in  the 
fissure  of  the  liver  ;  by  accumulated  feces  in  the  colon  ;  by  an  abdom- 
inal aneurism  ;  and  by  the  pregnant  uterus,  in  rare  instances,  may  cause 
jaundice.  Jaundice  due  to  disease  outside  of  the  ducts  is  gradual  in 
onset,  varies  in  degree  with  the  amount  of  pressure,  and  becomes 
chronic,  except  in  pregnancy  and  from  fecal  accumulation  ;  it  may 
cause  death,  or  persist  until  such  termination  results  from  the  primary 
disease.  It  is  recognized  by  the  absence  of  pain  ;  the  presence  of  dis- 
ease in  other  localities,  indicated  by  its  peculiar  symptoms  and  signs  ; 
the  absence  of  a  history  of  gallstones  ;  and,  finally,  by  the  patient's 
age.  Its  nature  must  be  inferred  from  the  symptoms  and  physical 
signs  of  disease  in  neighboring  structures.  If  the  jaundice  is  due  to 
enlargement  of  the  lymphatic  glands,  its  nature  may  be  inferred  from 
the  presence  of  primary  carcinoma  in  other  organs  of  the  body,  or  from 
the  condition  of  the  lymphatic  glands  in  other  parts.  If  they  are  the 
seat  of  malignant  disease,  it  can  usually  be  recognized.  Cancer  of  the 
liver  must  be  excluded  by  its  symptoms — enlargement  with  jaundice, 
with  moderate  fever,  rapid  emaciation,  and  short  duration  of  the  dis- 
ease. In  the  large  majority  of  cases  this  form  of  jaundice  is  due  to 
disease  of  the  pancreas,  particularly  carcinoma. 

2.  Jaundice  from  disease  of  the  ducts  themselves.  Catarrhal  in- 
flammation, suppurative  inflammation,  or  adhesive  inflammation  of  the 
ducts ;  and  cancer  or  other  tumors  of  the  duct  cause  jaundice. 

Jaundice  due  to  disease  of  the  ducts  presents  various  features.  The 
most  common  form  is  that  clue  to  catarrhal  inflammation  of  the  ducts. 
The  jaundice  comes  on  suddenly,  at  least  within  forty-eight  hours  after 
the  onset  of  the  symptoms  ;  there  is  no  pain,  but  it  is  attended  by 
vomiting  and  other  symptoms  of  mild  gastritis,  and  is  usually  accom- 
panied by  itching.  It  follows  indiscretions  in  diet,  and  occurs  in 
young  subjects.    A  definite  cause  for  the  gastritis  can  usually  be  found. 


DISEASES  OF  LIVER,  SPLEEN  AND  PANCREAS.  863 

The  diagnosis  is  based  upon  the  age,  the  association  of  the  jaundice 
with  gastritis,  for  which  a  definite  cause  can  often  be  assigned  ;  the 
absence  of  organic  heart  disease,  or  any  lesion  within  the  body,  on 
account  of  which  jaundice  might  arise  ;  the  moderate  degree  of  jaun- 
dice, the  absence  of  emaciation  and  symptoms  of  portal  obstruction, 
the  occurrence  of  moderate  enlargement  without  pain.  It  must  not  be 
forgotten  that  jaundice  due  to  obstruction  from  gallstones,  or  to  press- 
ure from  tumors  outside  of  the  duct,  is  characterized  in  its  onset  by 
symptoms  similar  to  those  just  mentioned.  It  is  often  necessary  to 
wait  before  giving  an  opinion  ;  a  history  of  previous  attacks  of  jaun- 
dice and  the  age  of  the  patient,  over  forty  years,  also  lead  to  caution 
in  the  diagnosis. 

If  the  jaundice  is  due  to  suppurative  inflammation  of  the  ducts,  cho- 
langitis, the  infection  is  usually  associated  with  a  previous  history  of 
gallstones.  It  must  not  be  forgotten,  however,  that  other  lesions,  which 
cause  jaundice,  may  mvite  an  infectious  inflammation  of  the  ducts  also, 
such  as  obstruction  by  external  pressure.  The  course  of  the  jaundice 
is  chronic.  Fever  and  other  symptoms  of  an  infection  attend  it.  In 
adhesive  inflammation  there  is  a  history  of  trauma  from  gallstones,  and 
the  affection  is  chronic.  In  cancer  of  the  gall-ducts  the  advent  of  jaun- 
dice is  slow,  the  course  protracted  ;  the  symptoms  are  the  symptoms 
of  carcinoma,  to  which  are  often  added  the  physical  signs  of  an  en- 
larged gall-bladder.     (See  Diseases  of  the  Gall-ducts.) 

3.  Jaundice  from  obstruction  within  the  ducts.  Foreign  bodies 
within  the  ducts,  as  inspissated  mucus,  gallstones,  or  parasites,  such  as 
round  worms  or  hydatid  cysts,  are  the  common  causes  of  the  occlusion 
of  the  ducts  which  may  cause  jaundice. 

Foreign  bodies  within  the  ducts  cause  jaundice  by  direct  obstruction, 
or  by  the  catarrhal  inflammation  which  their  presence  excites.  The 
symptoms  occur  suddenly  in  the  former  instance,  gradually  in  the 
latter.  The  characteristic  symptoms  of  gallstones  precede  the  jaundice. 
The  patient  is  usually  a  woman  past  forty  years,  with  habits  of  life 
which  predispose  to  the  formation  of  calculi.  Colicky  pains  occurring 
in  paroxysms,  intermittent  jaundice  varying  in  intensity,  and  an  inter- 
mittent fever,  point  to  this  form  of  obstruction. 

Jaundice  due  to  lowering  of  the  blood-pressure  in  the  liver,  so  that 
the  tension  between  the  bile-ducts  and  the  blood-passages  is  altered, 
occurs  suddenly,  is  light  in  degree,  and  is  not  attended  by  marked 
symptoms  ;  it  is  due  usually  to  shock  or  emotions. 

Hematogenous  Jaundice.  Jaundice  is  hematogenous  or  non- 
obstructive when  (1)  the  function  of  the  liver-cells  has  been  suppressed, 
as  in  acute  yellow  atrophy  of  the  liver  ;  (2)  when  blood-destruction 
is  in  excess  of  the  capacity  of  the  liver  to  remove  the  product  of 
destruction — the  urobilin,  as  in  certain  forms  of  malaria,  in  perni- 
cious anaemia,  in  certain  fevers,  and  other  toxaemias.  The  onset  of 
the  jaundice  is  rapid,  the  general  symptoms  are  more  pronounced,  par- 
ticularly the  cerebral  symptoms.  They  occur  simultaneously  with  the 
jaundice.  They  are  infectious,  as  in  acute  yellow  atrophy  of  the  liver 
and  in  Weil's  disease.  The  toxic  forms  of  hematogenous  jaundice  are 
not  severe  ;  the  discoloration  of  the  skin  is  light  yellow,  and  may  not 


864  SPECIAL  DIAGNOSIS. 

even  be  observed  by  the  patient,  nor  cause  pronounced  symptoms. 
The  blood  is  destroyed  rapidly  in  these  cases,  and,  as  it  cannot  be 
disposed  of  by  the  liver,  spleen,  or  kidneys,  the  transformed  haemo- 
globin is  deposited  in  the  tissues.  In  this  class  of  cases  the  urine 
contains  but  little  bile-pigment,  but  there  is  a  large  amount  of  urobilin 
and  indican.     The  stools  are  not  clay-colored. 

Malignant  or  Infectious  Jaundice.  Acute  Yellow  Atrophy  of  the 
Liver.  Acute  diffuse  inflammation  of  the  liver,  with  necrosis  of  the 
cells,  characterized  by  jaundice  and  cholsemia.  Many  of  the  cases 
occur  during  pregnancy.  It  is  most  common  prior  to  the  thirtieth 
year.  It  is  said  to  follow  fright.  The  symptoms  are  local  and  gen- 
eral. Jaundice  is  at  first  noticed  after  an  attack  of  gastroduodenal 
catarrh.  It  is  light,  occasionally  extends  over  the  entire  body,  and  is 
not  usually  attended  by  itching.  After  a  continuance  of  these  mild 
symptoms  for  from  two  days  to  two  weeks,  the  patient  complains  of 
headache  ;  delirium  sets  in  with  stupor  and  convulsions.  The  headache 
is  attended  with  vomiting.  Fever  of  moderate  degree  begins  at  the  same 
time,  although  in  some  cases  it  is  absent. 

Although  the  jaundice  is  not  intense,  the  effects  upon  the  blood  are 
early  seen  ;  hemorrhages  underneath  the  skin  and  from  the  mucous 
membrane  take  place.  In  pregnant  women  abortion  follows,  the  hem- 
orrhage from  which  may  be  very  excessive.  The  stupor  and  delirium 
are  followed  by  coma,  and  death  takes  place  in  the  first  week  ;  or  coma 
may  be  preceded  by  the  typhoid  state,  and  the  disease  lasts  longer 
than  a  week.  The  urine  is  bile-stained,  and  contains  albumin  and 
casts.  It  diminishes  in  amount,  and  is  soon  passed  involuntarily. 
Leucin  and  tyrosin  are  always  present.  The  latter  may  be  seen  in  the 
sediment,  although  it  is  more  marked  when  a  few  drops  are  evaporated 
on  a  cover-glass.  The  bowels  are  loose  and  the  stools  involuntary  and 
clay  colored. 

On  examination  the  liver  is  found  to  be  diminished  in  size  ;  this 
may  not  be  appreciated  by  percussion  in  the  anterior  region,  but  in  the 
axillary  region  the  width  is  reduced  one  to  two  inches.  There  may 
be  some  tenderness  over  the  liver  and  over  the  ducts. 

Diagnosis.  The  data  upon  which  a  diagnosis  is  based  are  the  age, 
sex,  pregnancy,  the  rapidity  of  onset  of  cerebral  symptoms  following 
jaundice,  diminution  in  the  size  of  the  liver,  with  leucin  and  tyrosin 
in  the  urine.  It  must  be  distinguished  from  the  jaundice  of  hyper- 
trophic cirrhosis  of  the  liver,  which  at  times  becomes  malignant.  Some 
observers  have  thought  that  acute  yellow  atrophy  may  supervene  upon 
this  form  of  cirrhosis,  thereby  causing  malignant  jaundice  ;  but  there 
is  more  fever  than  in  atrophy,  while  leucin  and  tyrosin  are  not  found 
in  the  urine.  It  must  not  be  forgotten  that  all  cases  of  jaundice  may 
terminate  suddenly  with  delirium,  followed  by  coma,  or  by  the  develop- 
ment of  the  typhoid  state. 

In  phosphor  as-poisoning  the  hemorrhages,  the  jaundice,  and  diminu- 
tion in  the  size  of  the  liver  are  the  same  as  in  acute  yellow  atrophy. 
Gastric  symptoms  are  more  marked,  and  leucin  and  tyrosin  are  not 
present  in  the  urine. 


DISEASES  OF  LIVER,  SPLEEN  AND  PANCREAS.  865 

Weil's  Disease.  This  infection,  in  which  jaundice  is  the  chief 
symptom,  is  considered  in  the  chapter  on  Infections  Diseases. 

Yellow  Fever.  The  account  of  the  jaundice  attending  this  infec- 
tion is  found  in  the  chapter  on  Infectious  Diseases. 

Infantile  Jaundice.  Jaundice  in  infants  is  due  to  two  causes  : 
First,  congenital  obliteration  of  the  ducts  ;  and,  second,  catarrhal  in- 
flammation. It  must  not  be  confounded  with  the  yellow  discoloration 
of  the  skin,  due  to  the  excess  of  coloring-matter  in  the  blood,  which  is 
not  disposed  of  by  the  liver. 

In  congenital  obliteration  of  the  gall-ducts  jaundice  rapidly  ensues 
and  deepens  to  an  intense  degree ;  hemorrhages  occur,  the  child  be- 
comes stupid  or  comatose,  may  have  convulsions,  and  death  takes  place 
in  coma.  There  is  rapid  emaciation,  and  the  liver  and  spleen  are  en- 
larged.    The  child  may  live  many  months. 

Simple  catarrhal  jaundice  in  infants  is  associated  with  moderate 
gastric  disorder.  The  jaundice  is  light ;  the  conjunctivae  alone  may 
be  discolored.  In  infants  malignant  or  infectious  jaundice  may  be 
due  to  inflammation  of  the  portal  veins,  secondary  to  umbilical  phleb- 
itis. The  jaundice  develops  after  suppurative  inflammation  about  the 
umbilicus,  and  is  attended  by  fever.  There  may  be  some  tenderness  over 
the  liver  ;  frequently  peritonitis  develops  at  the  same  time.  Pysemic 
symptoms  may  set  in,  and  pus  may  be  found  in  other  situations.  If 
death  does  not  ensue  early  the  jaundice  becomes  more  pronounced  and 
causes  cutaneous  and  mucous  hemorrhages.  Convulsions  and  coma 
are  apt  to  supervene  before  death.  Jaundice  in  infants  also  occurs  in 
interstitial  hepatitis  of  syphilitic  origin.  The  evidences  of  hereditary 
syphilis  are  seen  in  the  skin  and  mucous  membranes.  The  liver  is 
enlarged,  and  there  may  be  tenderness  from  perihepatitis. 

Fever.  Hepatic  Fever.  The  occurrence  of  fever  may  be  of  diag- 
nostic importance  in  distinguishing  the  various  forms  of  obstructive 
jaundice.  Fever  occurs  frequently  in  jaundice  ;  but  is  significant  in  cer- 
tain forms  only.  In  catarrhal  jaundice  it  is  present  for  three  or  four 
days  only,  disappearing  as  the  severe  gastric  symptoms  subside.  It  is 
probably  toxic.  In  hepatic  colic,  with  jaundice,  it  is  transitory  and 
associated  with  chills  and  SAveats.  In  jaundice  from  obstruction  it 
occurs  when  an  infectious  cholangitis,  primary  or  secondary,  arises. 
A  peculiar  type  known  as  intermittent  hepatic  fever  (see  page  202)  is 
often  seen.  The  intermittent  fever  is  associated  with  gallstones  in  the 
following  groups  :  First,  with  each  paroxysm  of  hepatic  colic  moder- 
ate fever  and  jaundice  are  present.  The  latter  becomes  more  intense 
after  each  paroxysm,  but  disappears  in  a  short  time.  The  paroxysmal 
attacks  may  recur  at  intervals  for  years.  Second,  the  hepatic  colic  is 
attended  by  distinct  ague-like  paroxysms  of  chill,  fever,  and  sweat, 
after  each  of  which  the  jaundice,  which  continues  to  the  end,  is  more 
intense.  Third,  hepatic  colic  and  gastric  disturbance  occur  with  fever, 
but  without  jaundice.  The  symptoms  occur  in  distinct  paroxysms. 
Gallstones  are  probably  the  cause  in  all  these  conditions,  leading  in 
some  cases  to  chronic  obstruction  of  the  duct  without  infection. 

If  an  infectious  cholangitis,  with  or  without  gallstones,  is  present,  the 
symptoms  are  somewhat  different,  although  the  fever  is  of  the  same 


866  SPECIAL  DIAGNOSIS. 

type.  Thus  (1)  there  is  more  tenderness  in  the  hepatic  region,  with 
enlargement  of  the  gall-bladder ;  (2)  the  paroxysms  are  more  frequent ; 
(3)  jaundice  is  not  so  intense  and  not  influenced  by  paroxysms  ;  (4) 
the  patient  is  ill  in  the  intervals,  and  there  is  wasting.  There  are  no 
periods  of  improvement  locally  or  in  the  general  condition.  The  most 
important  point  in  cases  of  gallstone  is  the  subsidence  of  all  symptoms 
between  the  paroxysm  of  fever. 

Intermitting  fever  of  this  character  must  be  distinguished  from 
malaria.  The  history  of  gallstones,  with  pain  in  the  region  of  the 
liver,  and  the  negative  appearance  of  the  blood,  are  sufficient  to  estab- 
lish the  diagnosis. 

Hepatic  fever  also  occurs  in  cancer  when  the  neoplasms  grow  rapidly, 
in  certain  forms  of  cirrhosis,  and  in  obstruction  from  other  causes  than 
gallstones.  It  is  particularly  common  in  suppurative  inflammation  of 
hydatid  cysts,  or  after  they  rupture  and  discharge  into  the  biliary 
vessels.  Without  previous  knowledge  of  the  hydatid  cyst  the  diagno- 
sis is  almost  impossible,  save  that  the  pain  is  less  wheu  the  obstruction 
is  due  to  this  cause  than  in  obstruction  from  the  passage  of  gallstones. 

Palpation.  By  palpation  the  lower  border  of  the  liver  can  be  de- 
termined in  thin  subjects,  or  in  those  in  whom  the  liver  is  greatly 
enlarged.  It  may  be  difficult  to  determine  the  border  when  the  abdo- 
men is  distended  on  account  of  flatulency.  Careful  palpation  must  be 
made  with  the  tips  of  the  fingers,  pressing  them  firmly  inward  along 
the  margin  of  the  ribs,  at  the  same  time  securing  relaxation  of  the 
abdominal  muscles  by  having  the  patient  take  a  full  breath,  and 
having  the  legs  drawn  up  and  the  shoulders  elevated.  The  pressure 
should  be  made  in  the  intervals  following  the  act  of  inspiration.  By 
care  and  patience  the  fingers  can  be  pushed  deeply  inward  and  be 
made  to  feel  the  border  of  the  liver,  even  in  health.  Care  must  be 
taken  not  to  cause  contraction  of  the  right  rectus  muscle,  for  if  this 
takes  place  the  indurated  mass  may  simulate  tumor  or  enlargement  of 
the  liver.  The  left  lobe  of  the  liver,  below  the  ensiform  cartilage, 
extends  half-way  to  the  umbilicus.  Here  it  is  most  accessible  to  pal- 
pation. By  palpation  we  also  determine  the  size  of  the  gall-bladder 
and  the  degree  of  movement  of  the  liver  in  respiration.  On  full  in- 
spiration the  liver  descends,  and  during  the  act  of  expiration  rises 
again.  This  movability  is  of  service  hi  distinguishing  the  liver  from 
other  organs  that  are  fixed  within  the  abdomen. 

In  amyloid  disease  the  lower  edge  is  smooth,  rounded,  the  tissue 
dense  and  unyielding  to  pressure,  and  the  anterior  surface  perfectly 
smooth,  as  a  rule  ;  but  when  the  liver  is  also  cirrhotic  or  syphilitic  the 
surface  may  be  irregular  and  fissured.1 

The  fatty  liver  has  also  a  rounded  smooth  border,  but  its  tissue  is  not  so 
dense  and  resistant,  except  when  cirrhosis  coexists.  Its  surface  is  smooth. 

In  single  abscess  the  liver  is  enlarged,  but  not  uniformly,  and  not 
invariably.  If  the  abscess  is  located  in  the  right  lobe,  and  nearer  the 
anterior  than  the  posterior  surface,  palpation  may  be  able  to  detect  not 
only  enlargement,  but  also  deep-seated  obscure  fluctuation,  surrounded 

1  See  Musser:   "Amyloid  Disease  of  Liver,"  Penna.  State  Medical  Journal,  1899. 


DISEASES  OF  LIVER,  SPLEEN  AND  PANCREAS.  867 

by  a  zone  of  hard  tissue.     The  tumor  is  round,  smooth,  tense,  tender, 
and  painful. 

In  multiple  abscesses  the  liver  is  enlarged  uniformly,  and  usually 
none  of  the  abscesses  are  large  enough  to  be  felt  as  a  distinct  promi- 
nence.    The  liver  is  tender  and  painful. 

In  hydatid  tumor  the  degree  of  enlargement  depends  very  much 
upon  the  situation  of  the  cyst,  upon  its  stage  of  development,  and  upon 
the  activity  of  the  echinococci.  Sometimes  the  cyst  is  so  small  that 
its  existence  remains  unsuspected  ;  at  other  times  the  enlargement  is 
so  great  as  to  fill  the  abdominal  cavity.  As  in  abscess,  the  possibility 
of  detecting  the  tense,  globular,  fluctuating,  painless  tumor  character- 
istic of  the  disease  depends  upon  its  situation.  If  it  is  on  the  anterior 
surface  or  lower  border,  it  is  easily  detected,  especially  if  the  tunior  is 
at  all  large  ;  but  if  it  projects  from  the  posterior  surface  or  from  the 
upper  or  lateral  borders,  detection  is  difficult,  and  may  be  impossible. 

In  congestion  of  the  live)-  the  enlargement  is  not  so  great  as  in  ab- 
scess, nor  are  pain  and  tenderness  so  pronounced.  Moreover,  the 
enlargement  is  usually  not  permanent.  The  lower  border,  if  it  pro- 
jects below  the  edge  of  the  ribs,  is  smooth. 

In  hypertrophic  cirrhosis  the  enlargement  is  moderate,  the  surface 
smooth,  or  but  slightly  roughened,  denser  than  normal,  and  somewhat 
tender. 

In  cancer  the  enlargement  resembles  that  of  single  abscess  and 
hydatid  tumor  in  that  it  is  irregular.  But,  unlike  hydatid  tumor,  the 
irregularities  are  due  to  knobs  or  bosses  which  project  from  the  sur- 
face of  the  liver,  are  usually  entirely  free  from  any  fluctuation,  and  are 
tender  on  palpation.  There  may  be  a  single  large  mass,  or  a  number 
of  knobs  or  nodules.  The  part  projecting  below  the  ribs  may  be  free 
from  any  nodules. 

Palpation  of  the  liver  may  discover  a  friction  from  perihepatitis,  and 
pain  or  tenderness  from  that  cause,  or  from  cancer  or  abscess.  Pulsa- 
tion of  the  liver  may  be  a  transmitted  impulse  from  the  abdominal 
aorta  or  a  venous  pulse,  such  as  occurs  also  in  the  jugulars,  from  tri- 
cuspid regurgitation. 

Floating  liver  is  diagnosticated  by  feeling  in  the  lower,  most  fre- 
quently the  right  portion  of  the  belly,  a  large  tumor,  which  may,  how- 
ever, easily  be  confounded  with  tumors  of  other  organs.  It  can  be 
distinguished  as  liver  :  (1)  By  recognizing  the  notch  ;  (2)  by  the  pres- 
ence of  a  tympanitic  note  in  the  proper  region  of  the  liver,  as  loops  of 
intestine  lie  between  the  diaphragm  and  liver  ;  (3)  by  the  excessive 
movability  of  the  tumor  ;  and  (4)  by  the  fact  that  it  is  possible  to  re- 
place the  liver  ;  (5)  by  its  size  and  consistency.  It  occurs  almost 
exclusiv elv  in  women,  possibly  as  the  result  of  a  congenital  lengthen- 
ing of  the  suspensory  ligament,  although  more  likely  from  relaxed 
abdominal  walls.  It  may  be  confounded  with  ovarian  cyst,  appendi- 
citis with  tumor,  and  movable  right  kidney  with  hydronephrosis. 

Constriction  of  the  liver  from  tight  lacing  (Schnurleber)  occurs  chiefly 
in  women.  Tight  corsets,  and,  still  more,  tight  waist-straps  or  bands, 
squeeze  the  liver  downward,  especially  the  right  lobe,  so  that  it  can  be 
palpated.     In  more  pronounced  cases  a  furrow,  often  palpable,  is  pro- 


868  SPECIAL  DIAGNOSIS. 

duced,  and,  below  this,  a  constricted  lobe  which  may  extend  as  far 
down  as  the  anterior  superior  spine  of  the  ilium  and  carry  the  gall- 
bladder with  it.  In  other  instances,  the  right  lobe  is  elongated,  ex- 
tending even  to  the  crest  of  the  ilium.1 

Lobes  so  depressed  are  usually  thin  and  easily  movable,  and  can  be 
grasped  with  the  hand  and  moved  to  and  fro.  If  the  lobe  does  not 
reach  so  far  downward,  it  is  more  rounded  and  blunt  in  shape.  It  is 
not  always  easy  to  demonstrate  its  connection  with  the  liver,  because 
coils  of  intestine  lying  over  the  liver  in  the  furrow  make  palpation  diffi- 
cult, and  cause  a  tympanitic  note  between  the  liver-dulness  and  the 
dulness  of  the  constricted  lobe. 

Confusion  with  tumors  of  other  kinds  can  be  avoided  usually  by 
deep  palpation  or  percussion. 

Gall-bladder.  When  the  gall-bladder  has  a  certain  degree  of 
fulness,  it  may,  according  to  Gerhardt,  be  not  only  felt  in  healthy 
persons,  if  the  stomach  and  bowel  are  empty,  as  a  smooth,  round,  fluc- 
tuating tumor  at  the  lower  border  of  the  liver,  but  be  even  visible  and 
be  outlined  by  percussion.  If  a  line  is  drawn  from  the  right  acromion 
process  to  the  umbilicus,  it  will  bisect  the  gall-bladder  at  a  point  where 
it  passes  over  the  margin  of  the  ribs.  The  fundus  is  situated  below 
the  edge  of  the  liver,  at  about  the  ninth  costal  cartilage,  just  outside 
the  edge  of  the  right  rectus  muscle.  Palpation  is  easy  when,  owing 
to  closure  of  the  cystic  duct,  the  gall-bladder  is  distended  with  bile  or 
with  inflammatory  exudate,  or  enlarged  by  thickening  of  its  walls  or 
by  an  accumulation  of  gallstones.  A  pear-shaped  tumor  is  then  felt 
which,  if  not  adherent  to  the  border  of  the  liver,  is  movable  with  it. 
In  simple  stasis,  hydrops  vesicae  fellese,  and  purulent  inflammation 
the  tumor  is  tense  and  elastic  ;  in  inflammatory  or  carcinomatous 
thickening  of  the  wall,  dense  and  irregular.  Calculi  can  often  be  recog- 
nized by  the  form  or  hardness  or  by  the  sound  made  by  rubbing  them 
together. 

Aspiration.  We  are  warranted  in  determining  the  nature  of  an 
obscure  enlargement  of  the  liver  or  of  the  gall-bladder  by  aspiration. 
In  abscess,  pus;  in  hydatid  disease,  the  characteristic  fluid,  may  be 
withdrawn. 

In  a  case  of  local  enlargement  the  apex  of  the  swelling  should  be 
aspirated.  If  aspiration  is  performed  near  the  upper  border,  the 
needle  should  be  thrust  downward  ;  if  near  the  lower  border,  upward. 
The  left  lobe  should  be  aspirated  with  care,  in  order  that  the  stomach 
be  not  pierced.     (See  Aspiration  in  Diagnosis.) 

Auscultation.  By  auscultation  we  may  detect  a  friction-sound  in 
perihepatitis  ;  a  grating  or  rubbing  when  the  gall-bladder  contains  cal- 
culi if  it  is  palpated  ;  a  continuous  murmur  in  tricuspid  regurgitation. 

Percussion.  The  Size  and  Shape  of  the  Liver.  (See  Plate 
XVI.,  Fig.  1.)  Diminution  in  size  can  only  be  recognized  by  per- 
cussion.    The  normal  extent  of  hepatic  dulness  is  diminished.     This 

1  Musser :  Transactions  Philadelphia  Pathological  Society,  vol.  x. 


DISEASES  OF  LIVER,  SPLEEN  AND  PANCREAS.  869 

is  usually  more  marked  in  the  anterior  and  lateral  regions.  The 
diminution  is  due  to  simple  or  acute  yellow  atrophy  of  the  liver  or 
cirrhosis.  It  must  not  be  confounded  with  the  apparent  diminution 
that  takes  place  in  emphysema,  or  that  which  occurs  from  distention 
of  the  bowels  with  flatus,  as  in  peritonitis.  Absence  of  hepatic  dulness 
may  occur  when  there  is  gas  in  the  peritoneal  cavity.  When  there  is 
considerable  distention  of  the  intestines  by  gas,  the  anterior  and  lateral 
hepatic  areas  may  be  tympanitic. 

Enlargement  of  the  liver  is  determined  by  inspection,  palpation,  and 
percussion.  By  percussion  the  size  of  the  liver  is  accurately  made  out. 
Any  marked  increase  of  hepatic  dulness  beyond  the  normal  limits  (see 
p.  861)  usually  means  increase  in  size  of  the  liver.  Both  superficial 
and  deep  percussion  must  be  performed.  Palpatory  percussion  is  of 
great  advantage. 

The  upper  border  is  determined  by  percussing  from  a  point  above 
the  liver-area  toward  the  liver — anteriorly  from  the  third  interspace 
downward,  laterally  from  the  fourth,  and  posteriorly  from  the  angle  of 
the  scapula.  In  health  the  upper  border  of  the  liver  is  found  at  the 
fifth  interspace  ;  in  the  axilla,  at  the  sixth  ;  and  in  the  back,  at  the 
ninth  interspace.  Thence  downward  hepatic  dulness  should  continue 
to  the  margin  of  the  ribs.  It  falls  short  of  this  position  by  at  least 
an  inch  in  the  aged,  and  in  deep-chested  persons  it  may  not  be  more 
than  two  inches  in  width  in  front.  The  width  of  the  liver-clulness  in 
the  right  mid-clavicular  line  is  about  four  inches,  in  the  mid-axillary 
line  six  inches,  and  in  the  mid-scapular  line  three  inches. 

Extent  and  direction  of  enlargement.  The  entire  liver  may  be  en- 
larged and  of  normal  shape,  or  its  outline  may  be  irregular  ;  again,  the 
enlargement  may  be  limited  to  one  lobe.  Hence,  the  area  of  dulness 
may  be  increased  in  all  directions,  or  the  increase  may  be  above  or 
below  the  normal  limit,  if  the  normal  shape  is  preserved.  By  percus- 
sion it  may  be  found  that  the  enlargement  is  regular  from  increase  in 
size  upward  or  downward,  or  increase  in  the  area  of  dulness  in  both 
directions.  On  the  other  hand,  if  the  enlargement  is  irregular,  the 
liver-dulness  may  begin  higher  in  the  anterior  region  than  in  the  axil- 
lary region,  or  may  extend  beyond  the  margin  of  the  ribs  in  a  limited 
area.  When  the  enlargement  is  limited  to  the  left  lobe  it  is  revealed 
by  increase  in  the  dulness  from  the  xiphoid  cartilage  downward  as  far 
as  the  umbilicus.  The  entire  middle  region  to  the  navel  may  be  filled 
up  by  the  enlarged  liver. 

Uniform  enlargement  of  the  liver  is  due  to  congestion,  hypertrophic  cir- 
rhosis, fatty  degeneration,  amyloid  disease,  leukaemia,  cancer,  and  some- 
times to  hydatid  disease  and  abscess.  Enlargement  of  one  lobe  of  the  liver 
is  due  to  hydatid  disease,  to  abscess,  or  to  cancer,  in  nearly  all  cases. 
Either  the  right  or  the  left  lobe  may  be  the  seat  of  such  enlargement. 

Enlargement  in  one  direction  is  due  also  to  the  three  conditions  just 
indicated.  Although  in  abscess  or  hydatid  disease  enlargement  down- 
ward is  the  more  common  one,  it  may  be  directly  upward,  the  lower 
border  of  the  liver  occupying  the  normal  position.  When  enlargement 
of  the  liver  extends  upward  it  is  due  to  a  cyst,  or  an  abscess  in  the 
convex  surface  of  the  right  lobe. 


870  SPECIAL  DIAGNOSIS. 

Irregularity  in  the  shape  of  the  liver-diiliiess  occurs  in  cancer,  in 
abscess,  and  hydatid  disease.  Notwithstanding  the  apparent  irregu- 
larity, enlargements  of  the  liver  conform  to  its  usual  outline,  with  but 
moderate  variations,  and  always  occupy  the  normal  site  of  the  organ. 

Diagnosis.  Enlargement  of  the  liver  must  be  distinguished  from 
enlargement  of  organs  in  contiguity  with  the  liver,  and  from  structures 
usually  containing  air,  which  have  become  solid  or  non-resonant.  The 
enlargement  must,  therefore,  be  distinguished  from  pleural  effusion, 
from  disease  of  the  lungs  which  causes  dulness  on  percussion,  or  from 
disease  of  the  abdominal  organs  causing  increased  dulness  near  the 
hepatic  region.  Hence,  in  renal  tumors,  in  tumors  of  the  large  intes- 
tine or  stomach,  in  ovarian  tumors,  in  tumors  due  to  accumulation  of 
feces,  the  physical  signs  on  percussion  may  simulate  enlargement  of 
the  liver. 

Simulated  Enlargement.  It  is  well  to  bear  in  mind  the  conditions 
which  simulate  enlargement  of  the  liver.     Of  these  we  have  : 

1.  Congenital  malformation  :  the  liver  may  be  of  abnormal  shape, 
on  account  of  which  the  area  of  dulness  will  be  increased  in  a  particu- 
lar direction.  It  may  be  quadrangular  or  rounded.  The  liver  may 
be  found  in  the  right  pleural  sac  in  congenital  diaphragmatic  hernia. 
The  increase  of  dulness  upward  will  simulate  enlargement  of  the  liver. 
Congenital  malformations  may  be  suspected  in  the  absence  of  any 
symptoms  of  hepatic  disease,  or  of  conditions  which  may  cause  other 
forms  of  spurious  enlargement.  Moreover,  the  increased  dulness  will 
have  existed  from  early  life. 

2.  In  rhaehitis,  on  account  of  the  malformation  of  the  chest,  the 
position  of  the  liver  may  be  such  that  its  area  will  be  increased.  For 
the  same  reason  the  liver  may  be  felt  below  the  margin  of  the  ribs. 

3.  Disease  of  the  spinal  column  causes  dislocation,  on  account  of 
which  the  liver  may  apparently  be  increased  in  size. 

4.  Enlargement  of  the  liver  must  be  distinguished  from  pleural 
effusions.  This  is  sometimes  difficult.  The  symptoms  of  the  pulmo- 
nary affection  must  be  considered.  The  general  conditions  which 
cause  hydrothorax  must  be  borne  in  mind.  The  difficulty  in  distin- 
guishing the  two  arises  because  the  dulness  of  each  is  continuous.  In 
pleural  effusion,  however,  there  is  uniform  bulging  of  the  affected  side. 
The  liver  is  not  movable,  the  chest-expansion  is  lessened.  The  upper 
border  of  dulness  of  the  fluid  may  be  movable  if  the  effusion  is  not 
large,  while  the  line  of  dulness  is  S-shapecl — that  is,  high  behind  and 
high  in  front.  If  the  effusion  is  large,  the  upper  limit  of  dulness  is 
horizontal.  The  upper  limit  of  dulness  in  the  pleural  effusion  changes 
its  position  in  many  instances.  In  enlargement  of  the  liver  the  lower 
ribs  are  often  everted,  but  in  pleural  effusion  a  depression  may  be  seen 
between  the  lower  margin  of  the  ribs  and  the  upper  surface  of  the 
liver,  if  the  latter  is  dislocated  by  pressure  of  the  fluid.  Sometimes 
enlargements  of  the  liver  give  rise  to  secondary  pleural  effusion,  so 
that  too  often,  after  finding  pleural  effusion,  the  size  of  the  liver  is  not 
estimated. 

5.  Pericardial  effusion  and  dilated  heart  are  said  to  simulate  enlarge- 
ment of  the  liver.     The  history  of  the  case,  the  origin  and  mode  of 


DISEASES  OF  LIVER,  SPLEEN  AND  PANCREAS.  871 

development  of  the  symptoms,  the  physical  signs  of  cardiac  disease, 
point  to  its  trne  nature. 

6.  Enlargement  of  the  liver  may  be  due  apparently  to  subdiaphrag- 
matic abscess.  The  history  of  the  case  is  generally  essential  to  a  diag- 
nosis. The  accumulation  between  the  liver  and  diaphragm  causes  the 
latter  to  be  pushed  downward.  It  is  very  difficult  to  distinguish  the 
spurious  from  the  false  enlargement  in  these  instances.  Aspiration 
may  help  in  the  diagnosis. 

7.  Abnormal  Condition  of  the  Abdominal  Parietes.  Increased  ten- 
sion or  spasm  of  the  recti  muscles,  giving  rise  to  phantom  tumors  of 
the  abdomen,  simulate  enlargement  of  the  liver.  They  occur  in  young 
girls,  and  are  associated  with  gastro-intestinal  catarrh  and  symptoms 
of  hysteria.  Anaesthesia  must  often  be  employed  to  disperse  the 
swelling. 

8.  Tight  Lacing.  This  may  displace  the  liver  upward  or  downward, 
according  to  the  direction  of  the  pressure.  It  may  also,  by  exerting 
lateral  compression,  bring  more  of  the  liver  into  contact  with  the  ante- 
rior abdominal  wall.  And  finally,  if  the  constriction  has  been  by  a 
strap  or  tight  cord,  a  portion  of  the  liver  may  be  more  or  less  detached 
and  appear  as  a  movable  tumor. 

9.  Some  enlargements  of  the  abdominal  contents  cause  spurious  en- 
largement of  the  liver.  In  the  same  way  increased  abdominal  pressure 
(ascites,  tympanites,  etc.)  causes  the  liver  to  rise  higher  than  normal. 

a.  The  accumulation  of  feces  in  the  colon.  This  causes  continuance 
of  liver-dulness  downward,  on  account  of  which  it  may  be  thought 
that  the  patient  has  liver  disease.     A  purgative  must  be  given. 

6.  An  ovarian  cyst. 

c.  The  presence  of  ascites.  Exclusion  of  the  latter  is  sometimes 
difficult,  because  the  ascites  may  be  loculated  and  situated  in  the  hepatic 
region.  It  may  give  rise  to  symptoms  of  hepatic  enlargement.  Prob- 
ably aspiration  alone  can  establish  the  diagnosis.  Ordinary  ascites 
should  be  easily  distinguished  by  the  physical  signs  and  the  result  of 
exploratory  puncture. 

d.  Tumors  of  the  omentum,  chiefly  tuberculous,  may  occupy  such 
relation  to  the  liver  as  to  increase  the  dulness  downward.  The  history, 
the  occurrence  of  the  omental  tumor,  with  symptoms  of  tuberculosis, 
may  aid  in  determining  the  true  condition. 

e.  In  tumors  of  the  kidney,  which  simulate  enlarged  liver,  it  is 
found  that  the  edge  of  the  liver  cannot  well  be  felt,  but  Murchison 
thinks  the  fingers  can  usually  be  inserted  between  the  ribs  and  the 
upper  part  of  the  renal  tumor.  The  renal  tumor,  however,  is  not 
fixed.  It  is  rounded  on  every  side  ;  it  has  the  shape  of  a  kidney. 
It  may  be  associated  with  changes  in  the  urine. 

/.  Enlargements  of  the  liver  must  be  distinguished  from  pancreatic 
cyst,  or  effusion  in  the  lesser  peritoneal  cavity.  This  can  usually  be 
accomplished  with  ease,  except  in  hydatid  disease  of  the  left  lobe  hear 
the  suspensory  ligament.  In  effusion  in  the  lesser  peritoneal  cavity 
the  tumor  occupies  the  left  upper  quadrant,  and  may  extend  as  low  as 
the  transverse  umbilical  line.  It  causes  dislocation  of  the  heart,  so 
that  the  apex  is  as  high  as  the  third  interspace,  and  beyond  the  mid- 


872  SPECIAL  DIAGNOSIS. 

clavicular  line.  It  is  accompanied  by  an  increase  in  the  dulness  pos- 
teriorly, so  that  the  upper  limit  may  extend  to  the  angle  of  the  left 
scapula.     Puncture  may  furnish  the  necessary  information. 

The  presence  or  absence  of  pain  may  sometimes  furnish  a  clue  to 
the  nature  of  the  enlargement  of  the  liver.  Murchison  considers  this 
a  reliable  distinction.  Painless  enlargements  of  the  liver  are  due  to 
passive  congestion,  to  hydatid  disease,  to  fatty  and  amyloid  disease  of 
the  liver.  Painful  enlargements  of  the  liver  are  seen  in  abscess,  cancer, 
and  syphilitic  disease,  with  perihepatitis. 

In  children  the  lower  border  of  the  liver  is  normally  lower  than  in 
adults,  because  the  liver  is  itself  proportionately  larger.  For  the  same 
reason  the  upper  border  is  at  a  higher  level. 

Enlargement  of  the  Liver.  Enlargement  of  the  liver  occurs 
in  the  congestions  ;  the  acute  inflammations,  except  acute  yellow  atrophy  ; 
the  chronic  inflammations,  except  cirrhosis ;  the  degenerations,  the 
morbid  growths,  and  in  hydatid  disease.  The  physical  signs  have  been 
considered  seriatim  in  the  pages  immediately  preceding.  It  must  be 
remembered  that  the  disease  may  occur  without  great  changes  in  the 
size  of  the  liver.  The  congestions  have  been  considered  in  the  previous 
pages. 

The  remaining  diseases  of  the  liver  will  be  considered  in  accordance 
with  their  pathological  classification.  After  the  congestions,  we  have 
the  inflammations,  then  the  morbid  growths,  then  the  degenerations, 
and,  finally,  hydatid  disease. 

Abscess  of  the  Liver. 

Two  forms  are  seen  :  tropical  abscess,  so-called,  in  which  one  or  two 
abscesses  are  found  ;  and  multiple  abscesses,  found  throughout  the 
liver-structure.  The  single  or  solitary  abscess  usually  occurs  in  the 
course  of  dysentery,  and,  in  all  probability,  in  the  amoebic  form  only. 
A  single  abscess  may  also  be  due  to  traumatism,  particularly  in  chil- 
dren. Multiple  abscesses  occur  secondarily  to  inflammation  somewhere 
in  the  portal  area.  Inflammation  and  abscess  about  the  rectum,  in- 
flammation of  the  appendix,  ulceration  anywhere  in  the  gastrointesti- 
nal tract  may  be  followed  by  multiple  hepatic  abscesses.  The  abscesses, 
however,  do  not  occur  directly  by  means  of  emboli,  as  in  the  case  of 
amoebic  abscess,  but  after  inflammation  of  the  portal  vein  or  suppura- 
tive pylephlebitis.  Multiple  abscesses  of  the  liver  also  follow  obstruc- 
tion and  infectious  inflammation  of  the  biliary  passages  (suppurative 
cholangitis). 

Tropical  abscess  or  amoebic  abscess  varies  in  its  clinical  course.  In 
a  typical  case  the  clinical  picture  is  that  of  the  general  symptoms  of 
suppuration  setting  in  in  the  course  of,  or  soon  after,  an  exacerbation 
of  amoebic  dysentery,  with  local  symptoms  referred  to  the  liver. 

Symptoms.  The  general  symptoms  are  those  of  intermittent  fever, 
paroxysms  of  which  may  occur  daily  or  only  every  second  day,  attended 
by  chill,  fever,  and  sweat.     The  fever  may  be  remittent  or  continuous. 

The  complexion  in  tropical  abscess  of  the  liver  is  peculiar,  as  all 
writers  upon  tropical  disease  agree.     The  skin  is  sallow,  1  he  complex- 


PLATE    XL. 


FIG.    1. 


Oedema 

Tender- 
ness 


w 


V5 


A\ 


Abscess  of  the  Liver. 

FIG.    2. 


Hypertrophic  Cirrhosis  of  the  Liver    with   Enlargement 
of  the    Spleen. 


DISEASES  OF  LIVER,  SPLEEN  AND  PANCREAS. 


873 


ion  muddy,  the  face  pale.     Through  this  a  slightly  icteroid  tint  may 
be  seen,  and  the  conjunctivae  are  bile-tinged.     Distinct  jaundice  is  rare. 

The  local  symptoms.  Pain  in  the  region  of  the  liver  ;  this  may  be 
referred  to  the  region  of  the  right  or  left  lobe.  It  may  be  seated  hi 
the  fifth  or  sixth  interspaces  anteriorly,  or  behind  at  the  ninth  and 
tenth  ribs.  There  may  be  pain  in  the  right  shoulder.  The  pain  may 
be  paroxysmal,  or  it  may  be  intense  and  persistent. 

The  patient  complains  of  weight  and  fulness  in  the  region  of  the 
liver  ;  the  enlargement  causes  some  dyspnoea,  and  may  cause  cough 
and  some  vomiting. 

Fig.  201. 


Intermittent  fever  in  abscess  of  the  liver. 


Physical  Examination.  (Plate  XL.,  Fig.  1.)  The  liver  is  enlarged. 
The  enlargement  may  be  uniform  ;  if  the  abscess  is  central,  the  entire 
organ  takes  part  in  the  swelling  ;  on  the  other  hand,  it  may  be  an 
enlargement  upward  in  the  anterior,  the  axillary,  or  the  posterior  region. 
If  the  convex  surface  of  the  right  lobe  of  the  liver  is  affected,  the  en- 
largement is  usually  upward.  If  the  lower  portion  of  the  right  lobe  is 
affected,  enlargement  extends  downward,  and  the  lobe  of  the  liver  can 
readily  be  detected  on  palpation.  The  mass  may  extend  outward  from 
the  liver-edge.  At  first  it  is  hard  ;  ultimately  it  softens  and  may  fluctu- 
ate. If  the  abscess  is  limited  to  the  left  lobe  of  the  liver,  and  is  situ- 
ated about  the  suspensory  ligament,  the  enlargement  may  be  seen 
below  the  xiphoid  cartilage.  It  may  extend  to  the  umbilicus  and 
project  forward.  Sometimes  it  may  be  so  large  as  to  cause  eversion  of 
the  ribs  of  each  side,  and  render  the  entire  epigastrium  unusually 


874  SPECIAL  DIAGNOSIS. 

prominent.  The  surface  may  become  reddened.  Over  the  tumor 
there  is  tenderness  on  palpation,  and  there  may  be,  as  in  other  situa- 
tions, fluctuation.     GEdema  of  the  surface  is  frequently  seen. 

The  irregular  enlargement  above  mentioned  is  made  out  by  percus- 
sion. The  enlargement  may  be  difficult  to  ascertain,  on  account  of 
secondary  pleural  effusion,  or  secondary  pleural  inflammation,  with  the 
development  of  a  hepato-pulmonary  fistula,  causing  dulness  posteriorly. 
If  the  case  has  been  seen  from  the  first,  a  friction-sound  may  be  heard, 
followed  by  the  physical  signs  of  effusion. 

The  appetite  is  lost,  and  nausea  at  the  sight  of  food  is  pronounced. 
The  condition  of  the  bowels  may  vary  with  the  state  of  the  intestinal 
tract  at  the  time  of  the  hepatic  complication.  The  dysenteric  symp- 
toms may  subside  entirely  or  they  may  continue.  Often  there  is  only 
constipation,  with  the  passage  of  mucus  and  hardened  feces.  In  an 
obscure  case  the  study  of  the  stools  should  be  made.  The  detection 
of  amoebae  in  the  mucus  or  in  the  feces  may  point  to  the  true  conclusion. 

Atypical  eases  are  characterized  by  the  absence  of  general  symptoms, 
or  the  absence  of  local  signs.  Fever  may  be  absent  entirely,  exhaus- 
tion alone  being  present,  which  could  probably  be  ascribed  to  the  pre- 
vious dysentery.  Pronounced  anaemia  due  to  the  dysentery  may  be 
associated,  and  even  be  the  most  marked  symptom,  as  well  as  inflam- 
mation of  the  joints,  or  neuritis.  In  a  case  under  my  care  the  only 
symptom  for  a  long  time,  with  the  exception  of  anaemia  and  loss  of 
appetite,  was  severe  pain  in  the  sixth  interspace.  In  other  instances 
there  are  no  liver-symptoms  whatsoever.  General  symptoms  of  infec- 
tion, or  an  irregular,  or  even  a  continued  fever,  the  cause  of  which 
cannot  be  ascertained,  may  alone  be  present.  In  one  of  my  cases 
there  was  moderate  continued  fever,  with  loss  of  appetite  and  dyspeptic 
symptoms.  There  was  no  diarrhoea.  ]STo  cause  could  be  given  for 
the  fever,  although  it  was  noted  that  there  was  slight  enlargement  of 
the  liver.  The  patient  slipped  out  of  the  ward  and  went  down  to  the 
yard  to  smoke  ;  on  his  return  he  was  seized  with  an  intestinal  hemor- 
rhage which  could  not  be  checked  and  which  resulted  fatally.  At  the 
autopsy  a  large  abscess  of  the  liver  was  found,  and  there  was  ulceration 
of  the  rectum  from  which  the  intestinal  hemorrhage  took  place. 

The  diagnosis  is  usually  not  difficult  in  the  typical  cases.  Under 
all  circumstances  attention  must  be  paid  to  the  facts  bearing  upon  the 
etiology  and  the  association  of  general  and  local  symptoms.  If  the 
general  symptoms  of  suppuration  are  present,  malarial  abscess  may  be 
mistaken  for  an  intermittent  fever.  The  result  of  an  examination  of 
the  blood  and  of  treatment  by  quinine  would  establish  a  diagnosis  of 
malarial  fever.  It  is  difficult  sometimes  to  determine  whether  the 
abscess  is  in  the  abdominal  wall  or  in  the  liver  proper,  or  whether  it 
is  situated  beneath  the  diaphragm.  If  the  liver  is  movable  with  respi- 
ration, the  two  former  conditions  may  be  excluded.  An  abscess  in  the 
abdominal  wall  is  not  influenced  by  respiration,  and  in  subdiaphrag- 
matic abscess  the  movement  is  impaired.  Suppuration  of  a  hydatid  cyst 
cannot  be  distinguished  unless  it  has  been  known  beforehand  that  a 
simple  hydatid  was  present  in  the  liver.  Under  such  circumstances, 
if  suppuration  occurs,  it  is  likely  to  be  confined  to  the  cyst.     Abscess 


DISEASES  OF  LIVER,  SPLEEN  AND  PANCREAS.  875 

of  the  liver  must  be  distinguished  from  gallstones,  attended  by  inter- 
mitting fever  without  suppuration.  While  the  distinction  is  difficult 
in  many  cases,  yet  the  history  of  the  case,  the  association  of  jaundice 
which  deepens  after  each  paroxysm,  and  the  good  general  nutrition  of 
the  patient  point  to  gallstones.  Abscess  of  the  liver  is  of  shorter  dura- 
tion than  cholelithiasis,  and  its  primary  cause  can  usually  be  ascer- 
tained by  examination  of  the  rectum  or  the  discovery  of  suppuration 
in  other  parts  of  the  body. 

Exploratory  puncture  must  be  employed  in  many  cases,  and  it  can 
usually  be  done  with  safety.  Puncture  must  be  made  over  the  region 
in  which  the  enlargement  is  greatest,  or  at  which  the  swelling  is  most 
prominent.  In  abscess  secondary  to  dysentery  a  brownish-colored 
pus  will  be  withdrawn,  resembling  anchovy  sauce.  It  may  be  of  a 
peculiar  odor,  and,  on  examination,  amoeba?  common  to  this  form  of 
dysentery  may  be  found.  If  there  is  no  point  of  election,  the  needle 
may  be  introduced  in  the  lowest  interspace  in  the  anterior  axillary,  or 
the  seventh  interspace  in  the  mid-axillary  line.  A  fairly  large-sized 
aspirator  should  be  used.  Suppuration  may  be  present,  and  yet  not 
be  reached  by  aspiration. 

Suppurative  Pylephlebitis.  Abscess  of  the  liver  may  be  due 
to  pycemia.  It  may  be  a  part  of  general  pysemia,  or  of  portal  pyaemia. 
Parasites  and  foreign  bodies,  as  well  as  gallstones,  may  excite  an  ab- 
scess. The  echinococcus  cyst  may  suppurate,  or  round-worms  may 
penetrate  to  the  liver  and  cause  suppuration. 

The  symptoms  of  suppurative  pylephlebitis  and  of  pywmic  abscess  are 
general  and  local.  Jaundice  is  more  common  than  in  solitary  abscess, 
and  there  are  greater  pain  and  tenderness  over  the  liver,  which  is  uni- 
formly enlarged  and  tender.  With  the  enlargement  of  the  liver  and 
jaundice  we  have  the  symptoms  of  pypemia.  They  are  not  peculiar. 
Sometimes  the  fever  is  distinctly  intermitting,  or  it  may  be  irregular 
and  septic  in  character. 

The  symptoms  of  solitary  abscess  of  the  liver,  as  has  been  previously 
stated,  may  be  obscure,  and  attention  be  called  to  the  liver  only  when 
symptoms  arise  due  to  a  rupture  into  the  neighboring  organs.  If  per- 
foration takes  place  into  the  peritoneum,  it  is  not  likely  that  the  cause 
can  be  established  during  life.  The  perforation  frequently  extends 
through  the  diaphragm  to  the  pleura,  and  then  to  the  lung.  An  em- 
pyema may  be  set  up,  the  true  source  of  which  may  not  be  ascertained 
unless  the  pus  is  examined.  The  physical  signs  are  those  of  empyema 
— dulness  or  diminished  resonance,  absence  of  fremitus  and  vocal  reso- 
nance, diminished  breath-sounds,  and  impaired  movement,  together 
with  symptoms  of  cough  and  dyspnoea.  When  the  lung  is  infected 
the  physical  signs  may  resemble  those  of  consolidation.  We  find  dul- 
ness, bronchial  breathing,  and  increased  tactile  fremitus.  A  harassing, 
convulsive  cough  occurs,  and,  sooner  or  later,  expectoration  of  a  red- 
dish-brown, brickdust-colored  material  which  resembles  anchovy  sauce. 
This  characteristic  expectoration  is  decisive.  It  contains  amoebre,  and, 
in  addition  to  blood-pigment  and  corpuscles,  orange-red  crystals  of 
hsematoidin,  cholesterin-plates,  and  leucin  and  ty  rosin.  When  the 
abscess  perforates  into  the  stomach  or  bowel  the  discharge  from  either 


876  SPECIAL  DIAGNOSIS. 

cavity  may  be  of  the  above-mentioned  nature.     Perforation  into  the 
pericardium  is  usually  followed  by  immediate  death. 

Cirrhosis  of  the  Liver. 

A  diffuse  interstitial  inflammation  of  the  liver,  frequently  with  atro- 
phy of  the  organ,  is  caused,  in  the  large  majority  of  cases,  by  irritants 
which  enter  the  portal  circulation  through  the  stomach.  Of  the  irri- 
tants alcohol  is  the  most  common,  and  particularly  the  stronger  liquors, 
as  gin  and  whiskey.  Other  irritants,  as  spices  used  to  excess,  may 
likewise  cause  the  diffuse  inflammation.  Cirrhosis  of  the  liver  may, 
however,  be  a  sequel  to  the  infectious  diseases,  notably  scarlatina,  and 
may  be  incited  by  malaria.  The  infectious  forms  of  cirrhosis  usually 
lead  to  atrophy  of  the  liver. 

Another  form  is  due  to  obstruction  of  the  bile-ducts,  with  secondary 
overgrowth  of  the  connective  tissue.  It  is  known  as  hypertrophic  or 
biliary  cirrhosis.  In  addition,  cirrhosis  of  the  liver  may  arise  in  the 
course  of  syphilis  ;  the  histological  characteristics  are  different  from 
those  of  true  cirrhosis.  A  secondary  cirrhosis  of  the  liver  arises  in 
the  course  of  passive  congestion  of  that  organ,  producing  the  so-called 
nutmeg-liver. 

Cirrhosis  of  the  liver  of  the  atrophic  form,  due  to  alcohol,  presents 
various  clinical  features.  In  the  first  place,  it  may  exist  without 
causing  any  symptoms  whatever  during  life.  It  may  be  found  after 
death  from  other  causes,  or  it  may  not  present  symptoms  until  an  acci- 
dent occurs  in  the  course  of  the  disease,  as  hemorrhage  from  some  por- 
tion of  the  collateral  circulation.  In  both  cases  the  symptoms  are 
absent  because  the  collateral  circulation  is  complete.  If  this  is  incom- 
plete, however,  grave  symptoms,  local  and  general,  ensue. 

Before  detailing  them  it  may  be  well  to  state  that  the  occurrence  of 
one  symptom,  which  we  have  termed  accidental,  may  lead  to  the  infer- 
ence that  cirrhosis  of  the  liver  is  present,  particularly  if  the  patient 
has  been  an  alcoholic.  This  symptom  is  hemorrhage.  It  may  be  of 
the  stomach,  causing  death  at  once  or  after  repeated  hemorrhages ;  it 
may  also  take  place  from  the  intestine. 

The  Symptoms  of  Cirrhosis.  The  symptoms  are  general,  due  to  in- 
terference with  the  nutrition  of  the  patient  ;  and  local,  their  extent 
depending  upon  the  degree  of  obstruction  to  the  portal  circulation. 
General  symptoms  rarely  occur  unless  the  local  symptoms  are  present, 
as  the  latter  cause  malnutrition  and  mal-assimilation  from  interference 
with  the  gastro-intestinal  digestion. 

The  symptoms  have  been  divided  into  those  of  the  first  stage,  or 
stage  of  enlargement,  and  those  of  the  second  stage,  or  contraction. 
Tiie  so-called  first  stage  is  not  always  observed. 

During  the  first  stage  the  symptoms  are  those  of  gastritis,  with  en- 
largement of  the  liver.  The  gastric  symptoms  are  :  morning  retching 
or  vomiting,  with  discharge  of  mucus,  associated  with  other  symptoms 
of  gastric  catarrh,  as  loss  of  appetite,  nausea,  tenderness  in  the  epigas- 
trium, eructations,  and  constipation,  with  loss  of  flesh  and  strength. 
The  liver  is  enlarged,  but  the  outline  is  regular. 


PLATE    XLI. 


,<^ 


Cirrhosis  of  the  Liver  with  Ascites. 


DISEASES  OF  LIVER,  SPLEEN  AND  PANCREAS.  877 

During  the  second  stage  more  severe  symptoms  arise,  due  to  obstruc- 
tion of  the  portal  capillaries.  The  abdomen  becomes  distended  and 
a  sensation  of  weight  and  pressure  is  complained  of.  On  examination 
ascites  is  detected.  This  may  be  enormous,  causing  monstrous  disten- 
tion, with  pouting  of  the  umbilicus.  The  spleen  is  found  to  be  en- 
larged, extending  over  twice  or  three  times  the  normal  area  of  per- 
cussion. If  ascites  does  not  interfere,  the  edge  of  the  spleen  can  be 
readily  made  out  The  portal  obstruction  causes  secondary  gastro- 
intestinal catarrh,  if  it  was  not  already  present,  on  account  of  the  alco- 
holism. Although  constipation  is  usually  present,  there  may  be  per- 
sistent diarrhcea,  usually  lienteric  and  occurring  in  the  morning  only. 
Hemorrhages  may  take  place  from  the  gastro-intestinal  tract  at  any 
time,  either  from  the  stomach  or  the  intestine.  Not  infrequently  they 
occur  from  the  oesophagus,  due  to  varicosity  of  the  veins  at  the  junc- 
tion of  the  oesophagus  and  the  cardiac  end  of  the  stomach.  Hemor- 
rhoids are  always  present  and  may  bleed  at  each  stool.  Jaundice  is 
not  the  rule,  and,  if  present,  is  usually  light  and  due  to  the  duodenal 
catarrh.  The  skin  has  a  yellowish  tinge  or  only  a  grayish  earthen 
color. 

Physical  Examination.  (Plate  XL.,  Fig.  2,  and  Plate  XLI.)  This 
may  be  rendered  difficult  before  paracentesis  is  performed  by  the  exten- 
sive ascites.  The  enlarged  liver  of  the  first  stage  will  be  found  to  have 
undergone  contraction,  although  diminution  in  the  area  of  dulness  is 
not  by  any  means  as  absolutely  confirmative  of  contraction  as  the  oppo- 
site condition  is  of  hypertrophy.  Percussion  should  be  performed  seve- 
ral times,  because  the  distended  intestinal  coils  may  affect  the  results. 

AVith  the  distention  of  the  abdomen  enlargement  of  the  superficial 
veins  is  also  observed.  This  may  be  very  pronounced,  particularlv 
about  the  umbilicus.  The  enlarged,  swollen  mass  of  veins  in  this  situ- 
ation has  been  called,  from  its  appearance,  the  caput  Medusce. 

The  general  symptoms  of  cirrhosis,  and  particularly  the  symptoms 
of  the  later  stages,  are  striking  and  diagnostic.  The  nutrition  is  much 
impaired.  The  patient,  who,  in  the  large  majority  of  cases,  had  been 
corpulent,  becomes  emaciated.  The  skin  changes  in  color  and  becomes 
of  an  earthy-gray  or  dirty  sallow  hue.  The  capillary  venules  of  the 
face  are  dilated ;  the  distended  capillaries  on  the  nose  are  distinct. 
Later,  ecchymoses  may  occur  in  the  skin,  and  hemorrhages  take  place 
from  the  mucous  membrane  and  into  the  retina.  Debility  ensues  ; 
oedema  of  the  ankles  is  almost  sure  to  occur,  and  sometimes  general 
anasarca  may  take  place.  It  is  extremely  rare  to  have  fever  unless 
complications  occur.  The  pulse  is  small  and  becomes  more  rapid  than 
normal ;  the  heart-sounds  grow  weaker.  The  skin  may  be  the  seat  of 
eruptions,  and  chronic  skin  diseases  of  various  kinds  develop. 

The  urine  throughout  the  disease  presents  no  characteristics  ;  as 
ascites  develops,  it  becomes  scanty  and  dark,  and  loaded  with  urates 
and  uric  acid.  In  rare  instances  it  may  contain  sugar,  and,  if  the  uric 
acid  is  in  excess,  albumin. 

Collateral  Circulation.  The  collateral  circulation  that  develops  in 
order  that  the  portal  blood  may  reach  the  right  heart  takes  place  in 
various  ways.     First,  communication  may  be  formed  between  the  veins 


878  SPECIAL  DIAGNOSIS. 

of  the  mesentery  and  those  of  the  posterior  abdominal  walls  ;  second 
between  the  coronary  veins  of  the  stomach  and  the  veins  of  Glisson's 
capsule  and  the  phrenic  veins ;  third,  between  the  hemorrhoidal  and 
the  inferior  mesenteric  veins  ;  fourth,  between  enlarged  veins  occupy- 
ing the  position  of  the  obliterated  umbilical  vein  in  the  ligamentum 
teres,  and  the  epigastric  and  mammary  vein. 

In  the  study  of  a  case  of  cirrhosis  of  the  liver  a  judgment  as  to  its 
nature  may  be,  in  a  measure,  confirmed  by  the  presence  of  other  phe- 
nomena due  to  the  same  cause.  Very  frequently  we  have,  at  the  same 
time,  cirrhosis  of  the  kidneys  and  sclerosis  of  the  arteries,  with  second- 
ary atheroma,  both  of  which  have  led  to  hypertrophy  of  the  heart. 
Striimpell  refers  to  the  association  of  cirrhosis  and  chronic  tubercular 
peritonitis.  He  thinks  the  former  is  the  primary  lesion  which  predis- 
poses to  the  development  of  the  latter.  The  course  of  the  disease  is 
prolonged. 

The  duration  cannot  be  determined  accurately,  as  the  onset  is  usually 
insidious.  After  the  ascites  appears  the  duration  may  vary  from  six 
to  eighteen  months.  Of  course,  this  depends  largely  upon  the  com- 
pleteness of  the  compensatory  circulation.  Death  usually  occurs  from 
intercurrent  disease  or  progressive  exhaustion.  In  not  a  few  cases 
cerebral  symptoms  occur.  In  addition  to  the  cirrhotic  cachexia,  the 
sudden  occurrence  of  coma  and  convulsions,  preceded  by  delirium, 
may  ensue  ;  the  cause  of  this  is  not  fully  known.  It  must  be  borne 
in  mind  that  the  occurrence  of  these  symptoms  in  an  alcoholic  subject 
may  be  due  to  a  cirrhosis,  the  presence  of  which  had  not  been  sus- 
pected during  life. 

Diagnosis.  The  diagnosis  is  usually  not  difficult  if  the  complete 
picture  of  the  case  is  presented.  It  cannot  be  established  positively 
without  definite  knowledge  of  the  cause.  If  the  patient  comes  under 
observation  after  ascites  has  developed,  the  diagnosis  is  more  difficult. 
It  must,  in  the  majority  of  cases,  be  based  upon  exclusion  of  heart, 
lung,  and  kidney  disease.  A  history  of  alcoholism  and  the  presence 
of  other  symptoms  of  liver  disease  point  to  the  hepatic  origin  of  ascites. 
Ascites  may  be  due  to  other  causes  within  the  abdomen,  notably  chronic 
peritonitis,  exclusion  of  which  is  sometimes  difficult.  The  general  ten- 
derness, the  less  marked  distention  of  the  abdomen,  and  the  absence 
of  enlargement  of  the  spleen  point  to  peritonitis.  The  fatty  cirrhotic 
liver  may  present  symptoms  similar  to  those  of  the  atrophic  form, 
except  that  it  is  enlarged. 

Hypertrophic  cirrhosis,  or  so-called  biliary  cirrhosis,  presents  a 
somewhat  different  picture.  In  the  first  place,  the  cause  is  different. 
There  is  a  history  of  gallstones,  or  obstruction  of  the  duct  from  other 
causes.  The  liver  is  uniformly  enlarged,  and  the  surface  is  smooth 
and  strikingly  indurated.  There  are  weakness  and  loss  of  appetite. 
Jaundice  ensues  very  early,  or  may  be  the  first  symptom.  It  increases 
and  persists  throughout  the  course  of  the  disease.  Ascites  is  very  slight 
or  absent  altogether.  The  enlargement  and  jaundice  may  continue  for 
months  or  even  years  without  the  development  of  grave  symptoms. 

Fever  may,  however,  set  in  at  any  time,  being  in  all  probability  due 
to  the  biliary  obstruction.     It  is  continuous  ;   the  temperature  rises 


DISEASES  OF  LIVER,  SPLEEN  AND  PANCREAS.  879 

to  from  102°  to  104°  ;  the  tongue  becomes  dry  and  brown,  the  pulse 
rapid.  All  the  symptoms  of  febrile  jaundice  ensue.  The  patient  may 
be  seized  with  convulsions  in  the  course  of  the  disease,  followed  by 
coma  and  death.  Most  authorities  state  that  the  enlargement  persists 
throughout  the  course  of  the  disease,  but  some  observers  say  that  after 
a  long  period  of  enlargement,  with  jaundice,  contraction  of  the  liver 
takes  place,  with  symptoms  of  portal  obstruction.  Then  the  spleen 
may  become  enlarged  and  ascites  take  place,  while  the  symptoms  of 
digestive  disturbances  become  more  prominent.  There  may  be  ner- 
vous symptoms,  due  to  acute,  diffuse  necrosis  (acute  yellow  atrophy), 
setting  in  in  the  course  of  the  disease. 

The  diagnosis  is  often  difficult.  Gradual  and  persistent  jaundice 
without  cause,  continuing  for  a  long  time,  associated  with  persistent 
enlargement  of  the  liver  without  symptoms  of  portal  obstruction  in 
the  non-alcoholic  subject,  points  pretty  certainly  to  hypertrophic  cir- 
rhosis of  the  liver. 

Syphilitic  Disease  of  the  Liver. 

Syphilitic  disease  of  the  liver  may  result  in  cirrhosis,  or  in  the 
development  of  gummata.  Syphilitic  cirrhosis  presents  the  same  symp- 
toms as  the  alcoholic  form.  The  history,  the  marked  irregularity  on 
the  surface  of  the  liver,  and  the  existence  of  syphilis  elsewhere  may 
lead  to  a  diagnosis  of  the  true  condition. 

In  congenital  syphilitic  disease  of  the  liver  the  inflammation  is 
diffuse  ;  the  liver  is  enlarged  and  hard  ;  the  surface  is  smooth  ;  there 
are  usually  syphilitic  lesions  in  other  organs  ;  the  patient  presents 
syphilitic  eruptions,  and  has  the  well-known  wizened  appearance  that 
belongs  to  this  affection. 

Syphilitic  gummata  in  the  liver  may  exist  without  presenting  any 
symptoms  whatsoever,  or  they  may  reveal  their  presence  by  pain  and  a 
localized  swelling  and  discomfort,  which  call  the  patient's  attention  to 
the  region,  particularly  if  his  general  health  is  reduced  at  the  same 
time.  Tumors  are  situated  in  the  left  lobe,  in  the  median  line,  or 
along  the  margin  of  the  ribs.  The  pain  is  usually  localized  in  this 
region,  but  may  extend  more  or  less  over  the  entire  liver,  particularly 
if  there  is  general  perihepatitis  along  with  other  evidences  of  syphilis  ; 
the  latter  are  not  always  present,  however.  If  the  temperature  is 
taken  frequently,  a  moderate  febrile  range  will  be  observed.  It  may 
not  rise  above  100§°,  but  in  the  absence  of  other  causes  it  is  a  valu- 
able diagnostic  symptom.1  In  other  instances  the  gummata  may  grow 
in  such  situation  as  to  interfere  with  the  portal  circulation,  or  press 
upon  the  gall-ducts.  The  latter  is  very  rare.  If  the  gummata  are 
felt,  they  appear  as  enlarged  bosses  which  give  the  sensation  of  flat- 
tened hemispheres.  Sometimes  several  separate  elevations  can  be 
made  out  on  the  surface  of  the  enlarged  organ.  To  determine  the 
exact  nature  of  the  lesion  is  often  very  difficult.  The  symptoms  may 
conclusively  point  to  hepatic  disease.     Knowledge  of  the  presence  of 

1  "The  Diagnostic  Importance  of  Fever  in  Late  Syphilis."  Musser:  University 
Medical  Magazine,  October,  1892. 


880  SPECIAL  DIAGNOSIS. 

syphilis  aids  in  the  diagnosis.  If  without  a  syphilitic  history  there 
are  scars  in  the  throat,  nodes  on  the  bones,  or  other  signs  of  syphilis, 
the  diagnosis  will  be  tolerably  certain.  Severe  pain  is  more  promi- 
nent in  svphilis  than  in  cirrhosis,  and  the  nodules  of  syphilis  are  very 
different  from  the  granular  surface  of  cirrhosis. 

The  Fatty  Liver. 

The  symptoms  of  fatty  liver  are  not  marked.  The  physical  sign  is 
a  uniform  enlargement  extending  in  all  directions.  On  palpation  the 
edges  can  be  felt ;  they  are  rounded  and  smooth.  They  are  soft  at 
first,  but  later  become  indurated.  Fatty  liver  may  be  followed  by 
cirrhosis  after  a  period  of  alcoholism.  The  general  symptoms  are 
those  of  the  primary  disease.  Fatty  liver  occurs  in  gouty  subjects, 
but  is  notably  present  in  wasting  diseases,  in  tuberculosis,  in  chronic 
hip-joint  disease,  and  in  amyloid  disease  of  the  liver. 

Fatty  liver  sometimes  follows  the  congestion  of  the  liver  which  is 
present  in  the  course  of  organic  heart  disease.  It  is  not  a  true  fatty 
liver,  but  a  fatty  cirrhosis.  There  is  increased  fatty  degeneration  with 
an  overgrowth  of  connective  tissue.  This  form  is  associated  with  heart 
and  kidney  disease.  On  palpation  the  edges  of  the  liver  are  indurated. 
The  liver  may  undergo  diminution  in  size  later,  and  the  symptoms  of 
cirrhosis  ensue. 

Amyloid  Disease  of  the  Liver. 

Enlargement  of  the  liver  without  pain  is  often  due  to  amyloid  dis- 
ease. Similar  disease  is  found  in  other  organs,  and  there  is  present, 
to  point  to  the  nature  of  the  enlargement,  syphilis,  bone  disease,  pro- 
longed suppuration,  or  tuberculosis.  In  amyloid  disease  the  pallor  of 
the  patient  is  great ;  the  face  may  be  swollen,  and  the  ankles  slightly 
oedematous.  The  spleen  is  enlarged,  the  urine  albuminous  and  abun- 
dant, but  of  moderate  specific  gravity.  A  history  of  syphilis  is  an 
important  point  in  establishing  the  diagnosis.  Fatty  liver  can  readily 
be  distinguished  from  amyloid  disease  by  palpation.  In  the  latter  the 
surface  is  smooth,  but  very  much  indurated. 

Cancer  of  the  Liver. 

The  etiological  factors  upon  which  the  diagnosis  of  cancer  is  based 
are  :  the  age  of  the  patient — most  frequently  between  the  fortieth  and 
sixtieth  year  ;  the  female  sex,  in  a  measure  ;  and  heredity.  The  dis- 
ease is  nearly  always  secondary  to  cancer  in  some  other  situation  ; 
consequently,  in  cases  in  which  symptoms  point  to  cancer  of  the  liver, 
search  must  be  made  for  the  primary  lesion  elsewhere.  The  most  fre- 
quent seat  is  the  rectum,  the  uterus,  the  stomach,  the  remainder  of  the 
gastro-intestinal  tract,  the  eye.  The  eye  has  been  removed  for  obscure 
disease,  and  symptoms  of  carcinoma  of  the  liver  have  subsequently  de- 
veloped. The  nature  of  the  hepatic  symptoms  was  obscure  during  life, 
but  at  the  post-mortem  examination  melanotic  sarcoma  was  found  ; 
the  primary  lesion  undoubtedly  had  been  in  the  eye.  Further  etio- 
logical influences  that  may  bear  upon  the  diagnosis  are  :  (1)  The  occur- 


PLATE    XLII. 


\      \ 


Carcinoma  of  the  Gall  Bladder  with  Involvement  of  the  Liver. 


-"-, 


Enlargement  of  the  Gall  Bladder 


DISEASES  OF  LIVER,  SPLEEN  AND  PANCREAS.  881 

rence  of  gallstones,  which  act  as  the  exciting  cause  in  the  development 
of  primary  cancer  of  the  ducts,  thence  spreading  to  the  liver  ;  (2)  the 
occurrence  of  trauma. 

The  symptoms  of  cancer  of  the  liver  may  be  due  to  (1)  increase  in 
the  size  of  the  liver  ;  (2)  to  pressure  of  the  growths  upon  the  ducts  or 
terminal  portal  vessels  ;  and  (3)  to  the  general  effects  of  carcinoma 
upon  the  system — the  cachexia. 

Physical  Signs.  (Plate  XXXVIII.,  Fig.  2,  Plate  XL.,  Fig.  2,  and 
Plate  XLIL,  Fig.  1.)  The  liver  is  enlarged  and  its  surface  irregular. 
The  organ  can  be  made  out,  by  palpation,  extending  below  the  margin 
of  the  ribs.  The  edges  are  irregular,  and,  on  the  surface,  bosses  can 
be  distinctly  felt.  In  rare  cases  one  or  two  masses  only  may  be  pres- 
ent, growing  out  of  the  substance  of  the  left  lobe  of  the  liver,  causing 
a  large  tumor  below  the  sternum.  The  nodules  are  usually  hard,  but 
sometimes  may  be  soft  and  even  fluctuate.  After  emaciation  becomes 
marked  the  nodules  can  be  seen  as  well  as  felt  near  the  surface  of  the 
skin,  and  their  number  distinctly  made  out.  The  abdomen  is  dis- 
tended. 

The  liver  is  movable  with  inspiration.  Progressive  enlargement  can 
be  noted  while  under  observation.  The  enlargement  can  be  well  de- 
fined by  percussion,  and,  while  the  surface  is  irregular,  the  general 
shape  of  the  dulness  corresponds  to  that  of  the  liver.  The  increased 
size  and  inflammation  of  the  capsule  cause  a  sensation  of  weight  in  the 
hepatic  region  and  pain  which  may  be  intermitting  in  character.  The 
nodules  may  be  tender  on  palpation.    The  superficial  veins  are  enlarged. 

In  not  every  instance  do  we  find  enlargement.  In  some  cases  the 
cancer  is  associated  with  cirrhosis  of  the  liver,  or  may  itself  be  of  a 
nodular  type,  and  in  the  course  of  the  disease  undergo  shrinkage.  The 
liver  is  then  normal  or  diminished  in  size,  as  indicated  by  percussion. 

The  symptoms  that  attend  cancer  are  :  1.  Jaundice,  which  is  not 
very  deep  unless  the  common  duct  is  affected.  2.  Ascites,  which  is 
always  present  in  the  atrophic  forms,  but  may  be  absent  when  the 
liver  is  enlarged.  3.  The  general  symptoms  are  those  of  rapid  emacia- 
tion, prostration,  and,  in  some  instances,  moderate  fever.  Fever 
attends  the  rapidly-growing  cases.  It  is  usually  continuous,  but  may 
be  intermittent,  especially  if  there  is  suppuration  or  suppurative  in- 
flammation of  the  ducts.  It  is  a  well-known  fact  that  gallstones  are 
of  common  occurrence  in  patients  suffering  from  cancer  in  any  location 
whatever.  The  symptoms  of  biliary  calculus  or  of  obstruction  may 
attend  those  of  secondary  cancer  of  the  liver,  and  the  stone  has  an 
etiological  significance. 

In  many  instances  secondary  cancer  of  the  liver  may  be  present 
without  symptoms  to  attract  attention  to  this  organ  during  life.  If 
cancer  in  certain  other  regions  has  continued  for  the  usual  period  of 
time,  it  is  almost  certain  that  at  the  autopsy  cancer  of  the  liver  will  be 
found  to  be  present. 

Diagnosis.  The  diagnosis  of  cancer  of  the  liver  is  not  difficult  when 
the  changes  in  the  liver  can  be  made  out  on  palpation  and  percussion. 
In  rare  instances,  in  which  the  liver  is  smooth,  it  may  be  mistaken  for 
fatty  or  amyloid  liver.     A  definite  cause  can  usually  be  assigned  for 

56 


882  SPECIAL  DIAGNOSIS. 

the  latter,  while  the  occurrence  of  jaundice,  the  rapid  increase  in  size 
of  the  liver,  and  the  general  symptoms  of  the  cancerous  cachexia  indi- 
cate cancer  of  the  liver.  The  syphilitic  liver  with  irregular  gummata 
may  cause  serious  doubt ;  the  history  of  the  case  and  other  signs  of 
syphilis  aid  in  the  diagnosis.  Locally  the  condition  may  exactly  sim- 
ulate carcinoma.  The  jaundice,  however,  is  not  so  frequent  in  occur- 
rence, or  so  deep  in  syphilitic  gummata  ;  the  cachexia  does  not  ensue, 
but  the  therapeutic  test  may  be  essential  in  order  to  make  a  diagnosis. 

In  hypertrophic  cirrhosis  of  the  liver  the  jaundice  is  deep  and  the 
liver  enlarged  ;  but  there  is  little  wasting  or  anaemia.  The  surface  of 
the  liver  is  smooth  ;  there  are  certainly  no  bosses,  and  the  organ  is 
painless.  Ascites  is  more  common  in  cirrhosis  ;  the  patient  is  usually 
affected  earlier  in  life  than  in  cancer. 

In  a  large  growing  cancer  one  or  two  of  the  nodules  may  suppurate 
and  simulate  abscess  of  the  liver.  Abscess  follows  a  definite  cause 
usually,  and  occurs  in  middle  life ;  cancer  is  secondary  to  disease  in 
other  organs  and  occurs  usually  in  late  life.  The  results  of  aspiration 
differ  in  each.  Moreover,  a  history  of  dysentery,  the  occurrence  of 
pain,  of  profound  anaemia,  of  pronounced  hectic  fever  with  irregular 
enlargement  of  the  liver,  but  without  jaundice  or  cachexia,  point  to 
abscess. 

Cancer  of  the  liver  may  be  simulated  by  cancer  of  organs  in  close 
proximity  to  the  liver,  as  the  pancreas,  the  pyloric  end  of  the  stomach, 
or  the  colon.  In  addition  to  the  usual  symptoms  of  pyloric  cancer,  it 
will  be  found  that  jaundice  occurs  late.  Cancer  of  the  pyloric  end  is 
not  movable  with  respiration  unless  it  becomes  adherent  to  the  liver. 
Cancer  of  the  omentum  and  colon  are  not  modified  by  respiration.  The 
percussion-note  over  them  is  different ;  they  frequently  extend  beyond 
the  liver-confines  and  are  associated  with  symptoms  of  obstruction  of 
the  bowels.  Fecal  accumulation  in  the  transverse  colon  must  not  be 
mistaken  for  cancer  of  the  liver.  The  large  masses  adjacent  to  the 
liver  may  closely  simulate  cancerous  nodules.  In  doubtful  cases  the 
colon  should  be  emptied.  Cancer  of  the  liver  and  hydatid  disease 
must  not  be  confounded.  The  tumor  in  hydatid  disease  is  usually 
single  ;  it  is  large,  and  may  fluctuate  or  yield  the  hydatid  fremitus.  It 
causes  irregular  enlargement  of  the  liver,  when  the  tumor  presents 
in  the  epigastrium  or  along  the  margin  of  the  ribs.  It  is  painless. 
Aspiration  yields  the  characteristic  hydatid  fluid. 

Cancer  of  the  bile-ducts  cannot  always  be  distinguished  from  cancer 
of  the  liver.  Jaundice  early  in  the  course  of  the  disease,  in  a  person 
who  has  had  gallstones,  followed  by  enlargement  of  the  liver  and  gall- 
bladder, in  the  absence  of  primary  disease  elsewhere,  suggests  cancer 
of  the  gall-bladder  or  ducts.  This  is  more  or  less  confirmed  if  the 
smooth  and  painless  gall-bladder  becomes  hard,  irregular,  and  tender 
on  pressure.  Cancer  of  the  pancreas  also  presents  difficulties ;  a  tumor 
in  the  mid-costal  region,  however,  with  vomiting  and  the  early  devel- 
opment of  jaundice,  before  the  liver  has  become  enlarged  or  nodular, 
and  associated  with  other  characteristic  symptoms,  such  as  intestinal 
dyspepsia  and  fatty  stools,  points  to  the  pancreas  as  the  primary  seat 
of  the  disease. 


DISEASES  OF  LIVER,  SPLEEN  AND  PANCREAS.  883 

Hydatid  Disease  of  the  Liver. 

Hydatid  disease  is  comparatively  rare  in  this  country,  but,  in  my 
own  experience  at  least,  it  is  undoubtedly  increasing  in  frequency. 
Without  any  increase  in  the  opportunities  for  observation,  I  have 
seen  seven  cases  within  the  last  two  years,  compared  to  the  same 
number  during  the  five  previous  years.  The  disease  occurs  in  people 
who  live  Avith  dogs.  It  may  occur  at  any  age,  but  is  most  common 
in  adult  life.     It  is  very  rare  before  the  fifth  year. 

The  symptoms  are  local,  depending  upon  the  size  of  the  tumor. 
Small  cysts  may  be  present  without  any  disturbance.  Large  and 
growing  cysts  cause  signs  of  tumor,  with  great  increase  in  the  size  of 
the  liver.  The  physical  signs  depend  upon  the  situation  of  the  tumor. 
It  may  be  found  in  the  median  line  above  the  umbilicus,  causing  a 
distinct  prominence,  tense  and  firm,  which  sometimes  yields  fluctua- 
tion. Quite  often  the  tumor  grows  at  the  suspensory  ligament,  pushing 
the  diaphragm  upward,  dislocating  the  heart,  and  causing  an  increased 
area  of  dulness  in  the  left  upper  quadrant.  In  this  position  it  may 
simulate  a  pancreatic  cyst  or  effusion  in  the  lesser  peritoneal  cavity. 
If  the  tumor  is  in  the  right  lobe,  the  enlargement  of  the  liver  may  be 
upward  or  downward.  The  upper  border  of  liver-dulness  may  begin 
two  or  three  interspaces  higher  than  normal  posteriorly  or  in  the  axil- 
lary region.  If  the  cysts  are  superficial,  when  palpated  Avith  the  fingers 
of  the  left  hand  and  percussed  with  the  right,  a  vibration  or  trembling 
movement  is  felt,  Avhich  may  continue  for  a  certain  time.  It  is  known 
as  the  hydatid  fremitus.  It  is  not  always  present.  The  enlargement 
is  painless.  Local  sensations  of  Aveight  and  dragging  may  be  complained 
of.     If  suppuration  sets  in,  there  may  be  a  good  deal  of  pain. 

The  general  symptoms  are  negative ;  the  nutrition  does  not  suffer 
unless  the  enlarged  mass  interferes,  by  its  pressure,  Avith  physiological 
acts  of  digestion  and  assimilation.  If  suppuration  sets  in,  the  general 
symptoms  of  abscess  of  the  liver  arise.  Jaundice  is  more  common  than 
in  tropical  abscess.  The  abscess  may  perforate  into  one  of  the  adjacent 
hollow  \riscera,  or  into  the  pleura  and  bronchi.  It  may  perforate  exter- 
nally. It  may  perforate  into  the  pericardium  or  vena  cava,  and  cause 
death.  If  perforation  takes  place  in  the  biliary  passages,  obstructiA^e 
jaundice  arises,  Avith  secondary  suppurative  cholangitis.  When  the 
cysts  rupture,  or  if  they  are  aspirated,  an  eruption  of  urticaria  may 
break  out.  This  is  not  of  diagnostic  significance,  except  that  it  may 
point  to  rupture  of  the  cyst. 

Diagnosis.  The  diagnosis  is  not  difficult.  The  occurrence  of  irregu- 
lar, painless  enlargement  of  the  liver  Avithout  general  symptoms  is  sig- 
nificant. If  fluctuation  is  detected,  or  the  fremitus,  a  more  positiA^e 
conclusion  can  be  reached.  When  suppuration  takes  place  the  symptoms 
are  like  those  of  abscess  of  the  liA^er.  Hydatid  disease  is  to  be  distin- 
guished from  syphilitic  hepatitis,  in  Avhich  the  enlargement  is  hard  and 
irregular,  and  does  not  fluctuate.  Sometimes  the  symptoms  resemble 
cancer,  but  the  age  of  the  patient,  the  presence  of  jaundice,  and  the 
extreme  emaciation  and  cachexia  indicate  that  affection  rather  than 
hydatid  disease.     Enlargement  of  the  gall-bladder  containing  a  mucoid 


884 


SPECIAL  DIAGNOSIS. 


fluid,  in  which  fluctuation  can  be  detected,  may  simulate  hydatid  dis- 
ease. The  enlargement,  however,  may  be  preceded  by  conditions  -which 
cause  obstruction  of  the  cystic  duct.  The  gall-bladder  is  movable.  In 
some  instances  there  may  be  resonance  between  it  and  the  liver.  It  is 
usually  of  a  pvriform  or  oblong  shape.    In  hydronephrosis  the  symptoms 


Human  echinococci.    (From  Finlayson,  after  Dayatne.) 

A,  a  group  of  echinococci,  still  adhering  to  the  germinal  membrane  by  their  pedicles. 

B,  an  echinococcus  with  head  invaginated  in  the  body.    X  107. 

C,  the  same  compressed,  showing  the  suckers  and  hooks  of  the  retracted  head. 

D,  echinococcus  with  head  protruded. 

E,  crown  of  hooks,  showing  the  two  circles.    X  350. 


X40. 


of  a  localized  cyst  are  present.  It  does  not  move  with  respiration,  as  in 
hydatid  disease  ;  it  is  attended  by  symptoms  of  renal  disease  ;  explora- 
tory puncture  is  sometimes  necessary  to  establish  a  diagnosis.  A  hydatid 
cyst  is  frequently  confounded  with  pleural  effusion  of  the  right  side,  for 
there  may  be  all  the  physical  signs  of  effusion  at  the  right  base.     The 


Fig.  203. 


Hooks  from  tenia  echinococcus.    X  350. 


distinction  can  be  made  by  the  character  of  the  line  of  dulness.  In 
hydatid  cyst,  as  Frerichs  points  out,  it  is  a  curved  line,  the  greatest 
height  of  which  is  found  in  the  scapular  region.  It  is  not  difficult 
usually  to  distinguish  hydatid  cyst  from  other  forms  of  painless  enlarge- 
ment.   In  fatty  and  amyloid  disease  the  enlargement  is  uniform.     Both 


DISEASES  OF  LIVER,  SPLEEN  AND  PANCREAS.  885 

occur  more  commonly  in  individuals  of  previous  ill  health,  whereas 
hydatid  disease  occurs  in  healthy  individuals. 

An  absolute  diagnosis  of  hydatid  disease  is  based  upon  the  results  of 
exploratory  puncture.  When  this  is  made  over  a  tumor,  or  the  centre 
of  dulness,  if  it  is  due  to  hydatid  disease,  a  clear  fluid,  slightly  opales- 
cent, is  withdrawn.  The  fluid  is  of  a  specific  gravity  of  1005  to  1009  ; 
it  is  of  neutral  reaction,  does  not  contain  albumin,  but  contains  chlorides 
and  sometimes  traces  of  sugar.  Hooklets  may  be  found  in  the  clear 
fluid. 

Diseases  of  the  Gall-ducts. 

Pain  and  jaundice  are  symptoms  of  disease  of  the  biliary  passages. 
Pain  may  be  constant  or  paroxysmal.  If  it  occurs  in  mild  degree,  with 
tenderness  and  with  jaundice,  it  is  probably  due  to  catarrh  of  the  biliary 
passages.  If  severe,  and  in  paroxysms  with  or  without  jaundice,  it  is 
due  to  gallstones. 

Inflammation  of  the  Bile -ducts.  This  is  due  to  inflammation  and 
obstruction  of  the  terminal  portions  of  the  common  bile-duct.  But  few 
words  are  necessary,  as  it  has  been  referred  to  frequently  in  speaking 
of  jaundice.  The  symptoms  are  those  of  moderate  jaundice,  occurring 
coincidently  with  or  following  in  a  few  days  upon  an  attack  of  acute 
gastritis.     The  disease  may  occur  in  epidemic  form. 

Gallstones.  Gallstones  form  in  the  biliary  passages,  and  may  remain 
there  without  creating  symptoms,  or  they  may,  by  the  efforts  to  pass 
them,  cause  attacks  of  pain  called  hepatic  or  biliary  colic,  after  which 
the  stone  may  pass  into  the  intestinal  tract  without  further  hepatic 
symptoms.  It  may  become  impacted  in  the  biliary  canal  and  set  up 
catarrhal  or  suppurative  inflammation,  which  in  turn  may  be  followed 
by  stricture.  Gallstones  usually  form  or  at  least  show  signs  of  their 
presence  after  the  age  of  forty  years,  most  frequently  in  women  and 
in  people  who  have  led  a  sedentary  life  and  partaken  of  rich  and  indi- 
gestible food.  Individuals  in  different  generations  of  the  same  family 
may  be  predisposed  to  them. 

Hepatic  Colic.  The  passage  of  gallstones  may  be  attended  by  a 
slight  amount  of  pain  only,  which,  unless  in  the  right  upper  quadrant, 
would  pass  for  an  attack  of  simple  indigestion.  In  the  large  majority 
of  cases  the  pain  is  severe.  The  attack  may  be  preceded  by  biliousness 
or  indigestion  for  twenty -four  hours,  and  moderate  pains  or  a  sense  of 
weight  and  fulness  in  the  liver.  It  frequently  follows  the  taking  of 
food.  Ringing  in  the  ears,  disturbance  of  vision,  or  undue  flushings 
are  said  to  precede  it  in  some  instances. 

The  attack  may  be  sudden.  The  patient  is  seized  with  pain  along 
the  margin  of  the  ribs  of  the  right  side,  or  there  may  be  pain  above 
the  ribs,  over  the  liver,  and  in  the  right  shoulder  at  the  same  time. 
From  the  hepatic  region  it  extends  to  the  median  line.  Very  fre- 
quently the  pain  begins  and  continues  in  the  epigastrium.  It  may  be 
most  pronounced  in  this  locality  from  the  first.  The  pain  is  intense 
and  paroxysmal.  The  patient  is  doubled  up  in  agony.  It  causes  more 
or  less  collapse.  The  pulse  increases.  Vomiting  usually  occurs  at  the 
same  time,  consisting  first  of  the  contents  of  the  stomach,  and  then  of  a 


SPECIAL  DIAGNOSIS. 

yellowish,  bile-stained  fluid.  The  vomiting  may  be  extreme,  so  that 
the  patient  is  tormented  by  the  pain,  the  retching,  and  vomiting.  The 
attack  sometimes  disappears  as  suddenly  as  it  occurred,  or  wears  off 
gradually.  When  most  severe,  symptoms  of  shock  follow.  The  bowels 
are  not  disturbed  during  the  attack.  The  urine  may  become  suppressed  ; 
it  is  usually  high-colored,  and  after  the  attack  may  contain  bile. 

At  the  time  of  the  attack  there  is  considerable  tenderness  below  the 
xiphoid  cartilage  and  in  the  hepatic  region.  The  tenderness  is  more 
marked  on  deep  pressure  in  the  gall-bladder  region  and  to  the  right  of 
the  mid-clavicular  line,  at  the  margin  of  the  ribs.  The  epigastrium 
may  be  slightly  swollen.  The  tenderness  persists  after  the  attack, 
and  the  stomach  may  be  weak  or  irritable  for  some  time ;  pain,  how- 
ever, usually  disappears  at  once.  The  attack  may  recur  frequently  until 
the  stone  has  been  passed,  so  that  in  twenty-four  hours  the  patient  may 
have  a  dozen  or  more  paroxysms.  After  the  attacks  have  subsided 
light  jaundice  may  supervene,  which  usually  does  not  continue  more 
than  a  week  at'  the  furthest,  during  which  there  are  also  symptoms  of 
mild  gastritis.     (See  Intestinal  Colic.) 

In  some  instances  a  chill  precedes  or  immediately  follows  the  pain, 
after  which  the  temperature  rises.  After  the  paroxysm  subsides  the 
fever  disappears  rapidly,  being  followed  by  profuse  perspiration.  If 
the  gallstones  have  set  up  catarrhal  inflammation,  moderate  fever  may 
continue  for  a  few  days.     (See  Fever  in  Obstruction.) 

During  any  paroxysm  of  hepatic  colic  it  is  desirable  to  determine 
whether  or  not  a  gallstone  has  been  passed.  This  can  only  be  done 
by  placing  the  feces  in  a  sieve  and  pouring  water  upon  them  until  they 
dissolve.  Instead  of  gallstones,  dark-colored  granular  bile,  which  has 
become  inspissated,  is  sometimes  seen  in  the  movements.  Bile  in  this 
form  gives  rise  to  as  much  pain,  according  to  Harley,  as  true  biliary 
concretions.  If  the  stone  is  not  passed,  it  may  fall  back  into  the  gall- 
bladder and  cause  no  further  symptoms  for  a  time,  or  become  impacted 
in  the  ducts.  The  impaction  may  be  such  that  no  obstruction  is  caused 
by  its  position,  the  bile  being  forced  through  or  around  it ;  or  complete 
obstruction  may  take  place.     (See  Jaundice.) 

Obstruction  of  the  Common  I) act  by  Gallstones,  (a)  In  addition  to 
jaundice  paroxysms  of  chill,  fever,  and  sweat  occur,  with  catarrhal 
inflammation  of  the  biliary  passages.  (1)  The  paroxysms  resemble 
intermittent  fever  ;  (2)  the  jaundice  may  continue  for  years  and  deepen 
after  each  paroxysm  ;  (3)  hepatic  colic  may  occur  with  the  paroxysm  ; 
(4)  the  health  fails  but  slightly.  The  paroxysms  may  occur  daily  or 
only  once  a  week,  or  they  may  be  tertian  and  quartan  in  type.  The 
pain  is  referred  to  other  situations  than  the  gall-bladder  or  the  epigas- 
trium. It  is  often  relieved  by  vomiting  or  by  certain  positions  of  the 
body.  The  jaundice  may  be  intermittent  or  remittent.  On  account 
of  the  obstruction  in  this  situation  the  liver  becomes  enlarged.  It  is 
firm  and  smooth  on  palpation.  The  enlargement,  as  determined  by 
percussion,  is  uniform.  The  gall-bladder  is  not  enlarged.  Fenger's 
thorough  studies  show  that  the  intermittent  phenomena  are  due  to  ball- 
valve  action  of  a  single  stone.  He  also  points  out  that  emaciation  is  of 
common  occurrence.    (6)  Gallstones  may  cause  suppurative  inflammation 


DISEASES  OF  LIVER,  SPLEEN  AND  PANCREAS.  887 

of  the  biliary  ducts,  just  as  suppuration  of  the  gall-bladder  may  ensue. 
The  symptoms,  both  general  and  local,  are  pronounced.  The  fever  may 
be  intermittent,  but  is  more  likely  to  be  remittent ;  jaundice  is  present, 
but  it  is  constant  in  its  intensity.  The  local  signs  of  enlargement  and 
tenderness  are  made  out.  The  patients  die  of  exhaustion  or  septicaemia. 
Sometimes  the  gall-bladder  ruptures  into  the  stomach  or  colon,  and 
temporary  abeyance  of  the  symptoms  may  result. 

The  Accidents  of  Gallstones.  While  these  effects  of  the  presence  of 
stones  in  the  biliary  passages  may  rightly  be  considered  as  accidents, 
nevertheless  their  occurrence  is  so  common  as  to  be  part  and  parcel  of 
the  history  of  gallstones.  As  accidents,  we  have  most  commonly  the 
occurrence  of  localized  peritonitis,  which  leads  to  dislocation  of  the  gall- 
bladder, constriction  of  the  duodenum,  with  secondary  dilatation  of  the 
stomach ;  we  also  have  the  formation  of  biliary  fistula,  with  passage  of 
the  gallstone  into  the  contiguous  organs  or  channels.  The  stone  may 
ulcerate  into  the  gall-bladder  from  one  of  the  ducts,  may  perforate  the 
portal  vein,  or  may  perforate  into  the  abdominal  cavity — the  most  fre- 
quent accident.  Perforation  also  takes  place  into  the  duodenum,  into 
the  colon,  and,  rarely,  into  the  stomach.  Such  perforation  can  only 
be  inferred  from  its  secondary  effects  :  (1)  An  attack  of  gallstones ; 
(2)  local  inflammation  with  fever ;  (3)  the  occurrence  of  peritonitis,  or 
the  discharge  of  pus  by  the  bowels,  or  by  vomiting.  That  it  is  due  to 
gallstones  is  proved  in  those  rare  instances  in  which  the  stone  is  passed 
per  rectum.  Often  it  may  be  impacted  in  the  intestinal  canal,  causing 
symptoms  of  acute  obstruction,  or  in  the  rectum,  causing  local  tormina 
and  tenesmus.  The  perforation,  however,  occurs  in  other  directions. 
Sometimes  fistulous  connection  is  formed  between  the  gall-bladder  and 
the  urinary  passages,  calculi  and  pus  being  discharged  in  the  urine.  In 
other  instances  nstulse  between  the  bile-passages  and  the  lungs  are 
formed.  The  bile  is  coughed  up  and  expectorated,  sometimes  with  small 
calculi.  In  the  most  common  form  ulceration  proceeds  toward  the  sur- 
face, with  formation  of  cutaneous  fistula.  After  the  fistula  has  opened 
externally  gallstones  in  large  numbers  may  be  passed.  If  not,  the 
cause  of  the  fistula  must  be  determined  by  the  history  and  the  results 
of  investigation  by  probe,  due  attention  being  given  to  the  condition  of 
other  organs. 

Enlargement  of  the  Gall-bladder.  (Plate  XLIL,  Fig.  2.)  Enlarge- 
ment of  the  gall-bladder  may  be  due  to  obstruction  in  the  cydic  duct. 
The  liver  is  not  secondarily  affected.  The  enlargement  is  noted  at  the 
edge  of  the  liver  in  the  usual  situation,  and  may  gradually  increase  to 
an  enormous  extent,  so  that  it  has  been  mistaken  for  an  ovarian  cyst. 
The  gall-bladder  is  often  quite  movable,  and  on  account  of  its  location 
and  movability,  as  well  as  its  long  shape,  has  been  mistaken  for  a  float- 
ing or  movable  kidney.  If  the  gall-bladder  is  not  too  large,  it  can  be 
felt  as  a  rounded  or  pyriform  mass  when  the  hand  is  placed  along  the 
margin  of  the  liver,  becoming  more  marked  when  the  patient  takes  a 
full  breath.  The  enlargement  is  not  attended  by  any  other  symptoms 
except  mechanical  ones,  unless  the  contents  of  the  gall-bladder  are 
purulent.  In  obstruction  with  simple  enlargement  the  fluid  of  the  gall- 
bladder, should  aspiration  be  performed,  is  thin,  of  a  mucoid  nature, 


SPECIAL  DIAGNOSIS. 

and  alkaline  in  reaction.    It  may  contain  cholesterin-plates,  and  some- 
times blood.    It  must  be  distinguished  from  the  fluid  of  a  hydatid  cyst. 

Simple  enlargement  of  the  gall-bladder  must  be  distinguished  from 
enlargements  due  to  inflammation.  (1)  Acute  phlegmonous  inflamma- 
tion of  the  gall-bladder  may  take  place,  attended  by  localized  pain  and 
tenderness,  by  high  temperature,  extreme  prostration,  and  the  rapid 
development  of  the  typhoid  state.  Peritonitis  rapidly  ensues.  It  can- 
not be  distinguished  from  other  forms  of  acute  inflammation  in  the  same 
region,  unless  there  was  (a)  a  history  of  gallstones ;  (6)  tumor  of  the 
gall-bladder  before  the  attack  developed.  (2)  Suppurative  inflammation 
of  the  gall-bladder  may  occur  from  gallstones  and  in  infectious  diseases. 
The  colon  bacillus,  the  diplococcus  of  pneumonia,  and  the  typhoid  bacil- 
lus give  rise  to  infectious  inflammation  of  the  gall-bladder.  The  enlarge- 
ment takes  place  suddenly  and  may  increase,  the  tumor  becoming  tender 
and  painful  on  palpation.  The  direction  of  growth  is  toward  the  umbil- 
icus. The  general  symptoms  are  those  of  suppuration.  Hectic  fever 
or  markedly  remittent  fever  occurs,  and,  unless  surgical  relief  is  given, 
peritonitis  ensues  from  infection  or  from  rupture.  This  complication 
may  be  suspected  from  the  occurrence  of  collapse  and  increase  of  the 
local  symptoms. 

Either  of  the  above  forms  of  cholecystitis  is  attended  by  pain  in  the 
region  of  the  gall-bladder  or  in  the  epigastrium  or  even  as  low  down  as 
the  region  of  the  appendix.  The  pain  is  severe  and  paroxysmal.  The 
symptoms  of  bacterial  infection,  of  which  vomiting  and  fever  are  the 
most  prominent,  rapidly  follow.  The  symptoms  simulate  appendicitis, 
intestinal  obstruction,  and  pancreatitis. 

Enlargement,  or  tumors  of  the  gall-bladder,  usually  due  to  cystic 
obstruction,  as  previously  mentioned,  may  be  mistaken  for  floating 
kidney,  for  tumor  of  the  pylorus,  and  for  ovarian  cyst. 

Tumors  of  the  gall-bladder  from  any  of  the  above-mentioned  causes 
are  recognized  by  their  position  and  shape,  and  by  the  character  of  the 
tumor.  The  position  varies.  The  usual  site  is  in  the  gall-bladder 
region,  but  it  may  extend  as  low  as  the  groin,  or  may  be  so  large  as  to 
distend  the  ribs  and  fill  almost  the  entire  abdominal  cavity.  If,  how- 
ever, the  case  has  been  under  observation  from  the  beginning,  the  tumor 
must  have  been  found  originally  in  the  gall-bladder  region.  This  region 
corresponds  to  the  point  of  intersection  of  the  border  of  the  ribs  by 
a  line  drawn  from  the  acromion  process  of  the  right  shoulder  to  the 
umbilicus,  or  in  the  direction  of  the  foramen  of  Winslow.  The  tumor 
grows  from  this  point  toward  the  umbilicus  in  nearly  all  the  cases.  It 
can  be  recognized  by  its  shape,  which  is  pyriform,  globular,  or  conical. 
The  character  of  the  tumor  varies.  It  is  usually  tender  and  firm,  but 
elastic  on  pressure,  and  movable.  Fluctuation  may  often  be  detected. 
The  septic  gall-bladder  is  symmetrical  and  resistant  to  the  touch.  If 
the  enlarged  gall-bladder  contains  calculi,  they  may  be  felt  as  small, 
hard  masses,  which  cause  a  grating  sensation,  to  be  transmitted  to  the 
finger.  On  aspiration,  if  the  cystic  duct  is  obstructed,  the  mucoid 
fluid  previously  mentioned,  or  pus,  is  withdrawn.  If  the  common  duct 
is  obstructed,  bile  will  pass  through  the  trocar. 

The  enlargement  must  be  distinguished  from  tumors  of  the  liver, 


DISEASES  OF  LIVER,  SPLEEN  AND  PANCREAS.  889 

stomach,  duodenum,  pancreas,  or  lymphatic  glands.  Tumors  of  the 
liver  are  usually  due  to  carcinoma.  They  are  multiple,  associated  with 
enlargement  of  the  liver,  with  jaundice,  ascites,  enlargement  of  the 
spleen,  and  emaciation.  Tumors  of  the  stomach,  duodenum,  and  pan- 
creas are  in  a  different  position,  and  are  attended  by  functional  disturb- 
ance of  the  respective  organs  from  which  they  spring.  An  abscess  of 
the  liver,  if  purulent,  may  simulate  enlargement  of  the  gall-bladder. 
If  the  abscess  can  be  palpated,  an  area  of  induration  is  first  felt,  fol- 
lowed afterward  by  softening  and  fluctuation  of  the  swelling.  In  judg- 
ing; of  the  true  nature  of  the  tumor  we  must  bear  in  mind  the  causes  of 

•  •  •       •  ■ 

abscess.  In  hydatid  disease  the  tumor  develops  slowly  ;  it  is  painless  ; 
it  may  yield  fremitus,  and,  if  movable,  the  course  is  slow  and  not 
attended  by  general  symptoms.  Multilocular  hydatid  disease  can  rarely 
be  distinguished  save  by  the  difference  in  position  of  the  tumor.  It  is 
nodulated,  hard,  and  tender,  but  is  associated  with  jaundice,  ascites, 
oedema  of  the  legs,  enlarged  spleen,  and  great  emaciation  and  prostra- 
tion, with  rapid  decline.  A  syphilitic  gumma  in  the  liver  may  occupy 
the  region  of  the  gall-bladder.  It  can  usually  be  made  out  as  continu- 
ous with  the  liver-structure.  It  is  tender  and  painful,  but  irregular  ; 
other  signs  of  syphilis,  or  a  history  of  the  infection  and  of  symptoms 
of  a  primary  and  secondary  period,  will  aid  in  the  distinction  of  the 
disease. 

Floating  Kidney.  The  gall-bladder  is  larger  and  fixed  at  one  end, 
whereas  the  entire  kidney  is  movable.  The  gall-bladder  may  fluctuate, 
and  is  associated  with  symptoms  of  hepatic  disease.  On  the  other 
hand,  the  well-known  symptoms  of  floating  kidney,  the  shape  of  the 
tumor,  the  sensation  of  nausea  induced  by  palpation,  point  to  the  renal 
origin  of  the  mass.  Tumors  of  the  kidney  must  be  distinguished,  such 
as  sarcoma,  hydronephrosis,  and  pyonephrosis.  1.  There  may  be 
changes  in  the  urine.  2.  In  renal  tumors  the  intestine  is  in  front  of 
some  portion  of  them,  or  a  zone  of  resonance  is  found  between  the 
liver-dulness  and  the  tumor.  3.  Renal  tumors  are  fixed.  They  may, 
as  in  hydronephrosis,  come  and  go,  preceded  by  attacks  of  renal  colic 
and  attended  by  anuria.  From  ovarian  or  uterine  tumors  the  diagnosis 
must  be  made  by  examination  of  the  genital  organs,  although  with  the 
former  there  is  often  difficulty. 

Enlargement  of  the  gall-bladder  on  account  of  calculous  obstruction 
must  be  distinguished  from  enlargement  due  to  cancer  of  that  organ. 
This  is  often  difficult  and  cannot  be  done  without  having  the  patient 
under  observation  for  a  long  period  of  time.  Cancer  of  the  gall-bladder 
is  usually  primary.  It  may  begin  in  the  gall-ducts.  In  the  larger 
number  of  cases  it  occurs  in  patients  who  have  had  gallstones.  It  is 
found  most  frequently  in  females,  and  after  the  fiftieth  year.  Tight- 
lacing  or  pressure  around  the  abdomen  may  predispose  to  it.  The 
symptoms  are  pain,  jaundice,  emaciation,  cachexia,  and  the  presence 
of  a  tumor.  The  pain  is  localized  and  lancinating  in  character.  Jaun- 
dice occurs  in  70  per  cent,  of  the  cases,  and  gradually  increases  in  inten- 
sity. The  tumor  is  situated  in  the  gall-bladder  region,  to  the  right  of 
the  umbilicus.  It  is  hard  or  firm,  painful,  and  the  seat  of  tenderness. 
The  tumor  is  fixed.    Sometimes  the  disease  is  found  in  the  cystic  duct, 


890  SPECIAL  DIAGNOSIS. 

and  then  the  gall-bladder  is  enlarged.  As  the  history  of  gallstones  is 
of  frequent  occurrence  in  both  instances,  it  is  impossible  to  distinguish 
the  two  forms  of  obstruction  causing  enlargement,  save  that  in  carcinoma 
the  emaciation  and  cachexia  may  point  to  the  true  nature  of  the  case. 
In  tumor  of  the  gall-bladder  due  to  cancer  the  secondary  effects  on  the 
liver  are  usually  more  marked  than  in  tumor  from  other  causes.  The 
liver  enlarges  and  its  surface  becomes  irregular  or  nodular.1 

Diseases  of  the  Spleen. 

Topography  of  Spleen.  (Plate  XXXV.)  The  spleen  lies  in  the 
left  upper  quadrant  beneath,  and  in  contact  with  the  diaphragm  above, 
and  below  with  the  tail  of  the  pancreas,  cardiac  end  of  the  stomach, 
and  suprarenal  capsule.  It  extends  transversely  between  the  upper 
border  of  the  ninth  rib  and  the  lower  border  of  the  eleventh  rib,  and 
from  the  middle  axillary  line  posteriorly  toward  the  spine. 

Palpation.  An  enlarged  spleen  usually  retains  the  normal  shape. 
The  direction  of  the  enlargement  is  downward  and  inward.  It  is  access- 
ible to  palpation  in  proportion  to  the  degree  of  enlargement  and  of 
relaxation  of  the  abdominal  walls.  It  is  movable  with  respiration. 
It  cannot  be  said  to  be  enlarged  unless  the  edge  is  palpable  at  the  end 
of  deep  inspiration,  notwithstanding  there  may  be  increased  dulness  in 
the  lower  axillary  region.  When  moderately  enlarged,  the  smooth, 
blunt,  rounded  anterior  surface  and  sharp  edge  of  the  spleen  can  be 
felt  at  the  margin  of  the  ribs,  in  deep  inspiration ;  when  the  enlarge- 
ment is  great,  as  in  leukcemia,  the  organ  can  be  grasped  with  both 
hands,  and  its  hilus  clearly  mapped  out.  The  same  thing  can  be  done 
in  the  rare  instances  of  floating  spleen,  but  here  a  knee-chest  position 
will  favor  successful  palpation.  The  posterior  border  of  an  enlarged 
spleen  can  usually  be  made  out  by  passing  the  hand  backward  over  the 
resisting  organ.  At  its  posterior  border  a  non-resisting  space  can  be 
detected  between  the  border  and  the  mass  of  lumbar  muscle.  In  chil- 
dren it  is  always  easy  to  define  this  border.  Xo  such  space  exists  in 
renal  enlargements.  The  existence  of  this  space  and  the  direction  of 
enlargement  of  the  spleen  are  due  to  the  costo-colic  fold  of  peritoneum 
(Jenner).  In  splenic  leukaemia  the  spleen  may  be  larger  after  a  meal, 
yield  a  creaking  fremitus  on  palpation,  a  murmur  on  auscultation,  and 
may  even  pulsate.  The  spleen  may  also  lessen  in  size  after  diarrhoea 
or  free  hemorrhage.  As  it  lies  entirely  behind  the  ribs,  it  does  not,  of 
course,  admit  of  palpation  when  the  size  is  normal. 

Percussion.  (Plate  XVI.,  Fig.  2.)  Being  a  solid  body  it  gives 
a  dull  sound  on  percussion,  contrasting  with  pulmonary  resonance 
above,  intestinal  tympany  below,  and  stomach  tympany  anteriorly. 
Posteriorly  and  below  its  dulness  merges  into  that  of  the  lumbar  region 
and  kidney.  The  upper  posterior  portion  is  hidden  behind  the  dia- 
phragm and  overlapping  lung,  and  hence  is  not  accessible  to  percussion. 
Practically,  therefore,  the  normal  splenic  dulness  extends  between  the 
ninth  and  eleventh  ribs,  in  the  middle  and  posterior  axillary  lines,  the 
spleen  being  there  in  contact  with  the  ribs. 

1  Musser:  Trans.  Assoc.  Amer.  Physicians,  vol.  iv.,  1889. 


DISEASES  OF  LIVER,  SPLEEN  AND  PANCREAS.  891 

In  percussion  of  the  spleen  the  patient  should  lie  on  his  right  side. 
Beginning  from  above  downward  we  percuss  gently  until  pulmonary 
resonance  is  succeeded  by  dulness ;  then  anteriorly,  proceeding  toward 
the  axilla,  until  stomach  tympany  yields  to  dulness.  In  the  same 
way,  percussing  from  below  upward,  the  line  is  reached  where  intestinal 
tympany  gives  way  to  dulness. 

Splenic  dulness  may  be  encroached  upon  by  the  stomach  or  colon 
distended  with  gas,  or  its  dulness  may  appear  increased  through  disten- 
tion of  the  stomach  and  colon  with  solid  matter,  or  by  a  left  pleural 
effusion,  or  left  basal  pneumonia.  The  spleen  may  also  be  pressed 
upward  by  ascites  or  by  a  large  abdominal  tumor,  so  that  its  normal 
dulness  is  much  lessened. 

If  the  ligament  which  holds  it  in  place  becomes  relaxed,  the  spleen 
may  become  floating.  According  to  Stint-zing,  a  floating  spleen  is 
increased  in  density,  is  generally  enlarged,  and  is  recognized  by  its 
form  (notch,  etc.),  by  being  movable  to  and  fro,  and  by  the  absence  of 
splenic  dulness  in  the  normal  position,  and  its  reappearance  when  the 
spleen  is  replaced. 

Enlargement  of  the  Spleen.  Enlargement  of  the  spleen  may  be 
acute  or  chronic.  Acute  enlargement  occurs  in  certain  infectious  dis- 
eases, particularly  typhoid  fever,  typhus,  smallpox,  relapsing  fever, 
scarlet  fever,  diphtheria,  epidemic  cerebro-spinal  meningitis,  the  mala- 
rial fevers  and  meningitis,  and  in  diseases  with  blood-poisoning,  as 
septicaemia,  puerperal  fever,  and  erysipelas. 

A  rare  cause  of  enlargement  is  acute  splenitis.  Generally,  it  is  the 
result  of  emboli  lodged  in  the  spleen  and  starting  from  an  endocarditis. 
The  area  of  splenic  dulness  extends  rapidly,  and  there  is  local  pain 
and  tenderness  on  pressure,  increased  by  coughing  and  deep  inspira- 
tion ;  other  symptoms  are  fever,  nausea  and  vomiting,  and  occasionally 
delirium.  If,  as  frequently  happens  in  splenitis,  emboli  lodge  in  the 
kidneys  also,  the  urine  will  be  albuminous  and  bloody.  If  suppura- 
tion ensues,  the  fever  becomes  hectic,  and  the  spleen  continues  to 
increase  in  size.  Splenic  abscess  may,  however,  remain  latent  until 
rupture  occurs. 

Chronic  enlargement  of  the  spleen  occurs  as  hypertrophy  and  as  the 
result  of  amyloid  disease,  leukaemia  and  pseudoleukemia,  chronic  mala- 
rial poisoning  (ague-cake),  syphilis,  hydatid  tumor,  and  cancer.  En- 
largement is  greatest  in  leukaemia  and  in  ague-cake.  The  spleen  in 
well-marked  cases  of  these  affections  may  reach  to  the  umbilicus  and 
even  beyond,  filling  up  the  hypogastrium  and  extending  to  the  right 
iliac  region,  measuring  thirteen  or  fourteen  inches  in  length  and  half 
as  much  in  breadth,  and  proportionately  increased  in  thickness. 

Primary  splenic  enlargement  may  occur  (1)  without  local  or  general 
symptoms  ;  (2)  anaemia,  profuse  hemorrhages,  and  brown  pigmentation 
of  the  skin  may  be  present  with  the  enlargement.  Hemorrhages  are 
usually  limited  to  the  gastro-intestinal  tract.  The  anaemia  is  of  a  chlo- 
ritic  type,  and  there  is  no  change  in  the  leucocytes.  (3)  Enlargement 
may  be  associated  with  cirrhosis  of  the  liver  and  jaundice,  with  gastro- 
intestinal hemorrhages  and  with  ascites.  This  affection  is  commonly 
known  as  Banti's  disease.    The  blood  changes  are  almost  a  counterpart 


892  SPECIAL  DIAGNOSIS. 

of  those  in  progressive  pernicious  anaemia.  It  may  be  confounded  with 
chronic  inflammation  of  the  peritoneum,  giving  rise  to  ascites  and 
associated  with  mediastinal  pericarditis. 

Diagnosis  of  Enlargement  of  the  Spleen.  (Plate  XLIIL, 
Figs.  1  and  2.)  Enlargement  of  the  spleen  can  be  distinguished  from 
enlargement  of  the  left  kidney  by  the  greater  movability  of  the  spleen. 

1.  The  spleen  does  not  extend  as  far  back  toward  the  spine  as  the  kidney, 
so  that  the  fingers  can  be  thrust  behind  its  posterior  border,  and,  if  the 
other  hand  grasps  the  anterior  edge,  the  organ  can  be  moved  backward 
and  forward.  Splenic  dulness  extends  to  the  ninth  rib  or  higher. 
Kidney-d ulness  has  no  thoracic  area,  but  reaches  to  the  spine  (lumbar). 

2.  Again,  the  spleen  is  more  movable  with  respiration  than  the  kidney 
is.  3.  The  spleen  falls  further  toward  the  median  line,  when  the  patient 
is  in  the  knee-chest  position,  than  does  the  kidney.  4.  An  enlarged 
kidney  has  the  colon  in  front  of  it,  and  hence  its  dulness  is  obscured  by 
the  tympany  of  the  bowel.  5.  The  shape  of  an  enlarged  kidney  is  more 
globular  than  that  of  the  spleen.  The  anterior  surface  of  the  latter  is 
smooth  and  rounded,  but  at  its  junction  with  the  flat  posterior  surface 
there  is  a  sharp  edge.  6.  Pain  in  renal  disease  often  shoots  down  the 
ureters  and  into  the  testicles.  In  diseases  of  the  spleen  the  pain  is 
generally  localized  to  the  splenic  region,  and  may  shoot  into  the  left 
shoulder.  7.  Result  of  examination  of  the  urine  will  often  make  clear 
that  the  disease  is  renal,  or,  by  its  negative  result,  will  point  to  the 
splenic  origin  of  the  tumor. 

It  is  sometimes  difficult  to  demonstrate  enlargement  of  the  spleen 
when  the  liver,  and  particularly  the  left  lobe,  are  enlarged.  Careful 
palpation  reveals  the  edge  of  the  spleen,  which  descends  further  than 
the  liver  in  full  inspiration.  Having  found  the  anterior  edge,  pressure 
with  the  other  hand  posteriorly  will  bring  the  spleen  forward,  which 
would  not  occur  if  the  suspected  enlargement  was  the  left  lobe  of  the 
liver. 

The  diagnosis  of  splenic  leukcemia  (Plate  XLIV.,  Fig.  1)  rests  princi- 
pally upon  the  blood-condition,  particularly  upon  the  existence  of  a 
marked  increase  of  white  blood-cells.  Red  cells  are  decreased,  and 
altered  forms  are  present.  In  addition  to  characteristic  blood-changes 
there  is  a  great  disposition  to  hemorrhages  ;  dropsies  and  priapism  are 
common  ;  and,  in  later  stages,  fever,  diarrhoea,  great  weakness,  and 
grave  complications,  such  as  pneumonia.  Hemorrhage  in  splenic  leu- 
kaemia occurs  from  the  nose,  bowel,  stomach,  gums,  or  kidney.  It  may 
also  be  subcutaneous,  intermuscular,  cerebral,  or  retinal. 

Regarding  the  diagnosis  of  splenic  hypertrophy  (ague-cake)  in  chronic 
malarial  affections,  Osier  says  :  "  The  history  of  malarial  cachexia,  the 
absence  of  lymphatic  enlargement,  and  the  blood-condition  will  usually 
be  sufficient  for  the  purpose  of  a  diagnosis.  Great  increase  in  the 
white  blood-corpuscles  is  not  often  seen  in  the  chronic  splenic  tumor  of 
malaria ;  indeed,  they  may  be  much  diminished  in  number.  Toward 
the  end  in  very  chronic  cases  the  clinical  picture  may  be  very  similar ; 
the  large  abdomen,  possibly  ascites,  dropsy  of  the  feet,  and'  irregular 
fever  may  resemble  closely  splenic  leukaemia,  and  the  absence  of  an 
increase  in  the  colorless  corpuscles  may  be  the  only  marked  difference." 


PLATE    XLIII. 


FIG.   1. 


FIG.  2. 


Enlargement  of  the  Spleen.  Tumor  of  the  Left  Kidney. 


PLATE   XLIV. 

FIG.    1. 


m^<i 


vM\v 


Mjv 


9 


Leukaemia — Enlarged  Liver  and  Spleen. 


FIG.    2. 


Cyst  of  the  Pancreas. 


DISEASES  OF  LIVER,  SPLEEN  AND  PANCREAS.  893 

Amyloid  spleen,  with  enlargement  of  the  organ,  occurs  in  conditions 
of  prolonged  suppuration,  especially  when  the  bones  are  involved,  and 
in  chronic  phthisis  and  syphilis.  The  spleen  is  enlarged,  hard,  and 
painless.  The  enlargement  is  rarely  great  enough  to  produce  distress 
on  that  account,  and  it  is  so  commonly  associated  with  a  similar  condi- 
tion of  the  liver  and  kidneys,  if  not  of  other  organs,  that  any  constitu- 
tional symptoms  produced  by  the  spleen  are  apt  to  be  masked  by  those 
produced  by  other  organs. 

Hydatid  tumor  of  the  spleen  rarely  causes  any  symptoms  except 
when  it  becomes  very  large ;  then  it  may  give  rise  to  discomfort  and  a 
dragging  pain  in  the  left  hypochondrium.  But  hydatid  tumors  of  the 
spleen  are  only  exceptionally  very  large ;  when  large  enough  to  admit 
of  palpation,  and  when  the  tumor  is  situated  anteriorly  or  projects  from 
the  lower  border  or  from  beneath  the  organ,  the  detection  of  fluctuation, 
the  withdrawal  of  the  characteristic  fluid  by  aspiration,  and  possibly 
the  hydatid  fremitus,  will  establish  the  diagnosis,  when  taken  in  con- 
nection with  the  gradual  development  of  the  tumor  and  exposure  to 
possible  infection.  In  the  absence  of  physical  signs  of  a  cyst  the  nature 
of  the  tumor  can  only  be  suspected  from  the  habits  of  the  patient  or 
his  place  of  residence.  Suppuration  of  the  sac  may  be  brought  about 
by  injury  or  rupture  mto  the  adjacent  cavities,  with  grave  if  not  fatal 
results. 

Inherited  syphilis  and  chronic  syphilis  are  accompanied  by  enlarge- 
ment of  the  spleen.  They  cause  a  chronic  interstitial  inflammation. 
The  enlargement  is  not  very  great,  and  does  not  present  characteristic 
features. 

Malignant  tumors  of  the  spleen  are  very  rarely  primary.  The  diag- 
nosis must  be  made  by  noting  malignant  disease  elsewhere,  the  very 
rapid  enlargement  of  the  spleen,  with  possibly  nodules  scattered  over 
its  surface,  and  the  presence  of  cachexia  and  the  usual  constitutional 
signs  of  a  malignant  disease. 

In  young  children  enlargement  of  the  spleen  is  not  uncommon.  It  is 
found  associated  most  frequently  with  rickets,  syphilis,  and  malarial 
poisoning,  and  has  been  attributed  to  each  of  these  diseases.  In  the 
London  Lancet,  April  30,  1892,  Dr.  J.  W.  Can*  analyzes  thirty  cases, 
and  comes  to  the  conclusion  that  the  enlargement  of  the  spleen  is  due 
to  splenic  anaemia,  the  essential  cause  being  unknown.  Rickets,  syph- 
ilis, and  ague  are  found  as  passing  causes  only,  since  the  disease  is 
found  in  some  cases  where  these  causes  can  be  excluded.  According  to 
this  author,  the  disease  is  extremely  rare  in  children  older  than  two 
and  one-half  years.  The  spleen  is  more  readily  palpated  in  children 
than  in  adults.  It  is  also  more  movable,  and  hence  by  bimanual  pal- 
pation it  can  be  more  easily  brought  forward  to  the  median  line. 

Diseases  of  the  Pancreas. 

Just  as  the  functional  activity  of  the  pancreas  is  separated  with  diffi- 
culty from  that  of  other  functionally  related  organs,  so  the  aberration 
of  such  activity  is  discerned  with  the  greatest  difficulty.  As  the  physi- 
ology and  pathology  are  blended  so  the  symptoms  are  intermingled. 


894  SPECIAL  DIAGNOSIS. 

The  pancreatic  secretion  aids  in  intestinal  digestion,  particularly  in 
emulsifying  fats,  hence  symptoms  due  to  disturbance  of  this  function 
are  looked  for,  and  it  is,  in  a  measure,  true  of  all  cases  of  pancreatic 
disease  that  there  is  some  intestinal  indigestion.  For  the  purpose  of 
determining  whether  the  function  of  digestion  of  fats  has  been  modified 
the  patient  with  suspected  pancreatic  disease  is  given  fats  in  some  form, 
and  the  stools  are  watched.  If  fat  is  passed  in  the  stool  in  the  amount 
taken  by  the  mouth,  without  being  broken  up,  or  emulsified,  it  is  held 
as  proof  that  disease  of  the  pancreas  is  present.  While  fatty%  stools  may 
be  indicative  of  pancreatic  disease,  the  absence  of  fat  in  the  stools,  in 
patients  who  are  fed  upon  it,  cannot  be  considered  to  exclude  disease 
of  this  organ,  for,  notwithstanding  its  absence  in  a  large  number  of 
instances  in  Avhich  the  experiment  was  tried,  the  pancreas  was  found 
to  be  the  seat  of  grave  disease.  Sugar  has  been  observed  in  the  urine 
in  many  cases  in  which  the  pancreas  was  the  seat  of  the  disease.  In 
fact,  glycosuria  has  been  attributed  to  pancreatic  disease  in  cases  of 
grave  diabetes.  This  symptom,  however,  is  not  constant  in  pancreatic 
lesions.  Three  classes  of  symptoms — intestinal  indigestion,  fatty  stools, 
and  glycosuria — are,  therefore,  not  diagnostic  of  pancreatic  disease,  but 
only  afford  presumptive  evidence  of  its  presence. 

Tumor  of  the  Pancreas.  The  most  striking  symptoms  of  disease  of 
the  pancreas,  apart  from  those  due  to  the  morbid  process,  as  suppura- 
tion or  cancer,  are  those  due  to  a  tumor  pressing  upon  surrounding 
structures.  It  may  press  upon  the  gall-duct,  causing  jaundice.  From 
its  situation  in  the  epigastric  region  it  may  resemble  an  aneurism,  or  a 
tumor  of  the  pylorus  or  of  the  transverse  colon.  Tumors  of  the  pan- 
creas are  usually  due  to  cancer.  This  is  usually  of  the  scirrhous  variety, 
and  generally  primary.  The  enlargement  cannot  be  distinctly  made 
out  unless  the  patient  is  very  much  emaciated.  When  it  has  advanced 
considerably  it  may  simulate  aneurism,  but  is  distinguished  by  the 
difference  in  the  character  of  the  pulsation.  In  aneurism  the  pulsation 
is  distensile,  in  disease  of  the  pancreas  it  is  an  up-and-down  movement ; 
the  hand  is  lifted  with  each  pulsation  of  the  aorta.  Tumor  of  the 
pylorus  is  excluded  largely  because  of  the  more  superficial  position  of 
the  mass,  because  of  its  association  with  pyloric  obstruction,  and  with  less 
frequent  jaundice  than  occurs  in  disease  of  the  pancreas.  A  pyloric  tumor 
is  more  movable  and  may  change  position  after  the  stomach  is  inflated 
by  gas  or  distended  by  fluid.  Examination  with  the  patient  on  the 
hands  and  knees  may  aid  in  the  distinction  between  the  two.  In  a 
tumor  of  the  transverse  colon  its  nearness  to  the  surface  and  its  mova- 
bility,  its  association  with  more  or  less  constipation,  and  the  occurrence 
of  intestinal  hemorrhage,  are  of  diagnostic  significance. 

The  general  symptoms  of  the  cancerous  cachexia ;  the  occur- 
rence of  intestinal  indigestion,  or  of  fatty  stools  ;  the  gradual  onset  of 
jaundice ;  the  occurrence  of  deep-seated  epigastric  pain  ;  an  immovable 
tumor,  with  glycosuria,  make  a  symptom-group  very  characteristic  of 
cancer  of  the  pancreas. 

When  the  patient  is  on  a  milk-diet  an  examination  of  the  feces  will 
show  that  an  excess  of  the  ingested  fat  is  lost — in  short,  that  there  is 
deficient  pancreatic  digestion  with  lessened  absorption  of  fat. 


DISEASES  OF  LIVER,  SPLEEN  AND  PANCREAS.  895 

Hemorrhage.  We  owe  to  F.  W.  Draper  and  Prince  our  knowl- 
edge of  hemorrhage  into  the  pancreas.  Since  they  have  published  the 
results  of  their  labors  the  affection  has  been  frequently  recognized. 
The  attack  conies  on  suddenly  in  perfect  health,  and  usually  terminates 
life  in  a  short  period.  Nothing  in  the  occupation  or  conduct  of  the 
patient  at  the  time  is  known  to  favor  the  development  of  the  hemor- 
rhage. He  is  seized  with  severe  pain,  which  is  localized  in  the  upper 
part  of  the  abdomen.  It  increases  in  severity,  and  may  intermit  like 
colic.  Nausea  and  vomiting  take  place  almost  at  the  same  time.  The 
vomiting  becomes  obstinate.  Extreme  depression  rapidly  sets  in  and 
the  patient  becomes  anxious  and  restless.  Collapse  ensues  in  a  short 
time.  The  extremities  become  cold  and  the  forehead  is  covered  with 
sweat.  The  pulse  increases  in  frequency,  and  rapidly  diminishes  in 
strength.  It  soon  becomes  imperceptible.  The  pain  and  vomiting 
call  attention  to  the  upper  abdomen.  It  is  tender  on  pressure ;  the 
tenderness  may  extend  throughout  the  entire  upper  half  of  the  abdo- 
men. Tympanites  may  develop.  There  is  constipation  in  many  cases. 
The  temperature  remains  normal,  or  becomes  subnormal.  The  pain, 
the  vomiting,  the  anxious  and  restless  state  continue  without  relief. 

From  the  above  group  of  symptoms  it  can  readily  be  seen  that  the 
diagnosis  is  obscure.  The  disease  can  be  taken  for  perforation  of  the 
stomach  by  ulcer,  although  the  vomiting  may  not  be  so  persistent  and 
frequent.  Intestinal  obstruction  in  the  upper  portion  of  the  tract 
presents  allied  symptoms.  The  hemorrhagic  symptoms,  however,  are 
more  pronounced  in  pancreatic  hemorrhage.  Pallor  of  the  face  is  sure 
to  ensue.  The  vomiting  is  not  fecal  in  character.  Constipation  can 
be  relieved.  It  is,  however,  difficult,  and  in  many  cases  impossible, 
to  establish  a  diagnosis.  The  rapidity  of  development  of  the  symptoms 
is  of  importance.  The  pain  and  collapse  may  be  due  to  rupture  of  an 
aneurism  of  the  aorta. 

Acute  Hemorrhagic  Pancreatitis.  For  our  knowledge  of  this 
disease  we  are  indebted  to  Fitz.  He  collated  the  facts  from  the  litera- 
ture, and,  adding  the  results  of  his  own  valuable  observations,  has 
enabled  us  to  recognize  this  affection  during  life.  It  usually  occurs 
after  the  middle  period  of  life,  although  it  may  occur  in  early  child- 
hood, the  youngest  patient  known  to  the  writer  being  eight  months  of 
age.  It  is  more  common  in  males  ;  in  those  addicted  to  alcohol,  and 
in  fat  subjects.  The  patient  has  often  been  the  subject  of  attacks  of 
indigestion  or  of  epigastric  pain  or  of  biliary  colic.  A  blow  on  the 
abdomen  or  injury  in  the  lumbar  region  appears  to  have  been  the 
exciting  cause  in  a  number  of  cases. 

The  attack  develops  suddenly,  resembling  somewhat  hemorrhage  of 
the  pancreas.  There  is  violent  pain  which  is  at  first  complained  of  in 
the  upper  abdomen,  although  it  is  sometimes  general.  Nausea  and 
vomiting  are  present  in  all  the  cases,  constipation  in  most  of  them. 
The  abdomen  is  frequently  the  seat  of  tympanitic  distention.  In 
many  instances  an  obscure  tumor  can  be  made  out  in  the  lower  epi- 
gastric region.  Collapse-symptoms  supervene,  although  fever  may 
occur,  the  temperature  rising  to  102°.  The  cases  terminate  by  the 
fourth  day,  even  earlier  in  some  cases.     The  pain  and  collapse  are 


896 


SPECIAL  DIAGNOSIS. 


probably  due  to  pressure  of  the  effused  blood  upon  the  coeliac  plexus. 
The  fever  is  due  to  a  colon-bacillus  infection.  Violent  delirium  resem- 
bling acute  mania  and  not  unlike  that  seen  in  atropine-poisoning,  occurs 
in  some  instances.  Symptoms  of  localized  peritonitis  arise,  and  if  the 
patient  lives  the  tumor  increases  to  a  considerable  size. 


Fig.  204. 


Tumor  of  the  pancreas. 


The  symptoms  resemble  acute  intestinal  obstruction,  an  irritant  poison, 
or  perforation  of  the  gastro-intestinal  or  biliary  tract.  In  several  in- 
stances laparotomy  has  been  performed  for  the  relief  of  supposed 
obstruction.  The  intense  pain  in  the  epigastrium,  with  violent  vomit- 
ing and  distention  of  the  upper  abdomen,  without  a  possible  cause  for 
obstruction,  are  favorable  to  acute  pancreatitis.  The  difficulty  of  diag- 
nosis, however,  is  so  great  that  resort  to  laparotomy  is  justifiable,  in 
order  to  determine  exactly  the  nature  of  the  condition.  In  a  most 
interesting  case  reported  by  W.  S.  Thayer,  the  diagnosis  of  acute 
pancreatitis  (confirmed  by  laparotomy)  was  based  upon  the  history  of 
previous  attacks  of  pancreatic  pain,  with  fever,  vomiting,  and  collapse, 
occurring  hi  an  adult,  who  was  over-fat  and  an  alcoholic  ;  the  exclusion 
of  disease  in  other  organs  and  the  absence  of  a  history  of  gallstones  or 
gastric  ulcer  or  abscess  from  other  causes ;  the  occurrence  of  pain ;  the 
presence  of  a  deep-seated  tumor  which  gave  indistinct  signs  of  fluctua- 
tion, which  was  not  movable  with  respiration,  and  the  dulness  of  which 
was  not  continuous  with  or  of  the  same  character  as  that  of  adjacent 


DISEASES  OF  LIVER,  SPLEEN  AND  PANCREAS.  897 

solid  organs.  Epigastric  tympany  was  also  a  point  in  favor  of  pancre- 
atic disease.  The  accompanying  figure  indicates  the  site  of  the  tumor 
in  Dr.  Thayer's  case. 

Suppurative  Pancreatitis.  Fitz  has  found  that  this  affection 
occurs  in  adults  under  forty  years,  more  frequently  in  males.  Symp- 
toms continue  during  several  weeks,  and  may  persist  for  a  year.  Pain 
in  the  epigastrium  is  complained  of,  associated  with  irregular  vomiting, 
the  latter  persisting  in  spite  of  care  as  to  feeding.  Fever  is  irregular 
in  type,  and  exhaustion  ensues.  Jaundice,  fatty  diarrhoea,  and  gly- 
cosuria have  been  met  with  in  some  cases.  In  a  case  under  my  observa- 
tion obstruction  of  the  portal  vein  took  place,  with  ascites.  The  latter 
was  large,  and  recurred  rapidly  after  tapping.  In  this  patient  pain 
and  gastric  disturbance  were  absent.  There  was  no  fever.  Emacia- 
tion,  constipation,  and  a  tumor  above  the  umbilicus  were  present ;  the 
emaciation  was  extreme.  The  tumor  was  ill-defined,  painless,  appar- 
ently superficial.  Many  other  symptoms  of  pancreatic  disease  pointed 
out  by  Roberts  wTere  present.  Apathy  and  despondency  were  marked  ; 
bronzing  of  the  face  was  also  present.  The  patient  was  a  middle-aged 
man,  forty-two  years  old,  addicted  to  the  use  of  alcohol.  He  was 
thought  to  have  cirrhosis  of  the  liver.  As  happened  in  this  case,  the 
pus  may  accumulate  in  the  duodeno-jejunal  fossa  and  fill  up  the  cavity 
of  the  lesser  peritoneum,  with  more  pronounced  symptoms  of  tumor 
than  occur  in  similar  fluid  accumulations  in  the  above-mentioned  cavity. 

Gangrenous  Pancreatitis.  This  may  follow  later  upon  hemor- 
rhages into  the  pancreas.  The  symptoms  are  extremely  obscure.  Symp- 
toms of  collapse  may  occur,  following  pain,  which  is  of  longer  duration 
than  in  the  acute  form,  or  vomiting,  which  is  not  so  persistent.  A 
patient  of  mine,  upward  of  sixty  years  old,  suffering  from  dyspepsia, 
vomited  blood  in  the  course  of  an  illness  which  was  characterized  by 
loss  of  flesh  and  weakness.  The  ansemia  became  very  profound  after 
the  gastric  hemorrhage,  and  exhaustion  was  extreme.  There  was  no 
marked  tumor,  but  only  resistance  in  the  region  below  the  xiphoid. 
There  were  dulness  and  tubular  breathing  at  the  base  of  the  left  lung. 
Fever  was  absent.  Death  ensued  from  exhaustion.  A  small,  flat  car- 
cinoma was  found  in  the  pyloric  end  of  the  stomach,  but  there  was  no 
perforation.  Gangrenous  pancreatitis,  with  signs  of  an  ante-mortem 
hemorrhage,  was  found.  The  accumulation  took  place  behind  the 
stomach  and  colon,  but  in  front  of  the  kidney  ;  its  outer  wall  was 
bounded  by  the  spleen.  It  was  circumscribed  above  by  the  diaphragm. 
Pleuritis  and  small  pulmonary  abscesses  at  the  base  of  the  left  lung 
were  found. 

In  some  instances  the  pancreas  has  sloughed  into  the  bowel,  and  in 
two  such  cases  recovery  took  place  after  its  discharge  from  the  rectum. 

Chronic pancreatitw  is  not  recognized  during  life,  although  its  possible 
presence  must  be.  considered  in  all  cases  of  diabetes,  and  in  jaundice 
not  otherwise  explained. 

Cyst  of  the  Pancreas.  (Plate  XLIV.,  Fig.  2.)  Cysts  of  the 
pancreas  follow  impaction  of  calculi  in  the  pancreatic  duct ;  sometimes 
the  biliary  calculi  obstruct  the  orifice.  The  symptoms  are  those  of 
tumor  in  the  upper  abdomen  which  occupies  the  median  position,  or  is 

57 


898  SPECIAL  DIAGNOSIS. 

chiefly  on  the  left  side  in  the  upper  quadrant.  It  may  fill  the  abdominal 
cavity  and  simulate  ovarian  tumor.  It  usually  develops  slowly,  but 
cases  of  rapid  onset  have  been  described.  Fatty  diarrhoea  is  not  present. 
There  is  a  sense  of  weight  and  fulness  in  the  epigastrium.  The  cysts 
are  not  really  true  cysts,  but  accumulations  of  pancreatic  fluid  in  the 
lesser  peritoneal  cavity. 

The  signs  are  those  of  tumor  to  the  left  of  the  median  line,  encroach- 
ing upon  the  left  lobe  of  the  liver  above,  and  extending  almost  to  the 
transverse  umbilical  line.  Korte,  in  a  series  of  sixteen  cases,  observed 
that  the  greatest  prominence  of  the  mass  was  below  the  navel.  The 
tumor  is  smooth,  and  may  fluctuate ;  it  is  not  hard  and  lobulated.  On 
account  of  its  presence  the  diaphragm  may  be  arched  so  that  the  heart 
is  dislocated  upward  to  the  left ;  the  apex  is  found  in  the  third  inter- 
space. It  also  causes  increased  dulness  behind  on  the  left  side,  the 
upper  border  approaching  the  angle  of  the  scapula.  Exploratory  punc- 
ture in  either  instance  determines  the  nature  of  the  fluid,  and  may  deter- 
mine the  diagnosis.  Boas  does  not  think  the  chemical  character  of  the 
fluid  is  sufficient  to  establish  a  diagnosis.  (See  Examination  of  Cyst 
Fluid,  page  367.) 

Senn  has  pointed  out  that  in  cysts  of  the  pancreas  the  complexion  is 
peculiar ;  it  is  described  as  an  unhealthy  yellow,  dirty,  or  earthy  hue. 
The  writer  also  considers  that,  in  the  diagnosis  of  pancreatic  cyst,  the 
history  of  the  case,  the  location  of  the  tumor,  and  its  relation  to  other 
organs  are  to  be  considered.  The  disease  occurs  in  adults,  and  usually 
follows  traumatism.  A  blow  in  the  epigastrium  is  a  prominent  ex- 
citing cause.  In  some  instances  it  occurs  after  an  attack  of  so-called 
biliary  colic  or  colicky  pains  in  the  upper  abdomen,  with  vomiting, 
but  without  jaundice — a  condition  characteristic  of  calculus  in  the 
pancreatic  ducts.  The  growth  of  the  tumor  in  some  cases  is  unusually 
rapid — a  point  in  favor  of  its  pancreatic  origin.  It  may  attain  an 
enormous  size,  as  previously  mentioned. 

In  contrast  to  cancer,  pain  is  absent.  Fatty  stools  are  absent.  Pre- 
vious gastro-intestinal  derangement  may  be  ascertained  upon  inquiry. 
Diabetes,  in  this  as  well  as  other  affections  of  the  pancreas,  may  be 
present.  The  cyst  is  always  found  at  first  in  the  region  occupied  by 
the  pancreas,  depending  somewhat  upon  the  portion  of  the  pancreas 
from  which  it  originated.  It  may  be  below  the  right  lobe  of  the  liver, 
below  the  xiphoid,  or  in  the  left  upper  quadrant.  In  the  great  majority 
of  cases  it  occupies  the  last  situation.  It  displaces  the  stomach  forward 
and  to  the  right,  the  transverse  colon  downward,  the  diaphragm  and 
the  contents  of  the  chest  upward.  The  cyst  may  be  movable  in  respi- 
ration. 

Diagnosis.  It  must  be  distinguished  from  cancer  of  the  pancreas  or 
adjacent  organs,  aneurism,  hydatid  cyst  of  the  liver,  the  spleen,  or  the 
peritoneum,  affections  of  the  retroperitoneal  glands,  hydronephrosis, 
cystic  disease  of  the  suprarenal  capsule,  circumscribed  peritonitis  with 
exudation,  ascites,  cystic  disease  of  the  ovary.  Pain  is  an  important 
symptom  of  disease  of  the  pancreas  in  its  more  acute  manifestations ; 
it  must  be  distinguished  from  the  pain  of  intestinal  obstruction  and  the 
pain  of  perforative  peritonitis.     The  pain  is  always  localized  in  the 


DISEASES  OF  LIVER,  SPLEEN  AND  PANCREAS.  899 

region  below  the  xiphoid,  or,  in  general,  is  confined  to  the  upper  half 
of  the  abdomen.  It  exactly  simulates  the  pain  of  the  affections  just 
described.  This  resemblance  is  more  pronounced  because  of  the  asso- 
ciation of  vomiting  and  collapse  in  obstruction  and  perforative  perito- 
nitis. Pain,  although  not  so  intense,  but  of  a  colicky  nature,  attended 
by  diarrhoea  or  constipation,  in  some  instances  with  intestinal  hemor- 
rhage, may  be  due  to  calculous  disease  of  the  pancreas.  Frequently 
this  form  of  pain  can  be  recognized  if  other  symptoms  of  pancreatic 
disease,  such  as  glycosuria,  steatorrhea,  and  intestinal  indigestion,  are 
present. 


CHAPTER    VII. 

DISEASES   OF  THE  KIDNEYS. 

The  kidneys  are  affected  by  disease  from  several  sources.  First, 
the  great  vascular  supply  is  subject  to  the  alteration  which  takes  place 
in  any  large  arterial  area,  either  from  direct  hyperemia,  through  the 
influence  of  the  vasomotor  nerves  (see  Hyperemia),  or  from  passive 
hyperemia  or  congestion  through  the  central  organ  of  the  circulation. 
Second,  the  bloodvessels  are  the  seat  of  thrombosis  and  embolism,  particu- 
larly the  latter,  causing  renal  infarction.  Third,  infectious  material,  as 
micro-organisms  or  toxins,  is  carried  to  the  kidney,  and,  in  passing 
through  the  structure,  gives  rise  to  inflammation  either  of  an  infective 
or  of  an  irritative  character.  Similarly,  poisons  that  are  ingested,  and 
the  products  of  metabolism,  which,  if  modified  in  character  or  in- 
creased in  amount,  excite  irritation  and  lead  to  inflammatory  changes. 

But  the  kidney  is  open  to  attack  from  sources  lower  down  in  the 
urinary  tract.  Through  the  bladder  and  ureter  infection  may  extend 
upward,  causing  the  consecutive  inflammatory  processes  which  are  often 
seen  after  disease  of  the  urethra,  bladder,  or  ureter.  The  kidney  is  at 
the  apex  of  a  system  of  tubes  or  channels.  Any  alteration  of  them, 
whether  mechanical  or  functional,  has  a  secondary  effect  upon  the  kid- 
ney. Obstruction  of  the  ureter,  or  obstruction  in  the  conduits  beyond, 
leads  to  consecutive  hypertrophy,  inflammation,  and  atrophy.  (See 
Morbid  Processes.)  If  the  urine  is  abnormal,  one  of  these  three 
causal  conditions  obviously  may  be  present. 

The  morbid  processes  which  may  take  place  in  the  kidney  are  such 
as  are  common  to  all  organs — congestion,  inflammation,  degeneration, 
and  morbid  growths.  The  symptoms  that  attend  the  morbid  processes 
are  such  as  accompany  similar  processes  elsewhere.  The  general  symp- 
toms of  the  morbid  processes  are  not  marked  except  in  the  case  of 
infectious  inflammation  or  of  morbid  growths,  as  carcinoma.  There  are 
fever  and  emaciation.  Fever  occurs  in  acute  nephritis,  perinephritic 
abscess,  suppurative  and  tuberculous  nephritis,  pyelitis,  and,  with  twists 
of  the  ureter,  in  floating  kidney.  Emaciation  occurs  in  chronic,  suppu- 
rative, and  tuberculous  nephritis  and  carcinoma.  Other  general  symp- 
toms in  renal  disease  are  due  to  the  interference  with  the  function  of 
the  organ  which  usually  results.  Pain  is  the  only  local  symptom  due 
to  the  morbid  process ;  a  sirelling  the  onlv  physical  sign. 

The  symptoms  of  renal  disease  are  also  clue  to  the  functional  or  ana- 
tomical alteration  of  the  kidney.  But  the  structure  is  so  closely  inter- 
woven with  the  function  that  morbid  changes  in  one  imply  morbid 
changes  in  the  other.  As  the  anatomical  alterations  are  usually  beyond 
the  pale  of  physical  investigation,  we  find  that  functional  symptoms 
alone  are  apparent.     Hence,  we  look  for  changes  in  the  urine,  which  is 


DISEASES  OF  THE  KIDNEYS.  901 

the  product  of  renal  function,  and  for  symptoms  resulting  from  abey- 
ance or  cessation  of  the  function.  Rarely  we  have  enlargements  due  to 
tumor,  as  cancer  or  abscess,  or  to  obstruction  of  the  channels,  causing 
hydronephrosis,  or  to  parasitic  disease. 

The  symptoms  due  to  the  alteration  of  function  are  :  1 .  Urcemia. 
2.  Cardio-vascular  symptoms.  3.  Ancemia.  4.  Dropsy.  5.  Altera- 
tions of  the  urine.  6.  Alterations  in  micturition.  The  symptoms  of 
renal  disease  are,  therefore,  both  subjective  and  objective. 

The  urine  is  not  simply  an  index  of  the  condition  of  the  kidneys. 
It  varies,  within  the  bounds  of  health,  in  color,  quantity,  and  quality. 
Food,  exercise,  and  other  conditions  modify  the  secretion.  It  can 
readily  be  seen,  therefore,  that  any  general  disease  and  many  local  dis- 
eases cause  alterations  in  the  character  of  the  urine.  Any  abnormal 
urine,  therefore,  may  be  symptomatic  of  renal  disease  or  of  disease 
beyond  the  point  at  which  the  urine  passes  out  of  the  body.  Usually 
abnormal  changes  in  the  urine,  due  to  the  general  condition,  do  not 
give  rise  to  local  renal  symptoms  or  to  abnormal  renal  function.  The 
exception  is  seen  when  an  excess  of  uric  acid,  or  of  urates,  or  of  oxalates 
is  passed.  They  may  give  rise  to  local  pain  and  may  set  up  sufficient 
irritation  to  cause  albuminuria. 

Classification.  The  best  classification  of  diseases  of  the  kidneys  is 
that  based  upon  the  propositions  of  Delafield,  who,  in  a  paper  entitled 
"  On  the  Diseases  of  the  Kidneys  Popularly  Called  '  Bright's  Disease,' "  * 
submitted  a  classification  dependent  upon  the  nature  of  the  morbid  pro- 
cess. The  morbid  processes  included  congestions,  degenerations,  and 
inflammations  of  the  renal  structure.  In  addition  to  these  affections 
we  must  also  include  in  the  nosology  of  renal  disease  tumors  (cancer, 
abscess,  and  hydronephrosis),  and  anomalies  of  growth  or  position 
(floating  kidney,  horseshoe  kidney),  affections  due  to  invasion  of  the 
kidney  by  parasites,  and  affections  due  to  obstruction  of  the  tubes 
through  which  the  offices  of  the  kidney  are  carried  on  (renal  calculus, 
hydronephrosis,  and  pyonephrosis). 

The  Data  Obtained  by  Inquiry.     The  Subjective  Symptoms. 

The  subjective  symptoms  are  due  to  morbid  processes  within  the 
kidney  or  to  alterations  of  its  function.  The  class  of  nervous  symp- 
toms which  belong  to  uraemia  are  subjective  in  character,  as  are  also  the 
symptoms  of  movable  kidney. 

Pain.  Pain  in  the  kidneys  is  referred  to  the  loins.  It  is  complained 
of  as  a  dull  aching,  sometimes  increased  by  movement,  often  attended 
by  a  sense  of  weight  or  pressure.  Pain  of  this  character  extends  over 
the  entire  lumbar  region  and  is  due  to  disease  of  both  kidneys,  as  in 
acute  nephritis.  It  is  bilateral.  We  have  also  unilateral  renal  pain, 
referred  to  one  kidney.  The  pain  may  be  seated  in  the  region  of.  the 
kidney  behind,  opposite  the  two  lower  dorsal  and  two  upper  lumbar 
vertebral  spines,  or  deep-seated  in  the  abdomen,  to  the  right  or  left  of 

1  Trans.'Acuer.  Physicians,  vol.  vi.,  189],  p.  1'24. 


902  SPECIAL  DIAGNOSIS. 

the  spinal  column  below  the  level  of  the  umbilicus.  It  is  not  generally 
mistaken  for  pain  due  to  other  causes,  as  myalgia,  or  disease  of  the 
vertebras.  If  rnyalgic,  it  may  follow  exposure  to  cold  and  be  associ- 
ated with  pain  in  other  muscles.  Neuralgia  of  the  kidneys  no  doubt 
occurs.  It  may  be  due  to  malaria,  lead-poisoning,  gout,  or  ansemia. 
It  partakes  of  the  character  of  neuralgia  elsewhere.  It  must  not  be 
forgotten  that  in  a  case  of  disease  of  one  kidney  the  pain  is  frequently 
referred  to  its  healthy  fellow. 

Unilateral  pain  may  be  constant  or  paroxysmal.  Constant  pain  is 
usually  due  to  organic  disease  of  the  kidney,  as  carcinoma  or  tubercu- 
losis. (See  Palpation.)  It  may,  however,  be  due  to  the  impaction  of  a 
calculus  in  the  pelvis  of  the  kidney.  It  may  also  be  due  to  a  displaced 
or  movable  kidney.  In  tumors  the  pain  may  follow  the  course  of  the 
sciatic  nerve,  simulating  sciatica.  In  pyelitis  and  hydronephrosis  the 
pain  is  of  a  tearing  character,  whereas  in  movable  kidney  it  is  variable. 

Paroxysmal  and  lancinating  pain,  the  paroxysms  occurring  at  long 
intervals,  is  usually  due  to  renal  calculus,  or  to  the  presence  of  a  foreign 
substance,  as  blood,  in  the  pelvis  of  the  kidney.  The  pain  is  seated 
not  only  in  the  regions  just  indicated,  but  extends  along  the  ureter, 
from  the  loin  to  the  front  of  the  abdomen.  It  may  persist  for  some 
time,  at  a  point  on  either  side  of  the  umbilicus  above  or  below  it,  or  at 
a  point  on  the  surface  of  the  abdomen  opposite  the  brim  of  the  pelvis. 
Thence  the  pain  extends  into  the  bladder,  either  above  the  pubis  (the 
hypogastric  region),  or  into  the  testicle,  or  down  the  inside  of  the  thigh. 
It  may  be  in  the  loin  and  at  the  end  of  the  penis  at  the  same  time,  or 
lancinate  along  the  whole  urinary  tract.  In  rare  cases  the  pain  is  in 
the  kidney  of  the  healthy  side.  The  pain  of  renal  colic  is  always  asso- 
ciated with  frequency  of  micturition,  with  or  without  pain  during  the 
passage  of  the  urine.  The  character  of  the  urine  often  points  to  the 
cause  of  the  pain.  The  urine  is  usually  bloody,  and  at  first  scanty ; 
when  the  obstruction  is  removed,  it  becomes  copious.  It  sometimes 
contains  pus.  Between  the  paroxysms  the  urine  may  contain  blood, 
pus,  and  pelvic  epithelium.  Renal  pain  or  colic  located  in  front  of 
the  abdomen  must  not  be  confounded  with  the  pain  of  hepatic  or  intes- 
tinal colic.  The  pain  is  usually  lower  than  in  hepatic  colic,  extends 
along  the  course  of  the  ureter,  and  is  attended  by  symptoms  referable 
to  the  urinary  and  not  to  the  hepatic  system. 

Nephrolithiasis  (Renal  Calculus). 

Renal  calculi  vary  in  size  from  "  sand,"  through  "gravel,"  to  "  stones.'' 
The  latter  may  be  from  the  size  of  a  cherry  to  one  large  enough  to  fill 
the  pelvis  of  the  kidney.  They  consist  usually  of  uric  acid,  and  are 
hard,  brownish-reel  or  blackish,  crystalline,  and  the  larger  ones  are 
arranged  in  distinct  layers.  More  rarely  we  have  calculi  of  calcium 
oxalate,  extremely  hard  and  nodular.  Some  stones  have  alternate 
layers  of  the  two  salts ;  others  consist  of  phosphates,  but  usually  the 
inside  is  of  uric  acid  or  calcium  oxalate,  the  phosphates  having  been 
deposited  after  the  urine  became  alkaline.  Very  rare  forms  are  of 
cystin,  xanthin,  indigo,  etc. 


DISEASES  OF  THE  KIDNEYS.  903 

A  consideration  of  the  frequency  of  the  affection  and  some  etiological 
data  aid  in  the  diagnosis.  It  is  not  a  common  affection.  I  have  had 
twenty-nine  cases  in  private  practice  and  eleven  in  hospital  practice. 
Thirteen  cases  only  have  been  treated  in  the  Presbyterian  Hospital  in 
twenty-five  years,  during  which  time  over  8000  cases  of  all  kinds  were 
treated.1  It  is  a  disease  of  the  middle  and  upper  classes.  This  is  par- 
ticularly true  of  uric-acid  calculous  disease.  It  is  not  a  disease  of  the 
old  or  the  very  young,  in  my  experience.  The  youngest  subject  was 
twenty-five  years  of  age  ;  the  oldest  sixty-nine.  The  ages  ranged  from 
thirty-five  to  fifty-five.  Twelve  of  my  private  patients  were  of  the 
female  sex,  seventeen  of  the  male  sex.  There  does  not  seem  to  be  much 
difference  of  frequency  in  the  two  sexes.  Most  authorities,  however, 
hold  to  the  preponderance  in  women,  the  ratio  being  as  3  to  1.  Seden- 
tary occupation  and  an  in-door  life  are  predisposing. 

Symptoms.  Symptoms  may  be  wanting  or  they  may  be  divided  into 
three  classes  : 

(«)  Calculi  may  remain  in  the  pelvis  of  the  kidney,  and  not  cause 
any  renal  symptoms.  They  may  cause  gastric  disturbance  or  catarrh 
of  the  bladder  or  renal  pelvis.  There  may  be  occasional  pain  in  the 
lumbar  region,  the  cause  of  which  is  unsuspected. 

(6)  They  may  excite  pain,  hematuria,  and  frequent  micturition. 
(c)  They  may  attempt  to  pass  from  the  pelvis  of  the  kidney  into  the 
ureter.    They  then  cause  renal  colic,  the  symptoms  of  which  have  been 
described  above.     In  the  intervals  of  the  attacks  of  colic  the  patient 
may  be  free  from  symptoms. 

The  symptoms  ascribed  to  the  presence  of  a  calculus  in  the  pelvis 
of  the  kidney  are  pain,  intermittent  hmnaturia,  pyuria,  pyelitis,  renal 
intermitting  fever,  acute  orchitis,  frequent  micturition,  and  renal  colic. 

Pain.  Pain  of  the  affected  organ  is  the  most  constant  symptom, 
and  this  pain  is  increased  by  movement,  by  jolting,  and  by  pressure. 
Indeed,  pain  induced  by  pressure  is  of  as  great  significance  as  sponta- 
neous pain.  It  frequently  is  persistent,  and  even  continues  in  any 
position  assumed  by  the  patient. 

Pain  in  the  region  of  the  kidney  occurs  from  renal  hyperemia,  neph- 
ritis, pyelitis,  tumors,  and  malignant  disease,  or  from  myalgia  of  rheu- 
matic or  other  causation.  Indeed,  we  have  seen  renal  pain  and  hema- 
turia in  a  case  of  commencing  appendicitis.  The  pain  of  renal  calculus 
(not  renal  colic)  comes  and  goes,  and  is  more  commonly  intermitting 
and  paroxysmal.  Very  frequently,  however,  it  is  constant  and  local- 
ized, either  in  the  region  over  the  kidney,  or  anteriorly  in  the  region 
mentioned.  In  my  experience  it  comes  on  during  the  day,  and  particu- 
larly the  after  part  of  the  day,  and  not,  as  Jacobson  would  have  us 
believe,  at  night.  That  it  may  occur  spontaneously  is  not  so  much 
a  peculiarity  of  renal  calculus  as  that  it  can  be  excited  by  pressure, 
movement,  etc. 

Pain  is  of  more  diagnostic  significance  in  renal  calculus  than  in  any 
other  renal  affection.  Every  attribute  that  has  been  applied  to  pain 
belongs  to  the  pain  of  renal  calculus.     Its  very  vagaries  render  its 

1  J.  H.  Musser:   "  Renal  Calculus,"  Philadelphia  Medical  Journal,  1898. 


904  SPECIAL  DIAGNOSIS. 

presence  one  of  the  most  valuable  signs  of  renal  calculus.  Its  behavior, 
however,  is  often  like  the  flitting  nerve-aches  of  hysteria,  and  we  must 
see  to  it  that  this  counterfeit  is  not  passed  upon  us.  Urinary  phenomena 
do  not  serve  for  the  distinction ;  other  neurotic  manifestations  or  the 
stigmata  of  hysteria  aid  in  the  diagnosis.  The  pain  may  be  aggravated 
by  the  function  of  menstruation  and  even  bear  close  relationship  to  it. 

Hematuria.  Hemorrhage  from  the  kidney  is  the  classical  symp- 
tom of  stone.  It  is  the  most  constant  and  positive  symptom  of  renal 
calculus.  Prior  to  the  use  of  the  centrifugal  machine,  blood  no  doubt 
escaped  the  eye  of  the  observer  when  in  small  amounts,  partly  because 
it  was  destroyed  as  the  urine  advanced  in  decomposition  during  the 
period  it  was  set  aside  for  the  deposition  of  its  solid  elements,  and 
partly  because  the  fewness  of  corpuscles  rendered  them  difficult  to  find. 
Excluding  all  causes  outside  of  the  kidney — i.  e.,  of  vesical  and  ureteral 
origin — renal  hsematuria  may  be  due  to  congestion  and  inflammation, 
to  infarctions,  to  new-growths,  to  tuberculosis,  to  renal  calculus,  and  to 
parasites.  The  fevers  and  infections,  and  scurvy,  purpura,  leukaemia, 
and  haemophilia  are  responsible  for  a  number  of  cases.  In  six  years 
2923  samples  of  the  urine  of  1997  persons  were  critically  examined 
in  my  laboratory.  Blood  was  present  in  364  cases  detected  by  micro- 
scopic examination  alone. 

The  haematuria  resulted  from  congestions  or  hyperaemias  (pregnancy, 
goitre,  heart-disease,  the  fevers,  infections,  and  jaundice)  in  fifty-six 
cases.  In  forty-two  cases  the  haematuria  occurred  in  the  course  of 
acute  and  chronic  Bright's  disease,  and  in  nineteen  more  in  arterio- 
capillary  fibrosis,  being  either  of  renal  or  cardiac  origin.  Gastric  dis- 
orders, rheumatism  in  many  forms,  gout,  neurasthenia,  and  anaemia 
account  for  eighty-one  of  the  cases,  conditions  always  associated  with 
the  copious  discharge  of  urinary  salts,  which  are  irritating.  Vesical 
disease  accounts  for  seventeen  cases,  renal  calculus  for  twenty-eight, 
and  in  twenty  the  diagnosis  was  not  noted  at  the  time  and  is  forgotten. 

All  the  cases  of  renal  calculus  had  haematuria.  It  is  not  an  inter- 
mittent phenomena  alone,  but  one  that  is  constantly  persistent. 

It  is  necessary  to  eliminate  all  sources  of  urethral,  vesical,  and  ureteral 
hemorrhage  before  coming  to  a  conclusion  that  the  hemorrhage  is  of 
renal  origin.  Cystoscopy  must  be  resorted  to,  of  course,  and  possibly 
in  the  right  hands,  ureteral  catheterization.  If  the  hemorrhage  is  free 
the  time  of  its  passage  in  the  act  of  urination  must  be  determined.  The 
reaction  of  the  urine  must  be  borne  in  mind.  It  is  true,  catheterization 
alone  can  avail  to  pronounce  from  which  kidney  the  hemorrhage  comes. 

Blood-cylinders  are  rare,  if  present  at  all,  in  renal  calculus.  They 
denote  hemorrhage  from  the  renal  substance. 

_  In  a  person  of  middle  life  with  uric  or  oxalic  acid  tendencies,  by 
virtue  of  heredity,  occupation  and  habits,  in  whoin  no  cause  for  the 
hemorrhage  can  exist  in  the  urethra,  bladder,  or  ureter,  the  chances 
are  that  it  is  of  pelvic  origin,  due  to  the  irritation  of  gravel  or  of  urine 
densely  loaded  with  salts. 

Klemperer l  has  recently  called  attention  to  haematuria  from  healthy 

1  Deutsche  med.  Wochenschrift,  March  4,  1897. 


DISEASES  OF  THE  KIDNEYS.  905 

kidneys,  as  the  result  of  overexertion,  in  one  case  from  horseback 
riding,  in  another  from  the  bicycle.  He  also  reports  four  cases  of 
haemophilia  and  a  group  due  to  an  angioneurosis.  Hyaline  casts  were 
not  present,  although  blood-cylindroids  were.  General  symptoms  of 
neurasthenia  support  the  diagnosis  in  the  angioneurotic  cases. 

Pyueia.  Pus  in  the  urine  is  looked  upon  by  all  authorities  as 
almost  essential  to  the  diagnosis  of  renal  calculus,  but  in  my  experience 
this  product  of  inflammation  is  usually  absent.  Of  the  twenty-eight 
cases  which  I  examined,  in  fifteen  there  was  no  pus ;  in  six  a  few  cells 
or  a  very  small  quantity  was  found  (four,  womb  cause  obvious) ;  in 
one  it  was  noted  as  considerable  (old  gonorrhoea  and  syphilis,  four 
examinations) ;  in  one  a  small  quantity  (male,  cause  assignable) ;  in 
one  it  was  small  in  amount,  twice  only  in  some  fifty  examinations ; 
in  one  it  was  abundant  and  due  to  genito-urinary  infection  as  well  as 
pyelitis.  Pyuria  is  not  present  unless  an  accidental  infection  has  taken 
place  from  the  lower  tract. 

Albumin.  In  twenty-one  patients  albumin  was  found.  It  was  in 
large  excess  in  three,  due  to  coexisting  Bright' s  disease.  As  a  trace  it 
is  of  frequent  occurrence  and  does  not  imply  a  coexisting  nephritis. 

Casts.  Casts  are  present  in  the  urine  in  nearly  all  cases  of  renal 
calculus.  Sedimentation  must  be  used.  They  are  hyaline — -not  abun- 
dant— long  and  narrow.  Their  persistence  without  other  kinds,  with 
or  without  albumin,  is  diagnostic  of  renal  irritation,  and  with  other 
signs  points  quite  unfailingly  to  calculus. 

The  specific  gravity  of  the  urine  is  an  aid  in  the  diagnosis.  Its 
persistence  above  the  normal  is  both  a  comfort  and  a  sign.  It  enables 
one  to  exclude  renal  cirrhosis  and  aids  to  eliminate  hysteria  or  a  renal 
neurosis. 

Fbequext  mictueitiox  is  not  in  my  experience  an  indication  of 
stone  in  the  kidney,  save  when  attempts  are  made  for  its  passage, 
although  spoken  of  as  a  symptom  of  value  by  most  authorities. 

Paroxysmal  eexal  fevee,  allied  to  hepatic  fever  in  its  expres- 
sion, rarely  occurs,  but  when  present  may  be  due  to  calculus.  It  may 
also  be  due  to  absorption  of  retained  products,  if  the  kidney  is  floating 
and  becomes  twisted.     It  may  be  due  to  pyelitis. 

Dueatiox  of  symptoms  axd  family  histoey  are  also  valuable 
data. 

Diagxosis.  Middle  life  is  a  predisposing  factor,  and  persistent 
hematuria  is  symptomatic,  but  pyuria  rarely  so,  while  albuminuria  and 
hyaline  casts  in  urine  of  high  specific  gravity  are  prominent  elements 
of  the  symptom-complex  upon  which  a  diagnosis  is  made. 

The  diagnosis  can  be  established  by  the  symptom-complex  of  pain, 
local  tenderness,  persistent  //"  maturia,albvminuria,  and  casts  (the  cardiac, 
vascular,  and  nephritic  origin  of  which  is  excluded),  by  the  phenomena 
of  renal  colic  and  by  passage  of  fragments  of  stone. 

If  the  hemorrhage  persists  after  prolonged  rest,  it  is  more  likely  of 
cancerous  or  tuberculous  origin. 

The  differential  diagnosis  must  be  made  from  appendicitis,  movable 
and  twisted  kidney,  biliary  colic,  and  other  affections  simulating  these. 
Catheterization  and  exploration  by  the  ureter  are  required  in  many 


906  SPECIAL  DIAGNOSIS. 

cases.  Hollander  believes  we  can  in  a  large  number  of  cases  make  a 
diagnosis  without  the  aid  of  catheterization,  and  fears  the  danger  of 
infection  from  below. 

Kelly,  very  skilfully  after  ureteral  catheterization,  aspirates  the 
ureters  and  thereby  brings  down  fragments  of  calculi.  He  also  explores 
the  ureters  with  hard-rubber  bougies  tipped  with  wax.  He  can  deter- 
mine the  presence  of  calculi  by  the  markings  on  the  tips  of  the  bougie. 

Frequency  of  Micturition.  There  are  four  causes  of  frequent 
micturition  :  (1)  Disease  of  the  kidneys,  the  ureters,  or  the  bladder ; 
(2)  an  increase  in  the  amount  of  urine,  as  in  diabetes ;  (3)  concentra- 
tion of  the  urine,  as  in  fevers,  gout,  or  acute  nephritis ;  (4)  a  reflex  or 
pure  neurosis. 

Increased  frequency  of  micturition  occurs  in  almost  all  organic  affec- 
tions of  the  genito-urinary  system.  It  is  seen  in  all  forms  of  congestion 
and  inflammation  of  the  kidneys.  In  some  forms  of  nephritis  the 
increased  frequency  may  be  due  to  increase  in  the  amount  of  urine  as 
well  as  to  increased  sensitiveness  of  the  organs.  In  chronic  nephritis 
it  may  not  be  noticed,  save  that  the  patient  is  called  upon  to  pass 
urine  at  night,  arousing  him  from  sleep  for  this  purpose.  Disease  of 
the  ureter  and  disease  of  the  bladder  are  also  associated  with  this 
troublesome  symptom.  It  occurs  in  its  most  aggravated  and  charac- 
teristic form  in  renal  calculus,  or  when  any  foreign  substance  is 
located  in  the  ureter  or  bladder.  The  frequency  amounts  to  six,  eight, 
or  even  a  dozen  times  in  an  hour.  It  is  often  associated  with  tenes- 
mus, the  patient  having  a  constant  desire  to  urinate,  but  passing  small 
amounts.  This  form  of  tenesmus  is  more  frequent  when  the  bladder 
or  urethra  is  the  seat  of  disease,  and  in  renal  calculus. 

The  Data  Obtained  by  Observation     The  Objective  Symptoms. 

The  data  obtained  by  observation  are  secured  :  1 .  By  physical  exam- 
ination of  the  kidney.  2.  By  an  examination  of  the  urine.  3.  By 
catheterization  of  the  ureters.  4.  By  a  skiagraphic  examination.  The 
examination  of  any  person  who  is  sick  is  not  complete  without  an 
examination  of  the  kidney  and  of  the  urine.  The  third  and  fourth 
methods  of  examination  are  not  necessary  unless  the  subjective  symp- 
toms indicate  their  necessity,  or  general  symptoms  are  not  otherwise 
explained. 

Topography  of  the  Kidneys.  (Plate  XIII.,  Fig.  2.)  The  kid- 
neys are  situated  in  the  right  and  left  lumbar  regions  respectively,  the 
left  being  a  little  higher  than  the  right.  They  extend  from  the  eleventh 
rib,  or  twelfth  dorsal  vertebra,  to  the  third  dorsal  vertebra.  The  left 
kidney  is  in  contact  above  with  the  spleen,  and  the  right  with  the  liver. 

Palpation  and  Percussion.  The  kidneys  are  enveloped  in  more 
or  less  abundant  fat ;  their  distance  from  the  anterior  surface  of  the 
abdomen  renders  them  inaccessible  to  percussion  from  that  direction, 
and  the  thick  dorsal  and  lumbar  tissues,  coupled  with  the  relation  of 
the  kidneys  with  the  organs,  spleen,  and  liver,  which  give  a  dull  note 
on  percussion,  make  it  difficult  to  outline  the  kidneys  from  behind. 

Palpation  of  the  normal  kidney  is  difficult.    It  can  only  be  bimanual. 


DISEASES  OF  THE  KIDNEYS.  907 

Place  the  fingers  of  one  hand  below  the  last  rib  outside  of  the  lumbar 
muscles — erector  spinse — and  apply  the  other  below  the  ribs  in  front. 
Firm,  persistent  pressure  with  the  abdominal  muscles  relaxed,  especially 
in  thin  subjects,  will  often  enable  the  normal  kidney  to  be  felt. 

Palpation  of  the  kidney  becomes  easy  when  it  is  either  enlarged  or 
displaced.  In  the  case  of  an  enlarged  kidney  the  patient  should  lie 
upon  Ins  back  or  be  slightly  turned  to  the  opposite  side ;  one  hand  is 
placed  beneath  the  kidney  and  pressed  upward,  while  the  other  is  pressed 
firmly  and  steadily  from  above,  or  laterally  toward  the  kidney.  In  this 
manner  the  kidney  can  be  grasped  between  the  two  hands,  its  size  esti- 
mated, and  its  physical  characteristics  as  regards  hardness,  softness, 
fluctuation,  and  mobility  determined.  Enlargements  are  also  detected 
by  palpation  of  the  abdomen.  (See  Palpation  of  the  Abdomen.)  The 
fact  that  the  tumor  moves  a  little  with  respiration  aids  in  its  detection  ; 
and  if  it  is  unusually  movable  the  edge  of  the  hand  can  be  slipped 
above  its  upper  end,  by  turning  edgewise  that  border  of  the  hand 
which  is  adjacent  to  the  ribs.  A  renal  tumor  is  usually  two  or  three 
inches  to  either  side  of  the  median  line,  a  little  above  the  transverse 
umbilical  line. 

A  very  favorable  position  for  palpating  movable  kidneys  is  that 
assumed  by  standing  and  leaning  forward  over  a  chair,  with  the  trunk 
supported  by  the  hands  resting  on  the  seat  of  the  chair.  In  this 
position  the  abdominal  muscles  are  relaxed  and  the  kidneys  fall  for- 
ward. 

In  the  diagnosis  of  renal  tumors,  in  general,  it  should  be  borne  in 
mind  that  they  are  slightly  movable  with  respiration  unless  adherent, 
as  in  malignant  disease,  abscess,  and  cysts.  Unless  too  large  they  pre- 
serve their  reniform  shape,  and  press  in  front  of  them  the  ascending  or 
descending  colon,  whereas  ovarian  tumors  lie  in  front  of  it.  The  posi- 
tion of  the  colon  should,  therefore,  always  be  ascertained,  and  to  this 
end  it  may  be  necessary  to  inflate  it. 

Percussion.  The  best  results  are  obtained  by  having  the  patient 
lie  face  downward,  and  placing  a  cushion  under  the  belly,  so  as  to  make 
the  lumbar  regions  a  little  more  prominent.  Strong  percussion  is 
required,  and  an  artificial  plessor  and  pleximeter  are  to  be  preferred. 
Percussion  should  be  conducted  with  a  view  to  marking  the  angle 
which  the  liver-dulness  and  splenic  dulness  make  with  that  of  the  kid- 
ney on  the  right  and  left  sides  respectively.  The  kidneys  extend  below 
the  lower  lines  of  liver  and  splenic  dulness,  and  laterally  for  a  width  not 
greater  than  four  inches.  The  difficulties  in  the  way  of  outlining  the 
kidneys  by  percussion  are  greatly  increased  in  persons  with  much  flesh, 
or  when  the  abdominal  walls  are  waterlogged,  as  they  become  in  ascites, 
and  it  is  practically  impossible,  under  such  circumstances,  to  be  sure  of 
the  boundaries  of  the  kidneys.  The  colon  must  be  emptied  to  yield 
trustworthy  results. 

Movable  Kidney. 

Movable  kidney  is  usually  seen  in  women  after  the  age  of  forty  years, 
who  have  done  physical  work  or  have  had  many  children.  Adult 
males  and  single  women  do  not  escape.     Its  occurrence  is  frequently 


908  SPECIAL  DIAGNOSIS. 

preceded  by  a  history  of  unusual  lifting  or  strain,  followed  by  teariDg 
or  dragging  sensations  in  the  abdomen.  Pain  may  continue  for 
several  weeks  after  the  injury,  and  then  subside  and  the  occurrence 
be  forgotten,  or  subjective  sensations  may  continue.  In  other  in- 
stances the  movable  kidney  is  a  part  of  a  general  visceral  displace- 
ment. Gastroptosis  and  gastro-enteroptosis  can  usually  be  made  out  in 
such  cases. 

The  symptoms  that  arise  are  due  to  the  local  dragging  or  pulling  of 
the  kidney  on  its  bloodvessels  and  nerves,  or  to  reflex  symptoms,  or  to 
pressure  upon  adjacent  organs. 

The  pain  that  attends  movable  kidney  is  usually  referred  to  the 
right  or  left  of  the  median  line;  sometimes  to  the  hypogastrium.  It- 
may  be  constant,  dull,  and  aching  in  character.  Paroxysms  may  arise 
in  the  course  of  the  constant  pain,  or  a  paroxysm  alone  may  take  place. 
The  paroxysms  continue  for  three  or  four  days,  during  which  time 
other  subjective  symptoms  are  more  pronounced.  The  attacks  are 
known  as  DietVs  crises.  Nausea  may  attend  the  paroxysms,  or  be  more 
or  less  constant.  Sometimes  vomiting  takes  place.  The  great  pain  is 
associated  with  swelling  and  tenderness  of  the  kidney.  The  pain, 
vomiting,  and  local  tenderness  may  simulate  peritonitis. 

In  addition  to  pain  a  dragging  sensation  is  experienced ;  the  patient 
may  be  aware  of  the  presence  of  a  tumor  or  lump  in  the  abdomen,  and 
also  of  its  movability.  The  reflex  symptoms  are  chiefly  referable  to 
the  nervous  system.  Emotional  disturbance  is  observed  when  the 
organ  is  displaced.  Hysteria  may  be  present.  Palpitation  of  the  heart 
is  a  common  reflex  symptom.  There  are  often  depression  of  spirits 
and  hypochondriasis.  Jaundice  may  occur  from  pressure,  and  the  intes- 
tine may  be  occluded. 

The  urinary  symptoms  are  of  interest.  When  the  local  pain  and 
other  symptoms  are  more  pronounced  the  urine  may  be  scanty.  In 
one  case  it  was  reduced  to  sixteen  ounces  in  twenty-four  hours.  At 
the  same  time  that  the  urine  is  scanty  hydronephrosis  will  develop.  It 
will  be  referred  to  again.  As  the  kidney  slips  back  into  its  bed  the 
twisting  of  the  ureter  is  relieved,  and  copious  discharges  of  urine  take 
place. 

Objective  Symptoms.  (Plate  XL V.,  Fig.  1.)  The  abdominal  walls 
are  usually  relaxed,  and  may  or  may  not  contain  a  large  amount  of  fat. 
Movable  kidney  is  best  detected  by  palpation.  The  patient  should  stand 
with  the  body  bent  forward  and  the  hands  resting  on  a  chair,  as  de- 
scribed above.  The  organ  is  recognized  by  its  rounded  borders,  its 
bean  shape,  its  movability,  the  detection  of  the  hilus  and  perhaps  of  the 
pulsation  of  vessels  in  it,  and  by  the  fact  that  it  can  be  replaced.  Pal- 
pation causes  a  sickening  feeling,  analogous  to  that  experienced  when 
a  testicle  is  compressed,  but  less  in  degree.  Percussion  will,  however, 
demonstrate  that  a  body,  supposed  from  palpation  to  be  the  kidney,  is  a 
solid  organ.  The  tumor  can  be  found  to  the  right  or  left  of  the  median 
line,  freely  movable  and  changing  its  position  with  that  of  the  patient, 
If  the  tumor  is  situated  on  the  right  side,  it  may  be  in  close  proximity 
to  the  liver,  or  be  felt  opposite  the  umbilicus,  or  often  in  the  iliac  region. 
When  near  the  liver,  by  careful  palpation  the  fingers  can  be  introduced 


PLATE    XLV. 


Movable    Kidney. 


••-  X  v       $   '~ 


ffy 


T 


V. 


Mjv 


Sarcoma  of  the  Right  Kidney. 


DISEASES  OF  THE  KIDNEYS.  909 

between  the  border  of  the  liver  and  the  mass.  Usually  it  does  not 
move  with  respiration,  but  sometimes  it  is  found  to  do  so.  On  the 
left  side  it  may  be  as  high  up  as  the  margin  of  the  ribs.  It  is  gener- 
ally felt  in  the  mid-clavicular  line,  a  little  above  the  level  of  the  umbil- 
icus. 

In  a  case  recently  under  the  writer's  care  the  woman,  aged  fifty-five 
years,  would  experience  pain  in  the  abdomen  about  once  a  month,  to 
the  right  of  and  above  the  umbilicus.  At  times  nausea  and  vomiting 
accompanied  the  attacks,  at  other  times  marked  depression  or  hysteria. 
Anuria  always  occurred  and  continued  for  a  variable  time,  not  longer 
than  five  days.  With  one  of  the  paroxysms  a  tumor  was  found  in  the 
region  of  the  gall-bladder,  movable  with  respiration,  but  distinctly 
defined  from  the  liver  by  placing  the  fingers  between  the  lobe  and 
kidney.  It  moved  with  each  change  of  position  of  the  patient,  and  at 
first  the  hilus  could  be  distinctly  felt.  As  the  pain  continued  the 
anuria  persisted,  and  a  marked  change  in  the  tumor  was  observable. 
It  gradually  increased  in  size,  and  a  portion  of  it  fluctuated  ;  it  was 
round  and  partook  of  the  character  of  a  cyst.  The  fluctuation  was  de- 
tected by  placing  the  hand  on  the  tumor  in  front  and  pressing  firmly 
toward  the  other  hand  placed  in  the  loin  above  the  pelvis.  After  sev- 
eral days  a  copious  discharge  of  urine  took  place  and  the  swelling 
subsided. 

Movable  kidney  may  be  confounded  with  tumor  of  the  gall-bladder, 
tumor  of  the  pylorus,  and  with  tumors  in  the  pelvis.  It  is  not  likely 
to  be  confounded  with  an  omental  tumor,  carcinoma,  or  tuberculosis, 
because  the  phenomena  of  these  processes  are  not  present  and  ascites 
does  not  occur,  nor  is  there  rise  of  temperature,  as  in  many  cases  of 
tuberculosis.  As  pointed  out  by  Henry  Morris,  tumor  of  the  gall- 
bladder and  movable  kidney  are  frequently  of  conjoint  occurrence. 
Movable  kidney  is  distinguished  by  the  absence  of  previous  history  or 
of  symptoms  or  signs  indicating  disease  of  the  gall-ducts.  If  jaundice 
is  present,  it  is  not  so  intense  as  in  tumors  of  the  gall-bladder.  While 
the  gall-bladder  is  movable,  it  is  not  so  distinctly  so  as  movable  kidney. 
The  gall-bladder  moves  in  an  arc  of  a  circle,  the  centre  of  which  is  at 
the  edge  of  the  right  lobe  of  the  liver.  It  can  be  pushed  further  to 
the  left  than  to  the  right,  but  never  downward  as  a  movable  kidney. 
Moreover,  the  gall-bladder  is  always  palpable,  the  movable  kidney 
cannot  always  be  felt.  The  gall-bladder,  if  it  contain  calculi,  is  very 
hard  compared  to  the  kidney.     Anuria  does  not  occur. 

The  kidney  tends  to  spring  back  to  its  place  in  the  loin ;  the  gall- 
bladder to  the  anterior  part  of  the  abdomen.  Even  if  the  gall-bladder 
is  enlarged,  the  kidney  can  be  felt  by  bimanual  palpation  ;  while  the 
opposite  does  not  obtain.  In  cancer  of  the  pylorus  the  emaciation  and 
anaemia  are  more  pronounced  than  in  movable  kidney.  The  vomit- 
ing, usually  characteristic  in  that  affection,  and  the  physical  signs  of 
dilated  stomach,  can  be  made  out.  Tumors  of  the  pelvic  organs  are 
determined  by  examination  according  to  the  usual  methods. 

Horseshoe  Kidney.  There  arc  usually  no  symptoms.  The  kid- 
ney can  sometimes  be  felt  through  the  abdomen  if  its  walls  are  relaxed, 
or  by  bimanual  examination. 


910  SPECIAL  DIAGNOSIS. 

Enlargement.     Renal  Tumor. 

Enlargements  of  the  kidney  may  be  detected  by  percussion  ;  the  width 
of  the  kidney  is  increased,  and  the  percussion-dulness  therefore  extends 
further  to  the  right  or  left,  according  as  the  right  or  left  kidney  is 
affected.  As  the  causes  which  produce  enlargements  of  the  kidney 
sufficiently  great  to  be  detected  by  percussion  do  not,  with  rare  excep- 
tions, involve  both  kidneys  at  the  same  time,  comparison  of  the  two 
sides  is  of  great  value  in  the  diagnosis. 

Renal  tumors  rarely  bulge  in  the  lumbar  region,  although  there  is 
a  sensation  of  increased  resistance  in  this  area.  The  mass  is  never 
notched,  is  usually  smooth,  and  often  takes  the  shape  of  the  kidney  if 
that  organ  is  involved  in  its  entirety.  Otherwise  the  outline  is  not 
reniform.  The  bowel  is  usually  in  front  of  the  mass,  although  in 
tumors  of  the  right  kidney  the  csecum  and  colon  may  be  pushed  to  the 
inner  side,  and  of  the  left  kidney  the  colon  may  be  pressed  outward. 

The  diseases  of  the  kidney  attended  by  enlargement  are  :  malignant 
tumors,  cystic  kidney,  hydronephrosis  and  pyonephrosis,  abscess,  and.  peri- 
nephritic  abscess. 

Sarcoma  and  Carcinoma  of  the  Kidney. 

Either  disease  may  be  primary  or  secondary.  Sarcoma  may  be  con- 
genital. The  tumor  may  occur  at  any  age,  but  is  relatively  common 
in  young  children.  Twenty-five  out  of  sixty-seven  cases  collected  by 
Dr.  William  Roberts  occurred  in  children  under  ten  years  of  age.  In 
older  persons  it  is  often  preceded  by  calculus.  Symptoms:  In  some 
instances  there  are  no  symptoms  during  life.  In  others  the  disease 
may  advance  considerably  before  it  presents  any  signs.  If  symptoms 
are  complained  of  they  are  usually  limited  to  pain,  the  occurrence  of 
hsematuria,  or  the  development  of  a  tumor.  The  pain  is  dull  and  seated 
in  the  lumbar  region.  It  may  be  neuralgic  in  character;  and,  indeed, 
there  may  be  a  true  sciatica  with  paresis  of  the  leg  from  pressure  of  the 
tumor.  The  tumor  (Plate  XLV.,  Fig.  2)  is  firm  ;  its  surface  is  smooth 
or  nodulated.  It  may  be  felt  in  the  loins,  and  in  front,  above  the  um- 
bilicus, a  few  inches  to  the  right  or  left  of  the  median  line  ;  the  descend- 
ing colon  lies  in  front  of  the  tumor.  The  latter  may  grow  with  great 
rapidity  and  attain  enormous  size,  filling  the  abdominal  cavity  and  giving 
rise  to  pressure-symptoms  in  surrounding  organs.  The  growth  occurs 
more  often  anteriorly  and  downward  toward  the  pubis,  because  there  is 
less  resistance  in  these  directions.  As  rapidly  growing  cancers  are  soft, 
the  tumor  frequently  exhibits  a  certain  degree  of  elasticity,  which  may 
be  mistaken  for  fluctuation.  It  is  immovable  either  by  the  hands  or 
with  respiration. 

On  percussion  the  resistance  is  increased  and  the  note  is  dull,  except 
in  front,  where  the  colon,  which  has  been  pushed  forward,  gives  a  tym- 
panitic note.  If  the  colon  should  be  flattened  out  between  the  tumor 
and  the  abdominal  wall,  it  may  be  felt  as  a  band  stretching  across  the 
tumor,  with  dulness  on  percussion.  In  such  a  case  inflation  of  the 
colon  will  be  of  great  assistance  in  the  diagnosis.     Rare  physical  signs 


DISEASES  OF  THE  KIDNEYS.  911 

are  pulsation  and  a  blowing  murmur.  The  hematuria  may  be  con- 
stant or  intermittent.     The  clots  of  blood  may  cause  renal  colic. 

The  general  symptoms  are  those  of  carcinoma.  A  marked  rapidity 
of  the  pulse  has  been  noted  in  several  cases.  In  girls  a  premature 
development  of  hair  on  the  pubes  and  in  the  axilla?  and  pigmentation 
of  the  skin  have  been  observed. 

Hemorrhage  is  an  early  symptom,  and  in  the  absence  of  nephritis  or 
cystitis  should  always  suggest  tumor.  It  may  occur  early  and  may 
be  intermittent  or  persistent.  In  some  instances  it  occurs  but  once, 
usually  it  is  frequent.  When  excessive,  the  growth  is  never  innocent. 
Pain  is  not  of  much  value,  and  may  be  absent  until  perinephritis  occurs. 
Symptomatic  varicocele  may  occur.  The  examination  of  the  urine,  save 
that  it  discloses  the  presence  of  blood,  is  negative.  In  this  sense  it  is  of 
value.  Pus  occurs  if  there  is  secondary  infection  or  if  calculi  precede 
the  growth.  Rarely  fragments  of  carcinoma  are  said  to  be  detected. 
In  order  to  determine  the  kidney  affected  separate  urine  should  be 
obtained  from  each  organ. 

The  tumor  must  be  distinguished  from  tumors  of  the  lymphatic 
glands,  of  the  liver,  of  the  spleen,  and  of  the  ovary.  It  must  not  be 
confounded  with  psoas  abscesses  and  perinephritic  abscesses,  which 
cause  a  tumor  in  the  lumbar  region. 

Cystic  Kidneys. 

1.  Congenital.  The  kidney  consists  of  a  small  mass  of  cysts  filled 
with  clear  fluid.  It  may  interfere  with  the  birth  of  the  child  on  account 
of  its  large  size. 

2.  Acquired.  The  cause  is  trauma  and  obstruction  of  the  ureter,  the 
presence  of  which  is  determined  by  catheterization.  The  symptoms 
are  those  of  a  fluctuating  renal  tumor.  The  urine  may  be  normal  or 
hematuria  may  be  present. 

Hydronephrosis. 

Causes.  It  may  be  congenital.  Obstruction  of  ureter  by  stone  ; 
pressure  of  tumor ;  twist,  as  in  movable  kidney  ;  exudates. 

Symptoms.  In  addition  to  the  symptoms  of  the  causal  condition  Ave 
have,  upon  the  development  of  hydronephrosis,  the  presence  of  a  tumor, 
arising:  in  the  region  of  the  kidnev  and  extending  toward  the  middle 
line.  Sometimes  fluctuation  can  be  detected ;  often  it  cannot.  Varia- 
tions in  size  of  the  tumor  may  occur  with  changes  in  amount  of  urine 
passed.  Puncture,  and  the  finding  of  a  fluid  with  elements  of  urine  in 
it,  are  valuable  means  of  diagnosis ;  but  if  the  hydronephrosis  is  old, 
this  fails,  as  the  fluid  loses  its  urinary  character,  and  cannot,  for  instance, 
be  distinguished  from  that  of  an  ovarian  cyst.  When  on  one  side  the 
urine  may  be  normal ;  when  on  both  sides  it  is  diminished  ;  anuria  and 
ursemia  may  occur.     If  pyelitis  is  present,  pyuria  is  observed. 

Intermittent  /ii/rfronejjhrosi*  is  associated  with  movable  kidney,  hence 
it  is  more  frequent  in  women.  It  is  characterized  by  the  development 
of  a  renal  tumor  with  variable  frequency,  and  with  pain,  nausea,  and 
vomiting.     At  the  same  time  the  urine  is  scanty.     In  a  few  hours  or 


912  SPECIAL  DIAGNOSIS. 

days  there  is  an  increase  in  the  amount  of  urine  with  subsidence  of  the 
tumor. 

Pain  may  or  may  not  be  present.  Gastric  symptoms  are  very  com- 
mon. Either  constipation  or  diarrhoea  is  seen.  Hypertrophy  of  the 
left  ventricle  may  occur,  as  in  chronic  nephritis. 

Hydronephrosis  consists  in  a  dilatation  of  the  kidney  pelvis  with 
urine,  which  is  prevented  from  escaping  by  obstruction  of  the  ureter, 
either  by  the  pressure  of  a  tumor,  or  by  disease  of  the  bladder  or  ureter 
itself.  In  time  the  kidney  atrophies  from  the  pressure  and  a  large  cyst 
forms.  The  tumor  has  the  physical  characteristics  of  pyonephrosis,  but 
the  history  is  different,  and  if  there  is  any  discharge,  it  is  free  from 
pus.  As  in  pyonephrosis,  the  tumor  may  become  small,  following  a 
copious  discharge — in  this  case  of  urine — or  may  even  wholly  disap- 
pear, if  the  obstruction  is  removed.     This  sign  is  pathognomonic. 

If  obstruction  continue  to  be  absolute,  the  diagnosis  must  be  made 
by  the  detection  of  a  fluctuating  renal  tumor,  the  absence  of  fever  and 
signs  of  suppuration,  and  by  the  result  of  exploratory  puncture.  The 
urine  is  usually  free  from  pathological  changes. 

It  may  be  confounded  with  ascites,  if  very  large,  but  hydronephrosis 
is  rarely  bilateral,  and  the  fluid  in  it  does  not  change  its  level  upon 
change  of  position  of  the  patient,  as  is  the  case  with  ascites.  The 
history  of  the  two  conditions  will  be  different. 

An  ovarian  cyst  can  usually  be  traced  into  the  pelvis ;  it  does  not 
carry  the  colon  in  front  of  it,  and  hence  is  dull,  even  on  superficial 
percussion,  and  it  leaves  the  loins  resonant. 

Pyelitis.     Pyonephrosis. 

Pyelitis  is  rarely  primary  ;  usually  secondary.  Severe  infectious  dis- 
eases (typhus,  variola,  diphtheria,  pysemia) ;  toxic  substances  ingested 
(cantharides,  etc.) ;  chronic  nephritis ;  inflammation  of  the  bladder  or 
ureter ;  strictures  of  the  ureter  or  urethra ;  hypertrophy  of  the  pros- 
tate ;  spinal  palsies  of  the  bladder ;  calculus ;  parasites ;  blood-clots, 
are  the  antecedent  causal  factors ;  infection  the  active  cause. 

Symptoms.  The  Urine.  Pus  in  the  urine  with  pelyic  epithelium — 
although  it  is  not  safe  to  base  a  diagnosis  on  the  presence  of  the  latter ; 
casts  of  the  canals  opening  into  the  pelvis  are  more  characteristic ; 
epithelial  casts,  and  casts  containing  micro-organisms.  The  urine  is 
often  increased,  acid,  and  contains  pus  and  albumin,  rarely  blood. 
Pyuria  may  be  the  only  renal  sign.  In  all  forms  of  pyuria  above  the 
bladder  Kelly  withdraws  the  pus  by  catheterization  and  suction.  He 
allows  the  catheters  to  remain  from  ten  minutes  to  four  or  five  hours, 
in  order  to  estimate  the  functional  power  of  each  kidney.  Of  course, 
the  pus  is  studied  microscopically  and  bacteriologically.  Pain  in  the 
region  of  the  kidney,  often  severe,  is  complained  of,  although  it  may 
be  absent.  When  present,  it  is  often  of  a  tearing  character.  Tumor. 
A  tumor  is  often  present.  It  is  most  prominent  in  the  loin  or  in  the 
abdomen.  In  the  latter  the  mass  can  be  felt  two  inches  to  either  side  of 
the  umbilicus,  usually  above  the  transverse  line. 

Pyelitis  differs  from  abscess  of  the  kidney.     The  latter  may  be  the 


DISEASES  OF  THE  KIDNEYS.  913 

result  of  a  local  infection  from  the  pelvis  of  the  kidney  or  may  be 
pysemic. 

In  abscess  of  the  kidney  there  is  some  fulness  in  the  loin  of  the 
affected  side.  The  kidney  is  felt  to  be  enlarged,  and  is  tender  and 
painful.  A  tumor  may  be  detected  anteriorly.  The  diagnosis  is  based 
on  a  study  of  the  cause  (acute  nephritis,  pyaemia,  impacted  calculus 
in  the  ureter,  erysipelas),  or  the  detection  of  blood  and  pus  in 
the  urine,  which  is  scanty,  and  on  the  constitutional  symptoms.  The 
progress  of  the  case  is  usually  acute.  If  the  abscess  is  tubercular, 
tubercle  bacilli  can  be  detected  in  the  purulent  sediment  of  the  urine, 
and  there  will  be  other  foci  of  tuberculosis  with  a  corresponding  clini- 
cal history. 

When  the  pus  is  confined  by  an  occluded  ureter,  the  pelvis  is  over- 
distended.  In  pyonephrosis  the  tumor  is  tense,  smooth,  and  globular. 
Fluctuation  may  be  detected.  Tenderness  is  usually  absent ;  the  course 
is  slow  and  does  not  affect  the  general  health  so  much  as  abscess.  The 
pus  may  be  discharged  copiously  from  time  to  time,  and  the  tumor  be 
therefore  diminished  in  size.  The  urine  may  be  occasionally  almost 
clear.  Pyonephrosis  arises  secondarily  to  pyelitis,  and  often  after  the 
latter  has  lasted  some  time. 

Fever  is  irregular,  remitting,  or  septic.  The  fever  and  pyuria  may 
be  the  only  symptoms.  If  the  bladder  is  healthy,  its  symptoms  fail  to 
aid  in  diagnosis. 

Perinephritic  Abscess. 

It  occurs  as  a  primary  disease  in  apparently  healthy  individuals,  or 
after  infectious  diseases. 

Perinephritis  arises  usually  from  extension  of  inflammation  and  sup- 
puration from  the  kidney,  but  may  be  the  result  of  strain,  exposure  to 
cold,  or  injury.  Perinephritis  may  also  be  pysemic,  and  occur  after 
infectious  fevers,  and  in  actinomycosis. 

Symptoms.  The  secondary  forms  have  symptoms  of  the  primary 
disease,  and,  later,  swelling  and  pain  in  the  renal  region. 

Primary  form.  Chills  and  fever,  pain,  difficulty  in  defecation.  The 
general  condition  suffers.  Finally,  in  all  cases,  there  is  the  formation 
of  a  swelling  in  the  lumbar  region,  at  first  hard  ;  then  oedema  of  the 
skin  follows,  and  fluctuation  is  detected.  The  abscess  may  descend 
and  point  above  Poupart's  ligament.  It  may  press  upward  and  cause 
dyspnoea.  Great  tenderness  and  pain  in  the  region  of  the  swelling  may 
arise,  and  the  pain  may  radiate  to  the  leg.  Irregular  septic  fever  and 
chills  appear.  The  urine  is  not  generally  changed  unless  some  com- 
munication with  the  pelvis  or  ureter  has  formed.  The  patient  lies  on 
his  back,  turned  toward  the  affected  side.  The  knee  and  hip  of  this 
side  are  flexed  and  the  thigh  rotated  outward.  The  affection  may  simu- 
late coxitis  and  append icif is. 

The  swelling  of  a, perinephritic  abscess  appears  in  the  lumbar  region 
of  the  side  affected.  It  is  rounded  in  form  and  doughy  (Da  Costa). 
Like  other  kidney  tumors,  it  is  not  affected  by  respiration.  The  usual 
signs  of  confined  suppuration  exist,  and  pulmonary  or  pleural  compli- 
cations may  occur.     As  the  abscess  progresses,  the  local  signs  of  suppu- 

58 


914  SPECIAL  DIAGNOSIS. 

ration  become  more  marked,  the  skin  reddens,  and  pus  may  be  discharged 
externally. 

The  most  marked  subjective  symptom  is  pain,  which  may  amount 
to  agony,  and  is  paroxysmal ;  soreness  from  restricted  motion  of  the 
psoas  muscle  is  apt  to  be  complained  of. 

A  tumor  was  present  in  the  loins  in  sixty-five  out  of  seventy-one 
cases  analyzed  by  Fenwick,  but  did  not  generally  manifest  itself  until 
the  inflammation  had  made  considerable  progress.  There  is  dulness  on 
percussion  even  in  the  early  stage,  and,  later,  fluctuation.  The  general 
symptoms  are  vomiting,  constipation,  fever,  and  sometimes  rigors.  It 
is  more  common  in  males  than  in  females  (sixty-one  males  to  thirty- 
nine  females  in  Fen  wick's  cases). 

Hydatid  Cyst. 

A  hydatid  cyst  of  the  kidney  presents  the  usual  physical  signs  of  such 
cysts.  A  fremitus  may  be  detected,  or  small  cysts  may  be  found  in  the 
urine. 

It  is  comparatively  rare.  Usually  there  are  no  symptoms  until  a 
tumor  is  felt.  Then  pain  gradually  develops.  The  cyst  may  open  into 
the  pelvis  of  the  kidney,  and  cysts  or  scolices  be  discharged,  with  colic. 

Pyelitis  and  cystitis  may  also  develop. 

Echinococcus  cyst  may  inflame  and  lead  to  general  pysemia.  Punc- 
ture of  the  discovered  tumor  is  otherwise  the  only  means  of  diagnosis. 
It  must  be  differentiated  from  hydronephrosis  and  ovarian  tumors. 
Puncture  is  necessary. 

Examination  of  the  Urine. 

1.  Inspection.  The  urine  in  health  is  a  clear  yellow  or  amber- 
colored  fluid,  having  a  specific  gravity  of  about  1020,  and  generally  acid 
in  reaction.  It  contains  normally  about  forty-five  parts  in  the  thousand 
of  solid  matter,  the  principal  part  of  which  is  urea — twenty-one  and  a 
half  parts.  The  other  solids  are  uric  acid  and  its  salts  ;  certain  extrac- 
tives— creatin,  creatinin,  ammonia,  hippuric  acid,  xanthin,  hypoxanthin. 
sarcin,  pigment,  etc. ;  and  chlorides,  phosphates,  sulphates,  with  their 
bases,  soda,  potash,  lime,  and  magnesia. 

The  volume  of  urine  passed  in  twenty-four  hours  is  usually  from  forty 
to  fifty  ounces,  but  it  may  fall  to  thirty  ounces  or  rise  to  seventy  with- 
out the  existence  of  disease.  TToinen  are  believed  to  pass  from  five  to 
ten  ounces  less  than  men.  The  volume  is  diminished  when  the  skin 
is  acting  freely,  as  in  warm  weather,  and  when  the  bowels  are  loose ; 
and,  on  the  other  hand,  cold,  constipation,  and  nervous  excitement,  espe- 
cially if  it  induce  anxiety  and  fear,  all  tend  to  increase  the  quantity 
secreted. 

Color.  The  color  of  the  urine  is  due  largely  but  not  wholly  to 
urobilin,  which  is  formed  from  the  hsematin  of  the  blood.  The  color 
deepens  when  the  urine  is  concentrated,  which  occurs  after  a  hearty 
meal,  or  exercise,  especially  in  warm  weather ;  and  it  becomes  paler 
when  a  large  quantity  is  passed.     The  color  is  frequently  changed  in 


DISEASES  OF  THE  KIDNEYS.  915 

disease.  In  fevers  the  urine,  soon  after  being  passed,  is  apt  to  become 
turbid  from  the  precipitation  of  urates,  and  the  color  varies  from  white, 
especially  in  children,  to  yellow,  brown,  or  pink.  When  the  precipi- 
tate settles  the  supernatant  urine  may  be  high-colored  and  clear,  or 
slightly  opaque  from  some  suspended  matter. 

The  admixture  of  pus  and  chyle  gives  the  urine  a  milky  color.  The 
urine  may  also  be  yclloicish-white  and  turbid  from  phosphates,  semen, 
sarcinee,  and  bacteria. 

The  urine  is  red,  reddish-brown,  or  "  smoky  "  in  acute  nephritis,  the 
color  being  due  to  blood.  It  is  bloody  in  hematuria,  cancer  of  the 
kidneys  and  bladder,  and  in  injuries  of  the  genito-urinary  apparatus. 
The  urine  is  very  red  and  clear  when  concentrated  and  containing  a 
large  amount  of  urates.  The  red  color  of  the  urine  may  be  due  to 
haemoglobin,  constituting  hemoglobinuria,  or  to  excess  of  urobilin,  as 
in  scurvy  and  pernicious  aneernia.  Hemoglobinuria  occurs  as  the  result 
of  the  action  of  certain  poisons,  such  as  chlorate  of  potash  ;  in  infectious 
diseases,  such  as  scarlet  fever ;  and  in  malarial  fevers ;  also  in  a  pecu- 
liar disease  known  as  paroxysmal  hemoglobinuria. 

Again,  a  golden-red  discoloration  of  the  urine  is  common  in  jaundice  ; 
frequently  the  upper  layers  have  a  greenish  tinge  by  reflected  light. 

Finally,  a  red  color  is  produced  by  the  internal  administration  of 
logwood  and  fuchsin. 

A  yellow  color,  when  opaque,  may  be  due  to  suspended  phosphates 
and  urates.  Urine  is  sometimes  golden  yellow  or  of  a  saffron  color  in 
jaundice,  and  from  the  effects  of  santonin,  picric  acid,  and  rhubarb 
taken  internally.  A  yellow  or  yellowish-white  turbidity  may  be  due 
also  to  a  mixture  of  pus  and  phosphates,  and  sometimes  to  semen,  sar- 
cina?,  and  bacteria.  The  urine  usually  becomes  more  or  less  opaque 
and  yellow  when  it  has  undergone  alkaline  fermentation.  Such  a 
change  occurs  normally  within  a  longer  or  shorter  time  after  the  urine 
has  been  passed.  It  is  promoted  by  heat  and  exposure  to  air,  and 
retarded  by  cold  and  exclusion  from  air.  If  possible,  the  urine  should 
be  examined  before  this  fermentation  has  occurred.  Pathologically,  in 
cases  of  cystitis,  the  urine  when  passed  is  already  in  alkaline  fermen- 
tation. 

The  urine  is  sometimes  chocolate-brown  when  it  contains  blood  and 
the  blood  has  been  acted  upon  by  the  urine,  producing  methsemoglobin. 

Brown,  greenish-brown,  or  black  urine  may  result  from  contained  bile- 
salts  ;  from  indican  ;  from  carbolic  acid,  creosote,  and  tar  used  inter- 
nally and  externally ;  from  the  internal  use  of  senna,  and  in  cases 
where  there  are  melanotic  tumors.  Senator  injected  melanin  into 
human  beings  and  obtained  in  four  cases  only  a  large  indicanuria. 

Urine  is  pale  usually  in  proportion  as  it  is  copious  in  quantity.  It 
is  paler  in  those  who  are  using  milk  or  vegetable  diet  than  in  those 
who  eat  meats.  Under  the  influence  of  nervous  excitement,  espcciallv 
anxiety  and  the  dread  of  an  approaching  ordeal,  such  as  an  examina- 
tion, an  abnormal  quantity  of  very  pale  urine  is  secreted. 

Pathologically,  pale  urine  is  characteristic  of  diabetes,  chronic  Bright's 
disease,  and  polyuria.  Such  urine  is  also  secreted  in  hysterical  attacks, 
at  the  crises  of  febrile  diseases,  and  in  anaemic  conditions. 


916  SPECIAL  DIAGNOSIS. 

The  Quantity.  The  volume  may  be  increased,  diminished,  or 
unchanged  in  disease.  It  is  increased  principally  in  three  diseases — 
diabetes  mellitus,  diabetes  insipidus,  and  in  the  middle  period  of  chronic 
Bright's  disease,  especially  the  interstitial  form.  In  diabetes  mellitus 
it  sometimes  exceeds  thirty-two  pints.  It  may  be  increased  also  in 
hypertrophy  of  the  left  ventricle,  which  induces  greater  pressure  in  the 
renal  arteries  as  well  as  in  the  whole  arterial  system ;  and  also  in  cystic 
degeneration,  and  in  double  hydronephrosis. 

Diabetes  Insipidus.  This  form  of  diabetes  differs  from  the  sacchar- 
ine in  that  the  urine  is  normal,  but  of  low  specific  gravity.  The 
disease  may  come  on  suddenly  after  mental  emotion,  or  develop  grad- 
ually. The  amount  of  urine  may  range  from  ten  to  forty  pints.  The 
urine  is  of  low  specific  gravity — from  1001  to  1005.  It  is  pale  and 
watery.  The  solid  constituents  are  not  reduced.  Urea  is  sometimes 
increased,  but  abnormal  constituents  are  very  rare.  The  passage  of 
large  amounts  of  urine  induces  thirst,  but  otherwise  the  symptoms  do 
not  tally  Avith  the  symptoms  of  diabetes  mellitus.  The  patients  are 
usually  well  nourished. 

The  disease  is  usually  secondary  to  some  organic  disease  of  the  brain, 
or  of  the  abdomen,  as  tubercular  peritonitis,  abdominal  tumors,  or 
aneurisms.  It  usually  occurs  in  males,  and  is  often  hereditary.  It  is 
most  common  in  young  people.  Traumatism,  meningitis,  affections  of 
the  brain  involving  the  sixth  nerve,  tumors  of  the  brain  or  of  the 
medulla,  are  causal  factors.  It  may  follow  fright,  a  protracted  debauch, 
or  perturbation  of  the  nervous  system  from  other  causes. 

The  diagnosis  is  not  difficult.  It  must  be  distinguished  from  the 
polyuria  that  is  seen  in  chronic  interstitial  nephritis,  and  in  amyloid 
disease.  In  hysteria,  polyuria  is  common,  although  transitory.  The 
presence  of  the  stigmata  and  other  hysterical  manifestations  lead  to  the 
diagnosis  in  hysteria. 

The  urine  is  diminished  in  acute  nephritis  and  in  the  final  stages  of 
chronic  nephritis  ;  sometimes,  also,  it  is  diminished  in  the  middle 
period  of  chronic  nephritis,  but  usually  it  is  here  increased.  All  dis- 
eases which  directly  or  indirectly  impair  the  force  of  the  circulation 
lessen  the  secretion  of  the  urine.  Hence,  the  quantity  is  diminished  in 
diseases  of  the  heart-muscle  and  in  valvular  diseases  not  fully  com- 
pensated ;  in  emphysema  and  in  chronic  bronchitis.  It  is  lessened  also 
in  cirrhosis  of  the  liver.  In  febrile  diseases  the  urine  is  scanty  and 
high-colored,  and  sometimes  it  is  almost  suppressed  (anuria). 

The  urine  is  sometimes  suppressed  in  acute  nephritis,  such  as  follows 
scarlet  fever,  and  in  the  final  stages  of  all  the  organic  affections  of  the 
kidneys  — chronic  nephritis,  hydronephrosis  and  pyonephrosis,  etc.  It 
may  result  (1)  from  the  destruction  of  the  secreting  tissue  of  the  kidney 
or  interference  with  its  nervous  or  vascular  supply,  or  (2)  from  mechan- 
ical obstruction  to  the  outflow  of  urine.  To  the  first  class  belong  the 
cases  of  suppression  occurring  in  acute  and  chronic  nephritis,  and  the 
suppression  from  shock  and  collapse,  whether  occurring  in  the  stage  of 
collapse  of  yellow  fever,  cholera,  and  other  grave  febrile  diseases,  or 
from  serious  internal  injuries. 

Such  suppression  sometimes  follows  slight  operations  on  the  urethra 


DISEASES  OF  THE  KIDNEYS.  917 

(urethral  fever) ;  or  results  from  the  internal  administration  of  drugs 
the  excretion  of  which  occasions  violent  irritation  of  the  kidney — 
cantharides,  turpentine,  and  even  the  inhalation  of  ether.  Clinically, 
suppression  not  due  to  obstruction  is  distinguished  from  the  obstructive 
form  by  the  character  of  the  urine,  which  is  usually  not  entirely  sup- 
pressed, and  by  the  more  rapid  course  of  the  disease.  The  urine, 
according  to  Roberts,  is  either  concentrated  or  it  contains  albumin, 
blood,  and  casts.  Death  or  recovery  results  within  a  day  or  two.  In 
the  obstructive  form,  on  the  other  hand,  the  urine  which  escapes  past 
the  obstacle  is  pale,  watery,  and  devoid  of  albumin  and  casts. 

Obstructive  suppression  is  the  result  of  the  plugging  of  the  ureter  by 
a  calculus,  when  the  opposite  kidney  is  either  absent  or  incapable  of 
secreting.  It  also  results  from  the  occlusion  of  the  ureters  by  morbid 
growths,  especially  at  the  vesical  orifices,  from  lateral  pressure  upon 
the  ureters,  or  from  some  interference  with  or  malformation  of  the 
ureters  or  renal  arteries. 

Acute  transient  obstructive  suppression  occurs  sometimes  in  persons 
with  enlarged  prostates,  or  old  strictures,  who  have  drunk  too  freely  of 
alcoholic  beverages,  and,  perhaps,  have  wound  up  a  debauch  by  sexual 
intercourse. 

The  Density  of  the  Ueine.  The  average  density  of  normal 
urine  is  about  1020.  It  may  fall  to  1015  or  rise  to  1025,  depending 
upon  the  quantity  of  fluid  and  food  taken,  the  condition  of  the  atmos- 
phere, especially  as  regards  temperature,  and  upon  mental  influences 
usually  of  an  emotional  character.  The  specific  gravity  of  the  urine 
is  tested  by  a  urinometer  graduated  for  degrees  of  density  between 
1000  and  1040.  Only  a  reliable  instrument  should  be  used.  As  the 
density  of  the  urine  passed  at  different  times  during  the  day  varies 
greatly,  the  urine  for  the  whole  twenty-four  hours  should  be  saved 
and  a  specimen  of  this  tested. 

The  method  of  taking  the  specific  gravity  is  very  simple.  A  test- 
tube  or  graduate,  having  a  diameter  of  about  one  and  a  quarter  inch 
and  a  length  of  six  or  seven  inches,  is  filled  with  urine  to  such  a  point 
that  the  lowest  part  of  the  urinometer  when  inserted  floats  clear  of  the 
bottom  of  the  tube.  The  instrument  must  also  float  free  of  the  sides 
of  the  tube.  The  specific  gravity  should  then  be  read  off  from  below — 
that  is  to  say,  by  holding  the  tube  up  so  that  the  level  of  the  fluid  is  a 
little  above  that  of  the  eye.  Most  urinometers  are  graduated  for  60°, 
but  in  ordinary  examinations  it  is  not  necessary  to  have  the  urine  ex- 
actly at  this  temperature  ;  it  should,  however,  be  allowed  to  cool  after  it 
has  been  passed,  otherwise  the  specific  gravity  will  appear  to  be  too  low. 

In  disease  the  specific  gravity  varies  more  widely  than  in  health  ;  it 
may  fall  to  1000  or  1005  in  diabetes  insipidus  and  chronic  Bright's 
disease,  and  rise  to  1060  or  even  higher  in  diabetes  mcllitus.  As  a 
rule,  to  which  the  urine  in  diabetes  mellitus  is  the  principal  exception, 
the  color  is  an  index  of  the  density,  pale  urine  being  of  low  density 
and  high-colored  urine  of  high  density. 

The  density  is  increased  when  the  urine  is  scanty  in  amount,  whether 
as  the  result  of  fever,  acute  nephritis,  large  consumption  of  solid  food, 
exercise,  or  free  sweating.     In  all  such  cases  the  specific  gravity  rarely 


918  SPECIAL  DIAGNOSIS. 

rises  above  1035,  and  usually  not  above  1028  or  1030.  When  the 
specific  gravity  rises  above  1035,  and  the  urine  is  pale  in  color,  the 
presence  of  sugar  is  to  be  suspected  ;  and  when  it  rises  above  1040 
sugar  is  almost  certainly  present. 

The  specific  gravity  is  lowered  by  drinking  copiously,  by  the  effect 
of  external  cold,  by  a  diet  of  vegetables  and  milk,  and,  in  general,  by 
the  same  causes  that  make  the  urine  copious.  Usually,  but  not  always, 
a  urine  containing  a  large  amount  of  albumin  is  of  low  density. 

Pathologically,  a  low  specific  gravity  is  encountered  in  diabetes  in- 
sipidus, in  which  it  may  fall  nearly  or  quite  to  1000 ;  generally  in  the 
middle  or  quiescent  period  of  chronic  Bright' s  disease ;  in  the  crisis  of 
fevers  ;  in  obstructive  suppression  ;  in  hysterical  attacks,  and  in  hydro- 
nephrosis. 

Specific  Gravity  as  an  Index  of  the  Amount  of  Solids.  If  the  last  two 
figures  of  the  specific  gravity  be  doubled,  the  sum  will  represent  the 
amount  of  solid  matter  in  1000  grains  of  urine.  This  is  Trapp's 
method  ;  the  estimate  is  only  rough,  but  it  is  useful.  Of  course,  the 
urine  for  twenty-four  hours  must  be  used. 

The  Reaction.  The  reaction  of  healthy  urine  is  usually  acid,  but 
it  may  be  neutral  or  slightly  alkaline  about  two  hours  after  a  meal  of 
mixed  food.  The  acidity  is  tested  with  litmus-paper ;  the  blue  paper 
is  turned  purple  or  red  by  an  acid,  and  the  red  paper  is  turned  blue  by 
an  alkali.  Violet  paper  is  to  be  preferred,  as  it  is  suitable  for  showing 
both  reactions,  an  alkali  turning  it  blue  and  an  acid  red. 

The  acidity  of  the  urine  is  increased  in  gout,  lithiasis,  acute  rheuma- 
tism, diabetes,  chronic  Bright's  disease,  and  as  the  result  of  the  admin- 
istration of  vegetable  or  mineral  acids. 

The  urine  is  alkaline  as  the  result  of  alkaline  fermentation  in  the 
bladder  in  cystitis ;  from  the  presence  of  much  blood  or  pus ;  from 
prolonged  immersion  of  the  body  in  a  cold  bath ;  in  debilitating  dis- 
eases and  in  some  cases  of  nervous  dyspepsia,  and  as  the  result  of  the 
internal  administration  of  alkalies. 

Urinary  Sediments.  A  white,  flocculent  sediment,  composed  of 
epithelium  and  mucus,  occurs*  normally  in  most  urines  after  they  have 
stood  for  some  hours. 

A  dense  sediment,  varying  in  color  from  that  of  brown  sugar  to  pink 
or  red,  consists  of  amorphous  urates.  It  dissolves  upon  the  appli- 
cation of  heat.  A  sediment  usually  resembling  red  pepper,  but  some- 
times of  a  brown  color,  consists  of  uric  acid.  It  can  be  proved  to  be 
uric  acid  by  the  murexid  test.  The  suspected  material  is  placed  in  a 
crucible  or  evaporating  dish  with  a  few  drops  of  nitric  acid.  As  heat  is 
applied  the  uric  acid  or  amorphous  urate  dissolves  with  effervescence. 
Heat  is  now  kept  up  until  the  material  is  evaporated  to  dryness  ;  it  is 
then  allowed  to  cool.  If  it  is  now  touched  with  a  glass  rod,  dipped  in 
strong  ammonia,  a  characteristic  blue  or  violet  color  is  produced.  Uric 
acid  is  not  usually  so  abundant  as  the  sediment  of  amorphous  urates ; 
it  sinks  more  rapidly,  and  is  deposited  from  acid,  high-colored  urines. 

A  yellowish  or  whitish  sediment  may  consist  of  urate  of  sodium. 

A  white  sediment  usually  consists  of  phosphates,  associated  with 
which  we  sometimes  find  a  white  sediment  consisting  of  urate  of  ammo- 


DISEASES  OF  THE  KIDNEYS.  919 

nium,  with  or  without  pus.  Such  urines  are  alkaline.  A  white  sedi- 
ment may  be  due  to  uric  acid,  especially  in  children. 

A  yellowish- white  sediment  may  consist  of  pus,  with  or  without 
mucus.  If  the  urine  is  acid,  the  sediment  is  loose  and  free  to  move ; 
but  when  the  urine  is  alkaline  the  sediment  consists  of  a  viscid,  coherent 
mass,  which  can  be  drawn  out  into  tough,  stringy  filaments. 

A  chocolate-brown  sediment,  occurring  in  a  reddish,  smoky  urine, 
consists  of  blood  from  the  kidneys.  Clots  of  blood  come  from  the 
ureters,  bladder,  or  urethra. 

Odor.  The  odor  of  normal  urine  is  sometimes  spoken  of  as  aromatic, 
but  generally  it  is  sufficiently  characteristic  to  be  best  described  as 
urinous.  When  the  urine  is  concentrated  the  odor  is  intensified,  and 
may  become  unpleasantly  strong,  like  the  urine  of  the  horse. 

Certain  articles  of  food,  such  as  garlic  and  asparagus,  give  the  urine 
characteristic  odors.  Turpentine,  both  when  taken  internally  and  in- 
haled, gives  to  it  the  odor  of  violets.  The  odors  of  copaiba  and  of  cubebs 
can  easily  be  detected  in  the  urine  of  patients  who  are  taking  these  drugs. 

In  marked  cystitis  the  natural  urinous  odor  becomes  more  pungent, 
and  is  blended  with  a  strong  ammoniacal  odor.  When  much  pus  is 
present,  and  the  urine  has  stood  awhile,  a  putrid  odor  is  developed. 

In  diabetes  mellitus  the  urine  has  a  sweetish,  hay-like  odor.  In 
diabetic  coma  the  odor  is  sometimes  that  of  chloroform,  due  to  the 
presence  of  acetone  and  diacetic  acid  in  the  urine.  This  odor,  however, 
is  more  likely  to  be  detected  in  the  breath. 

2.  Chemical  Examination  of  the  Urine.  Examination  of  the  urine 
by  the  unaided  senses,  which  has  been  dwelt  upon  thus  far,  is  simply 
preliminary  to  an  examination  by  chemical  methods  and  by  instruments 
of  precision,  particularly  the  microscope. 

Urea.  Urea  is  freely  soluble  in  water,  and  hence  never  appears  as 
a  sediment.  It  is  the  most  important  final  product  of  nitrogenous  dis- 
integration in  the  body,  and  is  an  index  of  the  eliminative  power  of  the 
kidneys.  Usually  the  density  of  the  urine  increases  in  proportion  to 
the  amount  of  urea  contained  in  it.  The  average  daily  amount  of  urea 
excreted  by  an  adult  man  between  the  ages  of  twenty  and  forty  years 
is  about  500  grains.  The  urea,  like  the  total  volume  of  the  urine,  is 
subject  to  variations  within  the  limits  of  health.  It  is  increased  after  a 
meal,  especially  if  the  latter  be  rich  in  nitrogenous  food ;  after  copious 
ingestion  of  liquids,  and  by  a  close  atmosphere.  On  the  other  baud, 
fasting,  free  perspiration,  a  loose  condition-  of  the  bowels,  and  a  vege- 
table or  milk  diet  diminish  the  quantity  of  urea.  Again,  the  quantity 
varies  with  the  age  of  the  person.  According  to  Ralfe,  at  five  years 
the  amount  daily  is  180  grains;  at  12,  320;  at  21,  535;  and  at  40 
years,  555  grains. 

A  large  man  will  excrete  absolutely  more  than  a  small  man,  and  a 
large,  muscular  man  will  excrete  relatively  more  than  a  fat  man  of  the 
same  height. 

The  excretion  of  urea  is  increased  in  fever  and  inflammatory  dis- 
eases ;  in  diabetes  mellitus  and  insipidus  ;  in  malaria,  pernicious  anaemia, 
and  after  a  crisis  in  pneumonia.     It  is  increased  also  by  certain  bever- 


920  SPECIAL  DIAGNOSIS. 

ages,  as  coffee,  and  by  many  drugs,  especially  those  which  act  as  hepatic 
stimulants. 

It  is  diminished  in  all  forms  of  nephritis,  especially  when  uraemia 
results  ;  in  acute  gout  and  chronic  rheumatism  ;  in  disease  accompanied 
by  emaciation  and  cachexia;  and  in  leprosy,  pemphigus,  melancholia, 
imbecility,  catalepsy,  hysteria,  and  cholera  (Saundby). 

Estimation  of  Urea.  For  the  methods  employed  in  the  exact  quan- 
titative estimation  of  urea  the  student  is  referred  to  special  works  on 
the  urine. 

For  ordinary  clinical  purposes  the  apparatus  devised  by  Professor 
Charles  Doremus,  and  known  as  his  ureometer,  gives  sufficiently  accu- 
rate results.  The  principle  upon  which  it  is  based  is  that  urea  when 
brought  in  contact  with  sodium  hypobromite  is  decomposed,  and  free 
nitrogen  is  eliminated.  The  nitrogen  evolved  is  the  measure  of  the  urea 
contained  in  the  urine.  The  instruments  are  graduated  so  that  each 
division  of  the  scale  represents  one  grain  of  urea  per  fluidounce  of  urine. 

The  hypobromite  solution  is  prepared  by  dissolving  100  grammes  of 
sodium  hydroxide  in  250  c.c.  of  water,  cooling  the  solution,  and  then 
adding  25  c.c.  of  bromine. 

It  is  better,  however,  to  freshly  prepare  the  hypobromite  solution 
for  each  examination.  This  can  readily  be  done  by  having  a  solution 
of  sodium  hydroxide  containing  six  ounces  to  a  pint  of  water.  It 
should  be  kept  tightly  corked  with  a  rubber  or  paraffined  stopper. 
The  sodium  hydroxide  solution  is  poured  into  the  long  tube  of  the 
ureometer  to  the  mark  =,  then  one-tenth  of  its  volume  of  bromine  is 
introduced  by  means  of  a  pipette,  and  sufficient  water  added  to  fill  the 
long  arm  and  the  bend  of  the  tube.  The  hypobromite  solution  should 
fill  the  tube  completely,  and  any  bubbles  rising  to  the  top  of  the  tube 
should  be  removed  before  the  introduction  of  the  urine.  The  pipette 
is  then  filled  with  the  urine  up  to  the  1  c.c.  mark,  any  urine  adhering 
to  its  surface  being  carefully  wiped  off.  The  pipette  is  introduced  care- 
fully, so  as  not  to  compress  the  bulb  until  the  point  extends  as  high  up 
as  possible  beyond  the  bend.  The  bulb  is  now  compressed  slowly  until 
1  c.c.  of  urine  has  been  introduced.  Decomposition  of  the  urea  occurs 
and  bubbles  of  nitrogen  rise  to  the  surface  of  the  long  arm  of  the  tube  ; 
when  bubbles  of  gas  cease  to  be  evolved  the  volume  of  nitrogen  gas  is 
read  off,  and  according  to  the  graduations  on  the  tube  considered  as  so 
many  grains  of  urea  per  fluidounce  of  urine,  or  as  so  many  milligrammes 
of  urea  in  1  c.c.  of  urine,  according  to  whether  it  is  graduated  in  the 
English  or  the  metric  system. 

The  Chlorides.  The  presence  or  absence  of  chlorides  is  sometimes 
of  diagnostic  value.  They  are  increased  when  absorption  of  exudations 
or  transudations  is  going  on,  and  in  malarial  fevers,  diabetes  insipidus, 
and  Bright' s  disease.  They  are  diminished  or  absent  in  pneumonia 
during  its  progressive  stage,  and  in  fevers.  The  chlorine  of  the  chlo- 
rides can  be  detected  and  roughly  estimated  by  an  8  or  10  per  cent, 
solution  of  argentic  nitrate.  A  few  drops  of  nitric  acid  are  first  added 
to  the  urine,  to  prevent  the  silver  from  precipitating  phosphoric  acid. 
A  single  drop  of  the  silver  solution  mentioned  will  precipitate  the 
chlorine  of  the  chlorides  in  a  thick  white  lump,  which  falls  to  the  bot- 


DISEASES  OF  THE  KIDNEYS.  921 

torn  of  the  test-tube,  provided  the  amount  present  is  normal.  If,  on 
the  other  hand,  the  quantity  is  diminished  to  one-tenth  per  cent,  or 
less,  it  will  not  be  precipitated  in  a  lump  or  lumps,  but  a  white  cloudi- 
ness is  produced  which  renders  the  whole  solution  opaque.  If  no  pre- 
cipitation or  cloudiness  occurs,  the  chlorides  are  absent. 

Serum-albumin.  Albumin  is  of  common  occurrence,  but  cannot 
ever  be  looked  upon  as  a  normal  constituent  of  the  urine,  though  its 
presence  by  no  means  indicates  disease  of  the  kidneys.  The  ordinary 
form  is  serum-albumin,  but  other  proteids,  as  globulin,  mucin,  pep- 
tone, albumose,  fibrin,  and  also  haemoglobin  methsemoglobin,  are  found 
at  times.  The  most  trustworthy  tests  for  ordinary  albumin  (serum- 
albumin)  are  :  boiling,  with  the  addition  of  nitric  or  acetic  acid  ;  over- 
laying cold  nitric  acid  with  urine  (Heller's  test) ;  the  picric  acid,  the 
potassium  ferrocyanide,  and  the  potassium-mercuric-iodide  (Tanret's) 
tests.  The  author  believes  that  many  of  the  recent  tests,  such  as  sodium 
tungstate,  acidulated  brine,  magnesium  nitrate,  phenic-acetic  acid,  and 
trichlor-acetic  acid,  are  too  sensitive  and  precipitate  other  substances 
in  the  urine,  and,  therefore,  are  not  reliable  for  clinical  work. 

Serum  globulin  responds  to  all  the  following  tests  for  serum-albumin. 
Its  differentiation  is  not  difficult,  but  usually  unnecessary.  (See  note 
on  page  937.) 

Boiling  and  Nitric  Acid  Test.  A  narrow,  long  test-tube  is  filled  two- 
thirds  full  of  urine  and  the  upper  third  boiled  thoroughly,  and  then  a 
few  drops  of  nitric  acid  are  added.  Any  albumin  present  will  be  coag- 
ulated and  appear  as  a  white  cloud,  contrasting  strongly  with  the  clear 
unboiled  urine  beneath  it.  When  the  albumin  is  moderate  or  even 
small  in  amount  it  can  be  detected  without  difficulty  by  simply  holding 
the  test-tube  up  to  the  light.  When  there  is  only  a  faint  trace  present 
it  will  be  overlooked  unless  the  tube  be  examined  against  a  dark  sur- 
face in  such  a  way  that  the  light  falls  upon  it  from  above,  in  front, 
and  preferably  a  little  to  one  side.  A  cloud  may  escape  detection  when 
looked  for  by  artificial  light,  but  may  be  distinct  by  daylight.  Serum- 
globulin  is  also  precipitated  by  this  test.  But  serum-globulin  is  not 
often  present  by  itself,  and  its  significance  is  not  yet  understood.  It 
may  be  detected  in  any  urine,  as  Roberts  points  out,  by  diluting  the 
urine  with  pure  water,  the  urine  then  becoming  more  or  less  milky. 
It  may  be  removed  from  urine  by  saturating  the  latter  with  magnesium 
sulphate  and  filtering  off  the  precipitated  globulin.  The  presence  of 
serum-globulin  in  no  way  interferes  with  the  test  for  serum-albumin. 

If  the  urine  is  opaque  from  amorphous  urates,  it  is  unnecessary  to 
filter  them  out ;  heat  much  below  boiling  will  dissolve  them,  the  pre- 
cipitation of  albumin  occurring  later  at  a  higher  temperature. 

If  the  urine  is  alkaline  or  faintly  acid,  phosphates  will  produce  a 
cloud  upon  heating  the  urine ;  but  they  are  instantly  dissolved  upon 
the  addition  of  a  few  drops  of  nitric  or  acetic  acid. 

Mucin  produces  an  opalescence  upon  heating  with  an  organic  acid, 
but  Saundby  declares  that  it  coagulates  not  in  flocculi,  as  is  the  ease 
with  albumin,  but  in  the  form  of  tiny  filaments. 

Boiling  and  Acetic  Acid,  Test.  This  is  preferred  by  many  to  the 
preceding  test.     It  is  performed  in  a  similar  manner.     Acetic  acid  is, 


922  SPECIAL  DIAGNOSIS. 

however,  not  reliable  for  acidulation  :  it  precipitates  the  mucin  which 
is  often  found  in  healthy  urine,  forming  a  white  cloud  which  is  apt 
to  be  mistaken  for  albumin ;  this  is  especially  true  in  urines  of  high 
specific  gravity  containing  uric  acid,  urates,  or  oxalates. 

The  Nitric  Acid  (Heller's)  Test.  This  test,  while  not  so  delicate  as 
the  acetic  acid  test,  is  very  simple  and  accurate  in  its  results.  Cold 
nitric  acid  is  poured  into  a  test-tube  to  the  depth  of  about  an  inch. 
The  tube  is  then  inclined  to  an  angle  of  about  45  degrees,  and  urine 
allowed  to  flow  gently  down  upon  the  acid  by  trickling  along  the  side 
of  the  tube  from  a  pipette  or  glass  tube.  At  the  point  of  contact  of 
the  acid  and  urine  a  zone  of  white,  coagulated  albumin  forms.  The 
test  can  also  be  made  as  follows  :  Into  a  short,  broad  test-tube  several 
cubic  centimetres  of  urine  are  poured ;  nitric  acid  is  introduced  with 
a  pipette  provided  with  a  rubber  bulb  by  passing  the  pipette  through 
the  urine  to  the  bottom  of  the  tube  and  gently  pressing  the  rubber 
bulb  ;  care  must  be  taken  to  withdraw  the  pipette  as  the  last  portion 
of  acid  is  expelled,  so  that  no  air-bubbles  will  break  up  the  point  of 
contact  of  the  urine  and  acid.  The  thickness  of  the  white  zone  is 
generally  an  index  of  the  amount  of  albumin  present.  If  there  is 
barely  a  trace  of  albumin,  half  an  hour  may  be  required  to  develop 
any  opalescence. 

A  cloud  of  urates  is  sometimes  produced  and  obscures  the  test.  This 
cloud  does  not,  however,  begin  at  the  point  of  contact  and  extend 
upward,  but  at  the  upper  level  of  the  urine  and  extends  downward, 
and  is  dissipated  by  heat. 

Patients  who  are  taking  copaiba  or  cubebs  pass  a  urine  which  gives 
a  white  zone  at  the  point  of  contact  with  cold  nitric  acid,  but  heat 
diminishes  the  opacity,  and  the  precipitate  is  soluble  in  alcohol ;  the 
odor  of  the  drugs  in  the  urine  assists  in  the  detection  of  their  presence. 

The  Picric  Acid  Test.  This  is  an  extremely  delicate  test  for  albumin. 
A  saturated  solution  of  picric  acid  is  allowed  to  flow  down  upon  and 
slightly  mix  with  the  upper  layers  of  the  urine,  which  half  fills  a  good- 
sized  test-tube.  At  the  point  of  contact  an  opaque  white  zone  of  coagu- 
lated albumin  is  formed.  If  no  white  zone  appears,  albumin  is  almost 
certainly  absent.  Hence,  the  picric  acid  test  is  a  valuable  negative 
test.  But,  unfortunately,  a  white  zone  is  formed  by  peptone,  mucin, 
and  various  alkaloids,  particularly  quinine.  The  white  zone  produced 
by  the  presence  of  the  substances  just  named  disappears  upon  the  appli- 
cation of  heat,  whereas  an  opalescence  due  to  albumin  becomes  diffused 
throughout  the  whole  urine. 

The  Potassium  Ferrocyanide  Test.  This  test  is  highly  recommended 
as  simple,  rapid,  and  accurate  by  Purely,  who  performs  it  as  follows  : 
Into  a  test-tube  are  poured  fifteen  to  thirty  drops  of  acetic  acid,  and 
then  two  or  three  times  that  amount  of  potassium  ferrocyanide  solution 
(1  to  20)  is  added,  and  the  two  thoroughly  mixed  by  shaking  the  tube. 
The  urine  is  now  added  to  the  depth  of  two-thirds  of  the  test-tube.  If 
any  albumin  is  present,  it  will  be  precipitated  throughout  the  whole 
volume  of  urine  in  the  form  of  a  milk-like  flocculent  cloud,  more  or 
less  according  to  the  amount  of  albumin  present.  By  this  method  all 
modifications   of  albumin,  acid  or  alkaline,  are  precipitated  and  the 


DISEASES  OF  THE  KIDNEYS.  923 

precipitation  of  mucin  is  avoided.  It  gives  no  reaction  with  phosphates, 
urates,  peptones,  vegetable  alkaloids,  or  the  acids  found  in  the  urine 
after  the  ingestion  of  copaiba,  etc.  This  test  may  also  be  performed 
as  follows :  An  ordinary  test-tube  is  half  filled  with  urine  and  a 
drachm  or  two  of  the  potassium  ferrocyanide  solution  (1  to  20)  are 
added.  After  thoroughly  mingling  the  reagent  and  the  urine  a  few 
drops  of  acetic  acid  are  added.  If  albumin  is  present,  it  will  plainly 
come  into  view.  This  test,  therefore,  depends  upon  the  production  of 
a  cloudiness  or  milkiness  throughout  the  entire  mixture  in  the  tube. 
To  some  eyes  the  albumin  is  not  so  readily  perceived  as  in  those  tests 
which  depend  upon  the  formation  of  a  distinct  line  at  the  point  of  contact. 

The  Potassium-mercuric  Iodide  Test  (Tanrefs).  The  solution  is  made 
as  follows  :  Potassium  iodide,  3.32  grammes ;  bichloride  of  mercury, 
1.35  grammes;  acetic  acid,  20  c.c. ;  distilled  water  about  30  c.c.  (the 
potassium  iodide  and  the  bichloride  of  mercury  should  be  dissolved 
separately  in  the  water  and  the  solution  mixed,  to  which  the  acetic  acid 
is  added  and  the  whole  made  up  to  60  c.c.  with  distilled  water).  As 
thus  prepared  the  test  is  applied  by  the  contact-method  by  overlaying 
the  reagent  with  urine.  This  test  responds  to  all  modifications  of  albu- 
min, also  to  peptones  and  proteoses,  as  well  as  to  the  vegetable  alkaloids 
and  acids  found  in  the  urine  after  the  ingestion  of  copaiba,  etc.  All 
reactions  except  those  occurring  with  albumin,  mucin,  and  the  acids 
found  in  the  urine  after  the  ingestion  of  copaiba,  etc.,  disappear  with 
heat.  It  is  a  very  good  and  delicate  control-test  for  albumin.  The 
solution,  however,  is  of  a  yellowish  hue,  quite  similar  to  the  color  of 
urines  of  low  specific  gravity.  This  sometimes  renders  the  line  of 
contact  difficult  to  perceive. 

It  is  well  to  follow  a  routine  method  in  testing  for  albumin  :  first, 
by  boiling  and  the  addition  of  nitric  acid,  and  then  the  contact  (Hel- 
ler's) test ;  if  there  is  doubt,  either  the  potassium  ferrocyanide  or  picric 
acid  test ;  finally,  Tanret's  solution  will  reveal  minute  quantities  of 
albumin,  and  may  be  used  as  a  confirmatory  test. 

In  all  the  tests  for  albumin  mentioned  a  clear  urine  is  necessary, 
especially  when  the  amount  of  albumin  is  very  small.  This  can  be 
obtained  by  filtration  when  the  opacity  is  due  to  pus,  blood,  mucus, 
and  uric  acid  ;  and,  more  effectively,  by  the  addition  of  a  small  quan- 
tity of  sodium  hydroxide,  warming  slightly,  and  filtering.  If  the 
filtrate  is  not  clear,  a  few  drops  of  magnesium  fluid  (sulphate  of  mag- 
nesium, pure  ammonium  chloride,  and  pure  liquor  ammonia?,  of  each  2 
drachms  ;  distilled  water,  2  ounces),  as  recommended  by  Hoffmann  and 
Ultzmann,  may  be  added,  and  the  urine  again  warmed  and  filtered. 

Resume;  of  Tests  for  Albumin. 

1.  The  heat  test. 

A.  Method  :  Albumin  is  precipitated  on  boiling. 

B.  Exception  :  1.  In  alkaline  urines  albumin  may  be  overlooked 
from  the  formation  of  soluble  potassium  and  magnesium  compounds. 
When  patients  are  taking  alkaline  salts  the  test  may  be  fallacious. 

2.  An  excess  of  acid  may  also  interfere  with  the  test. 

3.  Feebly  alkaline  or  neutral  urines  produce  a  precipitate  of  earthy 
phosphates,  but  it  is  instantly  soluble  in  a  small  quantity  of  acid. 


924  SPECIAL  DIAGNOSIS. 

4.  Patients  on  a  vegetable  diet  pass  urine  containing  carbonates  which 
precipitate  with  heat.  The  addition  of  an  acid  causes  great  evolution 
of  gas. 

II.  The  heat  and  acetic  acid  test. 

Method :  Determine  the  reaction  of  the  urine.  If  alkaline,  make 
faintly  acid  with  acetic  acid ;  then  boil  and  add  a  little  more  acetic 
acid.  If  there  is  no  precipitate,  boil  again.  The  acetic  acid  precipitates 
nucleo-proteids,  which  are  excluded  by  the  methods  above  described. 

III.  The  heat  and  nitric  acid  test. 

A.  Method  :  Bring  the  urine  to  the  boiling-point  and  add  nitric 
acid,  drop  by  drop,  shaking  the  mixture  between  each  addition.  A 
small  precipitate  is  thrown  down  even  if  a  very  small  amount  of  albu- 
min is  present.  The  nitric  acid  should  not  exceed  more  than  one-tenth 
of  the  volume  of  urine  examined.  The  urine  must  not  be  heated  after 
the  addition  of  the  acid. 

B.  Exceptions  :  1.  In  concentrated  urines,  uric  acid  or  its  salts 
may  precipitate.  Distinguish  from  albumin  by  filtering  off  the  pre- 
cipitate and  testing  it  by  the  biuret  reaction,  or  dilute  the  urine  with 
an  equal  volume  of  water  when  uric  acid  will  not  precipitate. 

2.  Resin  acids  in  turpentine,  benzoin,  cubebs,  and  other  balsams,  if 
present  in  the  urine,  are  precipitated  by  nitric  acid.  Distinguish  from 
albumin  by  adding  one  or  two  volumes  of  alcohol  when  the  solution  is 
cool.     The  precipitate  of  resin  acids  is  dissolved. 

3.  In  urines  containing  biliverdin  a  precipitate  is  formed.  Distin- 
guish from  albumin  by  adding  alcohol,  which  dissolves  biliverdin. 

IV.  Cold  nitric  acid  test. 

A.  Method  :  Pour  the  urine  gently  on  the  nitric  acid.  The  albumin 
coagulates  in  the  presence  of  an  excess  of  strong  nitric  acid.  A  ring 
appears  at  the  surface  of  contact  if  albumin  is  present.  A  second  ring 
may  be  seen  y1^  to  1  cm.  above  the  junction,  due  to  nucleo-proteids. 
Distinguish  from  albumin  by  repeating  the  test  with  urine  diluted 
with  two  or  three  volumes  of  water.  The  albumin  rin^  diminishes 
and  the  nucleo-proteid  ring  is  unchanged  or  increased.  A  haze  due  to 
nucleo-proteid  may  form,  and  also  continue  after  dilution. 

B.  Exceptions  :  1.  In  concentrated  urines  a  secondary  ring  due  to 
uric  acid  may  form  above  the  junction.  It  is  soluble  on  gently  heating, 
and  does  not  form  when  the  urine  has  been  diluted. 

2.  In  highly  concentrated  urine  a  precipitate  of  nitrate  of  urea  may 
fall.     Distinguish  by  its  crystalline  nature. 

3.  Resin  acids  cause  a  precipitate  of  uniform  cloudiness.  Distinguish 
by  solubility  in  alcohol. 

4.  In  highly  colored  urines  the  urinary  pigments  form  a  colored 
ring  at  the  plane  of  contact,  and  in  bilious  urines  the  play  of  colors, 
as  in  Gmelin-Malin-Heintz's  test  for  bile,  is  seen. 

5.  The  urine  of  patients  taking  alkaline  iodides  gives  a  dense  brown 
ring  of  iodine.  Distinguish  by  adding  a  few  c.c.  of  chloroform  and 
mixing  them.     A  violet  tinge  is  imparted  to  the  liquid. 

6.  Albumoses  are  precipitated,  as  well  as  all  forms  of  albumin.  Dis- 
tinguish by  the  previously  mentioned  tests.  Peptone  and  vegetable 
alkaloids  are  not  precipitated. 


DISEASES  OF  THE  KIDNEYS.  925 

V.  The  potassium  ferrocyanide  and  acetic  acid  test. 

A.  Method  :  It  is  best  performed  as  a  ring  test.  The  urine  should 
be  carefully  run  into  a  mixture  of  twenty  or  thirty  drops  of  acetic  acid 
and  sixty  or  ninety  drops  of  saturated  solution  of  potassium  ferrocyanide. 
A  white  ring  forms  at  the  junction  if  albumin  is  present.  With  small 
amounts  of  albumin  the  ring  takes  some  minutes  to  form. 

B.  Exceptions  :  1.  Albumoses  are  precipitated.  They  are  soluble 
in  excess  of  acetic  acid.  They  disappear  on  heating  and  reappear  on 
cooling. 

2.  Resin  acids  give  a  precipitate  which  is  soluble  in  alcohol. 

3.  Phosphates,  urates,  alkaloids,  and  peptones  are  not  precipitated. 

VI.  Roberts'  brine  test. 

Saturated  sodium  hydrate  solution  with  5  per  cent,  hydrochloric  acid. 
It  does  not  darken  the  urine  nor  precipitate  uric  acid. 

A.  Method  :  Use  the  ring  test,  which  shows  albumin  and  albumoses. 

B.  Exceptions  :  Resin  acids  precipitate.  Distinguish  by  dissolving 
in  alcohol. 

VII.  The  salt  and  acetic  acid  test. 

The  acetic  acid  is  substituted  for  HC1,  and  a  large  excess  of  salt 
solution  used. 

A.  Method :  The  salt  solution  is  first  added  to  the  urine  and 
thoroughly  mixed.  Acetic  acid  is  then  poured  in.  Xucleo-proteids 
are  not  precipitated.  (All  other  forms  of  albumin  are  precipitated.) 
Salt  and  vinegar  may  be  used,  and  the  mixture  heated  in  a  metal  spoon. 

B.  Exceptions  :  1.  Albumoses  form  and  disappear  on  heating,  to 
reappear  on  cooling. 

2.  If  albumoses  and  albumin  appear  together,  boil  for  a  short  time 
and  filter  the  hot  fluid  through  a  warm  filter.  The  clear  filtrate  becomes 
turbid  from  albumoses  as  it  cools. 

3.  Resin  acids  and  uric  acid  are  precipitated,  the  latter  only  in  con- 
centrated urines,  and  after  standing.     Distinguish  by  the  usual  tests. 

V.  and  VI.  do  not  generally  precipitate  nucleo-proteids.  With 
VIL,  if  equal  parts  of  urine  and  salt  solution  are  used  with  a  few 
drops  of  acetic  acid,  nucleo-proteids  are  not  precipitated.  The  solution 
must  be  boiled  when  test  VII.  is  employed. 

VIII.  Salicylsulphonic  acid. 

All  forms  of  albumin  are  precipitated.  The  precipitate  becomes 
flocculent  on  heating.  If  the  urine  is  alkaline  more  of  the  reagent  is 
needed  than  if  acid.  Phosphates,  urates,  bile,  alkaloids,  and  drugs  do 
not  give  a  reaction. 

A.  Method  :  After  adding  the  solution  to  the  urine  heat  and  allow 
to  stand. 

B.  Exceptions  :  Albumoses  are  precipitated,  but  disappear  on  heat- 
ing and  reappear  on  cooling. 

IX.  Trichloracetic  acid. 

Exceptions  :  1.  Precipitates  uric  acid  when  in  excess.  Distinguish 
by  heating,  which  dissolves  the  acid,  or  dilute  the  urine  before  applying 
the  test. 

2.  Xucleo-proteids  give  an  opalescence.  Albumoses  are  not  pre- 
cipitated. 


926 


SPECIAL  DIAGNOSIS. 


Fig.  205. 


X.  Picric  acid. 

A.  Method  :  A  saturated  solution  of  picric  acid  must  be  used  alone, 
in  combination  with  HO,  or  with  acetic  acid.     Value  doubtful. 

B.  Exceptions :  Uric  acid,  creatinin,  nucleo-proteids,  alkaloids,  potas- 
sium salts,  and  albumoses  are  precipitated. 

XL  Millard's  reagent. 

Value  doubtful.  Precipitates  albumoses,  nucleo-proteids,  alkaloids, 
and  resin  acids.     Distinguish  by  usual  tests. 

XII.  Tanret's  reagent. 

Very  delicate.  Precipitates  all  forms  of  albumin,  albumoses,  nucleo- 
proteids,  peptones,  alkaloids,  and  resin  acids.  Distinguish  by  usual 
tests. 

XIII.  Spiegler's  reagent. 
Delicate.    Precipitates  albumin,  albumoses,  and  nucleo- 
proteids,  but  not  peptones. 

XIV.  Acetic  acid. 

Method  :  Filter  the  urine  and  add  acetic  acid  to  a 
portion,  pouring  the  two  in  the  tube  held  against  a  black 
background.  Albumin  and  nucleo-proteids  are  precipi- 
tated. Distinguish  by  diluting  the  filtered  urine  with  two 
or  three  volumes  of  distilled  water,  then  add  acetic  acid, 
and  compare  the  precipitate  with  that  in  an  undiluted 
specimen.  A  nucleo-proteid  precipitate  will  increase  in 
intensity.  An  albumin  precipitate  will  diminish  or  re- 
main unchanged. 

Salicylsulphonic  acid  is  the  most  delicate  test.  An 
objection  to  it  is  the  fact  that  it  precipitates  nucleo- 
proteids.  Control  the  test  by  Heller's  cold  nitric  acid 
test,  from  which  the  nucleo-proteids  are  removed,  as 
above  described. 

The  quantitative  estimation  of  albumin  is  of  some  im- 
portance. The  most  direct  method  is  by  coagulating  the 
albumin  by  boiling,  collecting  it  upon  a  weighed  filter, 
washing  with  water  and  finally  with  alcohol,  drying  and 
weighing  it.  Such  a  process,  however,  consumes  too  much 
time  for  clinical  purposes,  and  it  is  not  faultless.  An 
approximate  estimation  may  be  made  by  boiling  the  urine 
in  a  test-tube,  adding  several  drops  of  nitric  acid,  allowing 
the  albumin  to  settle,  and  then  comparing  the  depth  of 
albumin  with  the  height  of  the  column  of  urine.  In  this 
way  we  may  speak  of  urine  furnishing  one-tenth  or  one- 
quarter  of  its  bulk  of  coagulated  albumin. 

Esbach  has  invented  an  albuminimeter  (Fig.  205)  which 
gives  good  results.  The  solution  used  to  precipitate  the 
albumin  consists  of  10  grammes  of  picric  acid  and  20 
grammes  of  citric  acid,  chemically  pure  and  dry,  dissolved 
in  900  c.c.  of  hot  water  ;  and  after  cooling,  diluting  the 
solution  to  1000  c.c.  The  urine  is  diluted  with  a  definite 
amount  of  water  if  it  contains  too  much  albumin.  The  albuminimeter 
is  filled  to  the  mark  U  with  urine,  and  from  that  mark  to  E  with  the 


"I 


Esbach's 
albuminimeter. 


DISEASES  OF  THE  KIDNEYS.  927 

reagent.  The  tube  is  then  corked  with  a  rubber  stopper,  turned  upside 
down  ten  times,  so  as  to  mix  the  urine  intimately  with  the  reagent,  and 
then  allowed  to  stand  undisturbed  for  twenty-four  hours.  At  the  end 
of  this  time  the  depth  of  the  sediment  of  coagulated  albumin  is  ascer- 
tained by  observing  where  the  top  of  the  sediment  comes  in  contact 
with  a  mark  on  the  scale  on  the  tube.  Each  mark  corresponds  to  one- 
tenth  per  cent,  of  albumin. 

This  estimation,  as  already  stated,  is  not  absolutely  accurate.  Never- 
theless, if  used  systematically,  and  always  in  the  same  way,  relative 
values  will  be  obtained,  and  these  are  the  most  important  in  watching 
the  progress  of  a  case,  as  they  give  positive  information  regarding  an 
increase  or  diminution  of  the  amount  of  albumin  in  the  urine.  It 
scarcely  need  be  said  that  the  urine  tested  must  be  a  portion  of  the 
whole  twenty-four  hours'  urine. 

The  esthnation  of  the  amount  of  albumin  is  also  readily  made  with 
the  centrifugal  machine  :  to  10  c.c.  of  the  albuminous  urine  are  added 
3.5  c.c.  of  potassium  ferrocyanide  solution  (1  to  10)  and  1.5  c.c.  of 
acetic  acid  ;  the  mixture  is  then  revolved  in  the  machine  about  three 
minutes,  and  the  amount  of  precipitate  read  off. 

Albuminuria.  Albuminuria  is  not  indicative  of  disease  of  any  one 
organ,  nor  does  it  point  to  any  general  pathological  condition.  It 
occurs  as  follows  : 

1 .  In  diseases  of  the  kidney  :  acute  and  chronic  Bright's  disease,  amy- 
loid disease,  tuberculosis,  cancer,  abscess,  and  calculus. 

2.  In  disturbances  of  the  circulation  :  diseases  of  the  heart  and  chronic 
pulmonary  diseases,  as  emphysema  ;  obstruction  of  the  renal  arteries  or 
veins,  cirrhosis  of  the  liver,  peritonitis,  pregnancy,  abdominal  tumors ; 
in  passive  congestions  due  to  great  weakness ;  in  anaemia  and  Graves' 
disease. 

3.  In  febrile  and  inflammatory  diseases  :  in  the  eruptive  and  infec- 
tious fevers,  and  in  rheumatism,  diphtheria,  pneumonia,  and  gout. 

4.  In  blood  diseases  :  purpura,  leucocythsemia,  and  scurvy. 

5.  From  the  poisonous  action  of  drugs  :  lead,  turpentine,  and  others. 

6.  In  nervous  disorders  :  concussion  of  the  brain  and  cerebral  hemor- 
rhage, epilepsy,  tetanus,  and  delirium  tremens  ;  as  Pye-Smith  remarks, 
it  is  doubtful  whether  albuminuria  is  caused  by  the  nervous  diseases. 

7.  Local  extra-renal  affections  :  pyelitis,  cystitis,  gonorrhoea,  and 
leucorrhoea. 

8.  Functional.  In  young  persons,  particularly  of  the  male  sex,  there 
occurs  occasionally  slight  albuminuria  after  exercise,  a  special  diet,  or 
a  cold  bath.  Albumin  may  be  found  after  rising;  in  the  morning1,  or 
early  after  dinner,  or  toward  evening.  On  account  of  its  occurring 
only  at  certain  times  it  has  been  called  "  cyclical  "  or  "  intermittent," 
and  because  there  is  no  evident  disease  present,  it  is  occasionally  spoken 
of  as  "  physiological "  albuminuria. 

Goodhart  examined  the  urine  of  1500  individuals  and  noted  albumin 
in  272,  or  in  20  per  cent.  In  39  cases  the  albuminuria  could  not  posi- 
tively be  said  to  be  due  to  disease  of  the  kidney.  Of  these  39,  26  were 
males  and  13  females.  In  32  of  the  39  cases  it  was  temporary,  and  in 
most  of  them  it  had  disappeared  within  forty -eight  hours,  or  sooner. 


928  SPECIAL  DIAGNOSIS. 

In  2  cases  there  were  oxalates  in  the  urine  ;  in  1  hseruoglobinuria ;  in  8 
leucorrhoeal  discharges  and  discharges  from  other  parts  of  the  genital 
passages  (see  division  7) ;  and  in  17  a  markedly  neurotic  temperament. 
These  last  he  thinks  the  most  typical  cases  of  intermittent  albuminuria ; 
on  the  whole,  he  regards  the  condition  as  less  common  than  has  been 
supposed. 

One  variety  of  functional  albuminuria  is  apparently  due  to  the  irri- 
tation of  the  kidney  produced  by  the  excretion  of  oxalates  and  uric  acid. 
The  urine  is  of  increased  density,  1028,  1030  or  higher,  and  contains 
uric  acid  or  oxalate  of  lime,  or  both,  and  cylindroids.  Tube-casts  are 
very  uncommon.  The  albuminuria  usually  disappears  under  proper 
diet.     This  condition  is  sometimes  called  "  morbus  Da  Costse." 

It  is  conceded  that  there  may  be  albumin  aria  of  renal  origin  without 
renal  disease,  but  the  diagnosis  must  be  by  exclusion,  and  can  be  reached 
safely  only  after  extended  observation.  The  most  important  elements 
in  the  diagnosis  are  :  the  age  of  the  patient,  unimpaired  general  health, 
a  specific  gravity  of  the  urine  normal  or  above  normal,  the  fact  that 
the  albuminuria  is  influenced  by  diet  and  exercise,  and  that  it  tends  to 
disappear  under  suitable  regimen.     The  prognosis  is  favorable. 

Mucin.  Nucleo-albumin,  or  nucleo-proteid,  is  nucleic  acid  and 
chondro-sulphuric  acid  combined  with  a  proteid.  Sometimes,  patho- 
logically, tauro-cholic  acid  enters  into  the  combination.  This  is  not 
true  mucus,  but  urinary  mucus.  It  is  present  in  the  urine  in  health, 
being  especially  abundant  in  women  from  the  admixture  of  the  vaginal 
secretion,  and  in  excess  in  inflammatory  conditions  of  the  urinary  tract. 
It  is  distinguished  from  albumin  by  the  fact  that  it  gives  a  precipitate 
upon  the  addition  of  vegetable  acids,  as  acetic  or  citric.  The  precipi- 
tate is  increased  by  removing  the  salts  of  the  urine  by  dialysis,  or  by 
dilution  of  the  urine,  with  two  or  three  volumes  of  distilled  water, 
diminishing  thereby  the  relative  proportion  of  salts  to  mucus.  It  is 
precipitated  by  dilute  mineral  acids,  but  is  soluble  in  concentrated 
mineral  acids  or  dilute  alkalies. 

According  to  Roberts,  the  best  method  for  the  detection  of  mucin  is 
by  means  of  a  saturated  solution  of  citric  acid,  employed  in  the  same 
manner  as  the  contact-method  of  applying  the  nitric  acid  test  for  albu- 
min. A  small  quantity  of  the  urine  is  first  put  in  a  test-tube,  and  citric 
acid  allowed  to  trickle  down  the  sides  of  the  tube  until  it  forms  a  dis- 
tinct layer  below  the  column  of  urine.  If  mucin  is  present  there  will 
gradually  appear  an  opalescent  zone  immediately  above  the  layer  of 
acid.  Acetic  acid,  mixed  with  one-third  of  its  volume  of  glycerin, 
answers  admirably  as  a  test  for  mucin.  Sometimes,  when  mucin  is 
very  abundant,  the  addition  of  an  excess  of  acetic  acid  produces  a 
marked  milkiness  in  the  urine,  which  is  not  discharged  by  boiling  the 
liquid. 

Blood.  Urine  containing  blood  is  usually  red  in  color  or  reddish- 
brown  and  opaque,  but  it  may  be  chocolate-brown  if  the  blood  is  present 
in  large  quantity  and  has  been  acted  upon  by  the  urine.  Such  urine 
necessarily  contains  albumin. 

Blood  occurs  in  the  urine  from  (1)  diseases  of  the  kidney  and  urinary 
2xissages,  among  which  are  Bright's  disease,  acute  congestion  of  the 


DISEASES  OF  THE  KIDNEYS.  929 

kidney,  renal  calculus,  cancer,  tuberculosis  ;  from  ureteritis,  cystitis,  and 
urethritis,  and  from  injuries ;  (2)  from  general  diseases,  such  as  the 
eruptive  and  intermittent  fevers,  scurvy,  purpura,  peliosis  rheumatica, 
leucocytheemia,  cholera ;  (3)  from  adjacent  organs,  as  in  menstruation 
and  hemorrhage  from  the  uterus  ;  (4)  from  the  toxic  action  of  drugs — 
cantharides,  turpentine,  and  other  violent  irritants  of  the  kidney ;  (5) 
vicariously — occasionally  menstruation  fails  to  occur  and  hematuria 
replaces  it.  The  same  is  true  of  bleeding  from  piles.  Latour  has 
reported  a  case  of  asthma  which  subsided  suddenly  upon  the  appear- 
ance of  hsematuria. 

The  chemical  tests  for  blood  are  the  same  as  those  for  its  coloring- 
matter,  and  will  be  referred  to  under  Haemoglobin. 

Haemoglobin.  Haemoglobin  is,  of  course,  present  whenever  blood 
is,  but  sometimes  it  occurs  independently  of  hsernaturia.  Thus,  it  is 
found  in  grave  infectious  diseases,  as  the  result  of  toxic  action  of  drugs, 
such  as  carbolic  acid,  and  in  an  independent  disease  known  as  parox- 
ysmal hseunoglobinuria.  A  suitable  test  consists  in  adding  one  or  two 
drops  of  freshly  prepared  tincture  of  guaiac  to  about  one  drachm  of 
urine,  then  shaking  the  mixture  and  adding  several  drops  of  a  solution 
of  hydrogen  peroxide.  If  blood-coloring  matter  be  present,  a  beautiful 
blue  coloration  will  be  produced. 

The  same  test  answers  for  methsenioglobin  and  heematin. 

Paroxysmal  Hemoglobinuria.  The  urine  contains  blood,  or  only 
the  coloring-matter  of  the  blood  is  present.  Hsemoglobinuria  is  more 
frequent  in  adult  males ;  it  may  be  excited  by  a  cold  bath,  or  exposure 
to  cold,  or  by  exertion.  It  is  sometimes  associated  with  Raynaud's 
disease.  The  attacks  come  on  suddenly,  often  preceded  by  chills. 
Sometimes  fever  accompanies  the  disease.  Vomiting  and  diarrhoea 
occur  with  hemoglobinuria.  Pain  in  the  loins  is  sometimes  com- 
plained of.  The  paroxysm  may  last  a  day  or  two,  or  two  or  three 
paroxysms  may  occur  in  the  course  of  twenty-four  hours. 

Albumose  (Proteoses,  propeptone  or  Meissner's  peptone).  Formerly 
the  reactions  which  we  know  now  determine  the  presence  of  the  albu- 
moses  were  thought  to  indicate  the  presence  of  peptone.  The  latter 
substance  is  extremely  rare.  Recent  chemical  investigations  show 
that  that  which  was  called  peptonuria  is  truly  albumosuria.  Albu- 
mose has  been  found  in  the  urine  in  osteomalacia  and  diseases  of  the 
medulla  of  bone  and  in  myxcedema.  When  persistent  it  is  in  all  proba- 
bility due  to  multiple  tumors  of  the  bones  or  to  myxcedema.  The 
albumosuria  may  be  considered  ;is  primary.  Transitory  albumosuria 
is  found  in  pneumonia,  deep-seated  suppuration,  meningitis,  and  in  der- 
matitis, intestinal  ulcer,  measles,  scarlatina,  and  mental  diseases.  Its 
frequent  occurrence  renders  its  presence  of  not  much  diagnostic  value. 
According  to  von  Jaksch,  its  presence  may  indicate  that  a  suppurative 
process  exists.  In  the  diagnosis  of  epidemic  cerebro-spinal  from  tuber- 
cular meningitis  transitory  albumosuria  speaks  for  the  former  if  no 
ulcerative  tuberculous  process  exists  elsewhere.  Urine  containing  it 
does  not  respond,  at  first,  to  the  heat  and  nitric-acid  test,  but  on  cooling 
a  precipitate  forms  which  responds  to  the  biuret  test.  (In  this  test  the 
urine  is  first  treated  with  about  one-half  its  volume  of  sodium  hydrox- 

59 


930  SPECIAL  DIAGNOSIS. 

ide  solution,  and  then  a  1  per  cent,  solution  of  cupric  sulphate  is  added, 
drop  by  drop.  If  albumose  is  present,  the  resulting  cupric  hydroxide 
is  dissolved,  and  the  fluid  becomes  of  a  violet-red  color.)  The  proba- 
bilitv  of  the  presence  of  albumose  is  strengthened  if  a  turbidity  occurs 
with  the  acetic  acid  and  potassium  ferrocyanide  test  (acetic  acid,  specific 
gravity  1064,  to  which  a  few  drops  of  a  10  per  cent,  solution  of  potas- 
sium ferrocyanide  have  been  added),  and  also  with  the  biuret  test, 
applied  directly  to  the  urine  itself.    Albumin  also  responds  to  this  test. 

The  best  test  for  albumoses  is  that  of  Hofmeister,  modified  by  Sal- 
kowski.  Twentv  to  fifty  c.c.  of  urine  are  acidified  with  acetic  acid  and 
then  added  to  an  equal  quantity  of  a  saturated  solution  of  common  salt, 
boiled  and  filtered.  In  this  manner  the  urine  is  freed  from  albumin  ; 
the  albumiD  remaining  as  a  filtrate  while  the  albumose  is  re-dissolved. 
The  filtered  fluid  containing  the  albumose  is  placed  in  a  beaker  and 
a  few  drops  of  HC1  added.  A  solution  of  phosphotungstic  acid  is 
added  and  the  precipitate  consolidated  by  heat  into  a  coherent  mass. 
Then  pour  off  the  supernatant  fluid ;  wash  the  precipitate  with  water 
and  dissolve  in  a  solution  of  soda  (sp.  gr.  1.16),  which  is  added,  drop 
by  drop,  until  dissolved.  If  the  solution  is  blue  it  is  to  be  gently 
heated,  to  decolorize.  A  few  drops  of  a  1  per  cent,  solution  of  sul- 
phate of  copper  is  added  to  the  soda  solution.  If  a  red  or  violet  color, 
the  biuret  reaction  results,  albumose  is  present. 

The  late  Dr.  X.  A.  Randolph  suggested  the  following  test,  which  is 
given  bv  Tvson  :  To  5  c.c.  of  urine,  which  must  be  cold  and  faintly 
acid,  add  two  drops  of  a  saturated  solution  of  potassium  iodide  and 
then  three  or  four  drops  of  Millon's  reagent.  If  albumoses  or  bile- 
acids  are  present,  a  yellow  precipitate  falls.  If  the  yellow  precipitate 
does  not  respond  to  the  test  for  bile-acids,  it  is  due  to  albumose. 

Sugar  (Glucose).  Next  to  albumin,  sugar  is  the  most  important 
abnormal  constituent  of  the  urine.  It  is  not  present  in  normal  urines 
in  quantities  that  can  be  detected  by  ordinary  clinical  methods.  The 
best  tests  for  its  detection  are  Fehling's  test  and  the  fermentation  test. 

Fehling's  Test.  Fehling's  solution  is  prepared  by  dissolving  34.652 
grammes  of  pure  crystallized  cupric  sulphate  in  about  200  c.c.  of  water. 
About  173  grammes  of  sodic  potassium  tartrate  (Eochelle  salt)  are  dis- 
solved in  about  480  c.c.  of  sodium  hydroxide  solution  of  1.14  specific 
gravity.  The  cupric  sulphate  solution  is  added  slowly  to  the  sodic 
potassium  tartrate  solution,  stirring  constantly  until  all  of  the  cupric 
sulphate  solution  has  been  added.  The  bluish-white  precipitate  of 
cupric  hydroxide  which  first  forms  will,  on  stirring  the  liquid,  be 
completely  dissolved.  The  blue  liquid  is  then  diluted  with  water  to 
exactly  1000  c.c.  One  c.c.  of  this  solution  will  be  reduced  by  0.005 
of  a  gramme  of  glucose.  Fehling's  solution  is  prone  to  decomposition, 
and  as  much  as  possible,  to  avoid  the  occurrence  of  decomposition,  it  is 
best  to  keep  the  cupric  sulphate  and  sodic  potassium  tartrate  solutions 
in  separate  bottles  closed  with  rubber  stoppers.  To  accomplish  this, 
the  34.652  grammes  of  cupric  sulphate  are  dissolved  in  water  and 
diluted  to  500  c.c,  and  the  sodic  potassium  tartrate  is  dissolved  in 
water  and  diluted  to  500  c.c,  and  the  two  solutions  preserved  in  sepa- 
rate bottles   closed  with  rubber  stoppers.     The  solution,  prepared  in 


DISEASES  OF  THE  KIDNEYS.  931 

this  manner,  is  made  ready  for  use  by  mixing  one  volume  of  the  cupric 
sulphate  solution  with  an  equal  volume  of  the  sodic  potassium  tartrate 
solution.  The  resulting  liquid  will  be  Fehling's  solution,  and  1  c.c.  of 
it  will  be  equal  to  0.005  of  a  gramme  of  glucose. 

Certain   precautious  are   necessary  in  the  application  of   this  test. 

1.  Any  albumin  present  must  be  removed  by  boiling  and  filtration. 

2.  The  Fehling  solution,  diluted  with  4  to  5  volumes  of  water,  must 
be  boiled  first  and  the  urine  added  to  it ;  the  urine  must  not  be  boiled 
first  and  the  Fehling  solution  added  to  it.  Boiling  the  reagent  first  is 
a  test  of  its  stability  :  if  a  precipitate  occurs,  the  solution  is  unfit  for  use. 
As  Wormley  correctly  says,  a  precipitate  is  more  likely  to  occur  when 
the  Fehling  solution  has  been  diluted  with  four  or  five  times  its  volume 
of  water  than  on  boiling  the  undiluted  solution.  3.  Prolonged  boiling 
is  to  be  avoided.  The  solution  is  to  be  heated  to  the  boiling-point 
and  the  urine  then  added  ;  if  no  precipitate  indicating  sugar  occurs 
until  urine  is  added  almost  equal  in  volume  to  that  of  the  reagent,  the 
mixture  should  be  again  heated  to  the  boiling-point  and  then  set  aside. 
4.  When  the  earthy  phosphates  are  abundant,  it  is  well  to  get  rid  of 
them  by  adding  a  small  quantity  of  sodium  hydroxide  and  filtering 
before  applying  the  sugar  test.  5.  Changes  in  color  may  occur  from 
the  presence  of  urea,  uric  acid,  and  extractives.  These  changes  can 
be  obviated,  when  necessary,  by  the  method  proposed  by  Seegen,  who 
recommends  repeated  filtering  through  animal  charcoal  until  the  urine 
is  rendered  colorless.    Fehling's  test  is  then  applied  to  the  filtered  urine. 

The  method  of  applying  Fehling's  test  is  as  follows  :  Fehling's  solu- 
tion is  poured  to  the  depth  of  about  one-quarter  of  an  inch  into  a  test- 
tube,  and  diluted  with  four  or  five  times  its  volume  of  water,  and  heated 
until  it  begins  to  boil ;  then  one  or  two  drops  of  the  suspected  urine  are 
added.  If  it  be  ordinary  diabetic  urine,  the  mixture,  after  an  interval 
of  a  few  seconds,  will  suddenly  turn  to  an  intense  opaque  yellow  or 
reddish-brown  color,  and  in  a  short  time  an  abundant  yellow  or  reddish- 
brown  precipitate  falls  to  the  bottom.  If,  however,  the  quantity  of 
sugar  present  be  small,  the  suspected  urine  is  added  more  freely,  but 
not  beyond  a  volume  equal  to  that  of  the  diluted  Fehling's  solution 
employed.  In  this  latter  case  it  is  necessary  to  raise  the  mixture  once 
more  to  the  boiling-point.  It  is  then  allowed  to  cool  slowly.  If  no 
cuprous  oxide  has  been  thrown  down  when  the  liquid  has  become  cold, 
then  the  urine  may  be  pronounced  sugar-free. 

Sir  William  Roberts  has  recently  pointed  out  the  value  of  repeated 
filtration  through  animal  charcoal  of  urine  which  reacts  doubtfully  to 
the  test  for  sugar  ;  by  this  filtration  the  urates,  uric  acid,  and  other 
normal  constituents  of  the  urine,  which  have  more  or  less  power  of 
reducing  Fehling's  solution,  are  removed,  while  the  sugar  passes 
through  and  is  found  in  undiminished  quantity  in  the  filtrate. 

The  test  is  made  as  follows  :  A.  test-tube  is  charged  with  Fehling's 
solution  to  the  depth  of  about  one-quarter  of  an  inch,  diluted  with  four 
or  five  times  its  volume  of  water,  and  brought  to  the  boiling-point ;  the 
urine,  filtered  through  charcoal,  is  added  to  the  depth  of  about  two 
inches,  and  the  two  fluids  mixed.  The  flame  of  a  lamp  is  then  applied 
to  the  upper  half  of  the  column  of  liquid,  and  this  is  boiled  for  a  couple 


932  SPECIAL  DIAGNOSIS. 

of  seconds.  If  sugar  is  present,  the  upper  half  loses  its  blue  color  and 
assumes  a  yellowish  tinge,  and  the  earthy  phosphates  which  are  thrown 
down  in  light  flakes  by  the  alkali  of  the  test  are  tinted  more  or  less  of 
a  gold  color  by  the  precipitation  on  them  of  the  cuprous  oxide. 

The  Fermentation  Test.  This  is  based  upon  the  fact  that  sugar  by 
fermentation  with  yeast  breaks  up  into  alcohol  and  carbon  dioxide. 
It  is  a  reliable  but  not  a  very  delicate  test  for  sugar. 

A  piece  of  yeast-cake  the  size  of  a  pea  is  added  to  a  test-tube  full  of 
urine.  The  open  end  of  the  tube  is  inverted  under  water  in  a  saucer 
or  beaker.  If  sugar  is  present  in  amounts  larger  than  two  and  a  half 
grains  to  the  ounce,  bubbles  of  carbon  dioxide  collect  at  the  upper  part 
of  the  tube  after  standing  twelve  hours  in  a  temperature  of  about  90°  F. 

The  Phenyl-hydrazin  Test.  Von  Jaksch  believes  this  test  to  be  a  very 
accurate  one.  About  two  grains  of  phenyl-hydrazin  hydrochloride  and 
about  three  grains  of  sodium  acetate  are  put  into  a  test-tube  half-full  of 
water.  The  contents  of  the  tube  are  heated  and  the  tube  filled  with  the 
suspected  urine.  The  tube  is  kept  for  fifteen  or  twenty  minutes  in 
boiling  water,  and  then  put  in  a  vessel  of  cold  water.  When  a  large 
amount  of  sugar  is  present  a  deposit  of  yellow,  needle-like  crystals  is 
visible  to  the  naked  eye ;  but  when  only  a  small  amount  is  present,  the 
sediment  must  be  examined  under  the  microscope.  The  crystals  appear 
singly,  or  in  sheaves  and  fine  radii.  Yellow  plates  and  brown  balls  do 
not  indicate  sugar.     (Plate  XL  VI.) 

Quantitative  estimation  of  sugar  can  be  made  with  Fehling's  solution 
by  using  a  burette  and  measured  quantities  of  urine  and  reagent. 
AVormley  recommends  a  method  which  answers  very  well  for  office- 
use  :  One  cubic  centimetre  of  Fehling's  solution  is  diluted  in  a  large 
test-tube  with  four  cubic  centimetres  of  distilled  water,  and  boiled. 
One-tenth  of  a  cubic  centimetre  of  the  suspected  urine  is  then  added 
from  a  graduated  pipette.  Heat  is  then  applied,  the  precipitate  watched, 
and  then  another  one-tenth  cubic  centimetre  added,  and  heat  again 
applied.  The  addition  of  one-tenth  of  a  cubic  centimetre,  followed  by 
heat,  is  continued,  until  it  is  found,  after  proper  subsidence,  that  all 
the  color  is  removed  from  the  diluted  Fehling's  solution.  If  in  doing 
this  one  cubic  centimetre  of  urine  has  been  added,  it  will  have  contained 
just  0.5  per  cent,  of  sugar.  If  more  than  one  cubic  centimetre,  it  will 
have  contained  less  than  0.5  per  cent.  If  exactly  two  cubic  centimetres 
are  used,  it  will  have  contained  exactly  0.25  per  cent.  If  one-tenth  of 
a  cubic  centimetre  has  been  used,  the  urine  will  have  contained  5  per 
cent,  of  sugar.  If  the  quantity  of  sugar  in  the  urine  is  large,  the  urine 
should  first  be  diluted  with  a  measured  volume  of  water,  allowance 
being  made  for  this  hi  the  estimation. 

When  the  quantity  of  sugar  is  relatively  large  fermentation  is  the 
simplest  and  most  trustworthy  method.  Roberts  has  shown  that 
saccharine  urine  loses  by  fermentation  one  degree  in  density  for  every 
grain  of  sugar  contained  in  an  ounce  of  urine.  For  example,  if  the 
urine  before  fermentation  had  a  specific  gravity  of  1040,  and  after  fer- 
mentation a  specific  gravity  of  1010,  then  the  urine  contained  30  grains 
of  sugar  to  the  ounce.  In  the  application  of  this  method,  about  four 
ounces  of  diabetic  urine  are  put  in  a  twelve-ounce  bottle,  and  a  piece 


PLATE   XLVI. 


■    / 


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Crystals  of  Phenyl-glucosazone. 

(Oc.  4,  Obj.  D.)       Drawn  by  J.  D.  Z.  Chase. 


DISEASES  OF  THE  KIDNEYS.  933 

of  Vienna  yeast,  about  the  size  of  a  pea,  is  broken  up  and  then  added 
to  it.  This  bottle  is  closed  with  a  perforated  cork  to  allow  the  C02 
to  escape,  and  stood  aside  in  a  warm  place  to  ferment.  Beside  it  is 
placed  a  tightly  corked  four-ounce  bottle  filled  with  the  same  urine, 
but  without  any  yeast.  In  about  twenty-four  hours  the  fermentation 
will  have  ceased.  The  specific  gravity  of  the  fermented  urine  is  then 
taken  and  also  that  of  the  unchanged  urine.  Every  degree  of  loss  in 
density  represents  one  grain  of  sugar  per  ounce  of  urine. 

Diabetes  Mellitus.  The  occurrence  of  any  of  the  following  condi- 
tions should  lead  to  an  examination  of  the  urine  for  sugar,  and  an  esti- 
mation of  the  quantity  of  urine  passed  in  twenty -four  hours,  apart  from 
the  routine  examination,  which  should  be  made  in  every  case  of  chronic 
disease  or  of  obscure  acute  disease :  1.  Muscular  weakness  without 
cause.  The  weakness  is  progressive  and  rapidly  advances  to  an  ex- 
treme degree.  2.  Emaciation.  In  young  subjects  this  is  rapid  in 
cases  of  diabetes.  In  older  patients  it  is  not  so  striking,  particularly 
if  the  gouty  diathesis  is  present.  3.  Thirst.  This  is  a  symptom 
which  is  of  common  occurrence  in  diabetes,  and  is  most  distressing. 
If  the  amount  of  fluids  taken  be  compared  with  the  amount  of  urine 
excreted,  it  will  be  found  that  the  two  bear  a  definite  ratio.  The  thirst 
is  greater  immediately  after  meals,  although  the  patient  does  not  neces- 
sarily have  indigestion.  4.  Hunger.  Excess  of  appetite,  boulimia  or 
polyphagia,  also  occurs  in  diabetes.  The  amount  of  food  that  is  taken 
is  sometimes  enormous,  and  the  ravenous  way  it  is  devoured  is  revolt- 
ing.    5.  Loss  of  sexual  power. 

The  five  symptoms  just  mentioned,  with  increased  frequency  in 
micturition,  are  the  common  symptoms  of  diabetes  mellitus.  They 
may  develop  gradually.  In  rare  instances  the  onset  is  sudden.  The 
occurrence  of  these  symptoms  should  lead  at  once  to  an  examination  of 
the  renal  secretion. 

Three  special  characteristics  of  the  urine  are  observed.  A.  The 
amount  is  increased,  so  that  from  six  to  ten  pints,  or  even  as  much  as 
thirty  to  forty  pints,  are  passed  in  twenty-four  hours.  B.  The  specific 
gravity  ranges  from  1025  to  1045,  and  may  even  be  higher.  C.  The 
presence  of  sugar.  The  sugar  is  detected  by  the  ordinary  tests.  (See 
Examination  of  Urine.)  In  addition  the  urine  is  usually  of  pale  color, 
of  a  sweetish  odor  and  acid  reaction. 

In  addition  to  thirst  and  increased  appetite,  some  gastro-intestinal 
symptoms  may  be  of  diagnostic  importance.  Of  these,  first,  the  appear- 
ance of  the  tongue  is  characteristic.  It  is  dry,  red,  and  glazed.  The 
dryness  is  increased  because  of  the  scanty  flow  of  saliva.  The  gums 
are  swollen  and  spongy,  and  marginal  gingivitis  and  stomatitis  are  often 
present.  There  are  no  marked  dyspeptic  symptoms.  Constipation  is  of 
common  occurrence. 

In  diabetes  other  secretions  diminish.  Perspirations  do  not  occur, 
except  in  inflammatory  complications.  The  shin  is  harsh  and  dry.  As 
the  disease  progresses  the  hearts  action  becomes  weak  and  the  pulse 
frequent,  with  lowered  tension.  The  temperature  of  the  body  is  usually 
below  normal. 

Diabetes  may  occur  at  any  age,  but  is  most  frequent  in  adidt  life. 


934  SPECIAL  DIAGNOSIS. 

In  young  adults  the  symptoms  are  more  pronounced,  and  the  duration 
shorter.  In  patients  past  middle  life  the  disease  may  continue  for  a  num- 
ber of  years  without  marked  interference  with  the  health  and  nutrition. 

While  the  symptoms  just  mentioned  should  lead  to  an  examination 
of  the  urine,  diabetes  mellitas  may  not  be  suspected  by  any  of  the  usual 
objective  or  subjective  symptoms.  It  may  happen  that  none  of  these 
symptoms  is  sufficiently  marked,  and  that  only  by  routine  examination 
of  the  urine,  or  by  the  occurrence  of  affections  known  to  be  associated 
with  sugar  in  the  urine,  is  the  disease  discovered. 

Of  the  complications  which  should  lead  to  the  suspicion  of  sugar  in 
the  urine  the  following  are  the  most  important  : 

1.  Cutaneous  Complications.  Boils  and  carbuncles  should  always 
lead  to  an  examination  of  the  urine.  Pruritus  and  chronic  eczema 
may  have  diabetes  in  the  background.  Gangrene  of  the  extremities, 
chiefly  of  the  feet  and  legs,  and  gangrene  in  other  situations,  is  of  com- 
mon occurrence  in  the  course  of  diabetes. 

2.  Lung-complications.  Tuberculosis,  both  of  the  chronic  and  the 
acute  pneumonic  type,  is  frequently  associated  with  diabetes.  Lobar 
pneumonia  is  apt  to  occur.  In  all  cases  of  pneumonia  the  urine  should 
be  examined  for  sugar.  Its  presence  would  modify  the  prognosis  of  an 
otherwise  moderate  case.  Gangrene  is  likely  to  ensue  in  the  acute  and 
chronic  lung  affections.  Gangrene  of  the  lung  in  the  course  of  diabetes 
may  be  latent,  and  recognized  only  by  the  odor  and  the  character  of  the 
expectoration,  or  it  may  run  an  acute  febrile  course. 

3.  Nervous  Symptoms.  Diabetic  coma  may  develop  in  the  course  of 
the  disease.  In  young  subjects,  particularly,  the  occurrence  of  coma 
should  lead  to  a  suspicion  of  diabetes.  Such  coma  may  occur  before 
the  disease  has  been  recognized.  The  coma  may  follow  an  attack  of 
fainting  and  prostration,  with  stupor,  which  deepens  into  complete 
unconsciousness.  It  may  be  preceded  by  nausea  and  vomiting  or  by 
the  lung-complications  previously  mentioned.  This  form  of  coma  is 
usually  preceded  by  extreme  dyspnoea,  by  agitation,  pain  in  the  head, 
and  some  delirium.  The  pulse  becomes  rapid  and  feeble,  and  coma 
develops  gradually.  For  this  form  of  coma  the  term  acetoncemia  is 
used.  The  breath  is  of  a  peculiar  sweetish  odor,  due  to  acetone,  and 
this  compound  is  detected  in  the  urine.  Coma  may  occur  without  any 
premonitory  symptoms  whatsoever,  the  patient  reeling  for  a  short  time, 
and  complaining  of  pain  in  the  head  as  if  intoxicated. 

Peripheral  neuritis  should  always  lead  to  an  examination  of  the 
urine.  It  may  be  limited  to  one  group  of  nerves,  or  may  be  more  or 
less  general,  with  symptoms  like  those  of  locomotor  ataxia,  as  the  light- 
ning-pains, abolition  of  reflexes  and  loss  of  power  in  the  extensor 
muscles.  Diabetic  patients  are  also  subject  to  neuralgia,  and  to  periph- 
eral hyperesthesia  and  paresthesia,  probably  due  to  neuritis.  The 
neuritis  may  be  so  extreme  as  to  lead  to  paraplegia. 

4.  Eye-symptoms.  A  curious  symptom  of  diabetes  is  the  occurrence 
of  cataract.  This  may  develop  at  any  age,  and  is  often  rapid  in  its 
course.  Cataract  or  alterations  of  vision  should  always  demand  an 
examination  of  the  urine.  Diabetic  retinitis  is  sometimes  present. 
Atrophy  of  the  optic  nerves,  or   muscular  insufficiencies,   may  take 


DISEASES  OF  THE  KIDNEYS.  935 

place,  the  latter  causing  the  pronounced  symptoms  of  eye-strain. 
Ringing  in  the  ears,  deafness,  the  occurrence  of  acute  otitis,  are 
phenomena  which  arise  in  the  course  of  diabetes. 

Diagnosis.  Sugar  in  the  urine  occurs  temporarily  when  there  is 
an  excess  of  saccharine  diet,  or  when  there  is  functional  disorder  of  the 
liver.  The  sugar  is  small  in  amount,  and  the  glycosuria  is  transient. 
The  diagnosis  of  true  diabetes  is  not  difficult,  although  the  disease  may 
be  overlooked  unless  the  habit,  previously  insisted  upon,  of  constant 
urinary  examinations  is  fully  developed. 

Indican.  An  excess  of  indican  in  the  urine  is  known  as  indicanuria. 
The  substance  is  detected  by  several  methods.  Jaffe's  test :  Equal 
volumes  of  hydrochloric  acid  and  urine  are  mixed.  By  means  of  a 
glass  pipette  a  solution  of  sodium  hypochlorite  is  dropped  into  the  fluid. 
An  indigo-blue  color  is  produced  if  indican  be  present.  The  hypochlo- 
rite must  not  be  added  in  excess.  A  quantitative  determination  is 
made  by  the  colorimetric  process  of  Salkowski.  A  rough  analysis  is 
first  made,  to  determine  the  quantity  of  calcium  hypochlorite,  which 
causes  the  greatest  amount  of  indigo  to  unite  with  it.  If  the  urine 
contains  much  indican,  a  small  portion,  as  2.5  to  5  c.c,  is  diluted  with 
water  to  10  c.c.  If  there  is  but  little  indican,  10  c.c.  of  the  urine  are 
used  without  dilution.  An  equal  quantity  of  hydrochloric  acid  is 
added.  To  this  the  amount  of  hypochlorite  solution  with  which,  in 
the  first  test,  indigo  combined  in  the  greatest  amount  is  added.  Then 
the  liquid  is  neutralized  with  sodium  hydroxide,  then  enough  sodium 
carbonate  is  added  to  make  it  alkaline.  The  indigo-blue  is  thus  pre- 
cipitated and  collected  on  a  filter.  The  precipitate  is  repeatedly  washed 
with  water  until  the  alkaline  reaction  disappears.  The  filtrate  is  dried 
and  extracted  by  heating  with  chloroform,  until  the  latter  no  longer 
assumes  a  blue  color.  The  chloroform  extract  is  increased  to  a  round 
number  of  c.c.  by  the  addition  of  chloroform,  and  placed  in  a  vessel 
with  parallel  sides.  The  intensity  of  its  color  is  compared  with  a 
freshly  prepared  chloroform  solution  of  indigo  blue  of  known  strength. 
To  one  or  other  of  these  chloroform  is  added  until  the  tint  of  both  is 
the  .same.  The  quantity  of  indigo-blue  derived  from  the  urine  is  deter- 
mined, and  its  percentage  calculated  from  the  intensity  of  color  and 
strength  of  the  solution  of  indigo  of  known  strength.  Five  to  twenty 
milligrammes  of  indigo-blue  are  passed  in  twenty-four  hours  in  health. 
Indican  is  increased  by  animal  diet — an  increase  which,  under  other 
circumstances,  is  pathological.  Its  presence  is  a  sign  of  intestinal 
putrefaction.  It  may  accompany  a  decomposition  of  albumin  in  cavi- 
ties. It  is  present  in  empyema  and  in  puerperal  peritonitis.  By 
detection  of  its  presence  in  these  diseases  cavities  due  to  pus  may  be 
distinguished  from  those  due  to  other  causes.  Indican  is  increased  in 
acute  diarrhoea  and  in  intestinal  tuberculosis.  Von  Jaksch  states  that 
large  quantities  of  indican  in  the  urine  imply  that  abundant  albuminous 
putrefaction  or  putrid  suppuration  is  in  progress  in  the  system.  It  must 
not  be  forgotten  that  indicanuria  will  often  arise  in  simple  constipation. 

Bile-pigments  and  Bile-acids.  Bile-pigment  or  bilirubin  occurs 
in  the  urine  in  cases  of  hepatogenic  and  hematogenic  jaundice  and  in 
portal  thrombosis. 


936  SPECIAL  DIAGNOSIS. 

Gnielin's  test  and  its  modifications  are  the  ones  usually  employed. 
A  small  quantity  of  nitric  acid,  to  which  some  nitrous  acid  has  been 
added,  is  put  into  a  test-tube  and  then  gently  overlaid  with  urine.  If 
bile-pigment  is  present,  a  series  of  colors  appear  at  the  junction  of  the 
two  fluids — green,  blue,  violet,  and  yellow.  A  green  color  (biliverdin) 
must  be  present  to  prove  the  existence  of  bile-pigment. 

The  same  test  may  be  applied  by  placing  a  few  drops  of  the  acid 
upon  one  side  of  a  plate  and  the  urine  on  the  other,  and  then  allowing 
the  two  to  run  together.  The  play  of  colors  takes  place,  as  before,  at 
the  line  of  junction  of  the  acids  and  urine. 

Rosenbach's  modification  is  an  improvement.  About  200  c.c.  of  urine 
are  allowed  to  flow  through  pure  white  filter-paper,  and  then  a  drop  of 
nitric  acid  is  placed  upon  the  paper  saturated  with  the  urine.  The 
colors  appear  as  before  described. 

A  very  simple  test  consists  in  allowing  a  few  drops  of  the  acid  to 
fall  into  a  test-tube  full  of  urine.  If  bile-pigment  is  present,  a 
green  color  appears  at  the  line  of  junction  of  the  two  fluids.  This 
test  may  fail,  however,  if  only  small  quantities  of  bile-pigment  are 
present. 

The  tests  for  bile-acids  are  either  too  elaborate  or  too  unsatisfactory 
for  clinical  use. 

Pus.  Pus  is  found  in  the  urine  whenever  there  is  suppuration  or 
a  catarrhal  condition  of  the  genito-urinary  tract.  Hence,  it  occurs  in 
abscess  of  the  kidney,  pyonephrosis,  pyelitis,  tuberculosis,  cystitis,  gonor- 
rhoea, leucorrhcea,  etc.  It  is  relatively  common  in  women,  from  a 
catarrhal  condition  of  the  vulva  and  vaginal  mucous  membrane,  and 
is,  therefore,  of  less  significance  than  in  men.  Urine  containing  much 
pus  is  slightly  albuminous  ;  but  frequently  pus-cells  are  found  in  urine 
which  gives  no  reaction  for  albumin. 

The  chemical  test  for  pus  is  its  conversion  into  a  tenacious  (gelat- 
inous), glairy  mass  by  boiling  with  caustic  potash. 

Acetonuria.  An  excess  of  acetone  occurs  in  the  following  diseases  : 
(1)  In  diabetes ;  (2)  in  cancer  independent  of  starvation ;  (3)  in  starva- 
tion ;  (4)  in  certain  psychoses  ;  (5)  in  auto-intoxications  ;  (6)  in  derange- 
ment of  digestion  ;  (7)  in  fevers.  In  diabetes  acetone  indicates  an 
advanced  stage  of  the  disease.  Lieben's  test  for  acetone  is  as  follows  : 
To  several  c.c.  of  urine  a  few  drops  of  iodo-potassium  iodide  solution 
and  sodium  hydroxide  are  added.  If  acetone  is  in  excess,  the  precipi- 
tation of  iodoform  takes  plaoe,  which  may  be  recognized  by  its  odor. 

Diaceturia.  Diacetic  acid  is  found  in  the  urine  in  diabetes,  in  fevers, 
and  in  auto-intoxications.  It  is  common  with  children  in  fever.  It 
is  of  grave  significance  when  in  the  urine  of  adults.  Coma  usually 
follows  its  occurrence  in  the  urine  in  fevers  and  in  diabetes.  Test :  A 
concentrated  solution  of  ferric  chloride  is  cautiously  added  to  the  urine. 
If  a  precipitate  be  formed,  it  should  be  removed  by  filtration  and  more 
ferric  chloride  added  to  the  filtrate.  If  diacetic  acid  be  present,  the 
liquid  will  become  claret-red  in  color. 

Haematoporphyrinuria.  This  is  a  rare  constituent  of  the  urine 
derived  from  the  blood.  It  is  said  to  be  a  form  of  hsematin  freed  from 
iron.     Nakarai  thinks  that  the  occurrence  of  htematoporphyrinuria  is 


DISEASES  OF  THE  KIDNEYS.  937 

constant  in  lead-poisoning,  and  occurs  with  some  degree  of  frequency 
in  intestinal  hemorrhage. 

Alkaptonuria.  The  substance  in  the  urine  which  has  been  identi- 
fied as  alkapton  is  also  known  as  pyrocatechin  (Ebstein  and  Miiller, 
Virchow's  Archiv,  Bd.  lxv.  s.  394),  protocatechinic  acid  (Smith,  Dub- 
lin .Town.  Med.  Sg.,  1882,  vol.  i.  p.  465),  urrhodinic  acid  (Kirk,  British 
Medical  Journal,  London,  1886,  vol.  ii.  p.  1017),  glycosuric  acid  (Mar- 
shall, Medical  News,  Philadelphia,  1887,  p.  35),  uroleucinic  and  uro- 
xanthinic  acids  (Kirk,  British  Medical  Journal,  London,  1888,  vol.  ii. 
p.  232),  and  homogentisinic  acid  (Baumann  and  Wolkow,  Ztschr.  f. 
physiol.  Chem.,  Strassburg,  Bd.  xv.  s.  228).  It  reduces  copper,  as 
does  glucose,  and  its  occurrence  is  of  interest,  because  the  presence  of 
the  substance  has  led  to  the  diagnosis  of  glycosuria  in  many  instances, 
in  consequence  of  which  persons  have  been  refused  life  insurance. 
The  urine  containing  this  substance  deepens  in  color  on  exposure  to 
air.  It  is  of  a  peculiar  aromatic  odor,  and  reduces  cupric  salts  rapidly. 
There  is,  however,  no  reaction  to  the  fermentation  test,  to  Bottger's 
bismuth  test,  or  to  phenylhydrazin,  and  no  deviation  of  the  rays  of 
polarized  light.  The  urine  does  not  contain  bile-pigment.  It  is  of 
normal  specific  gravity,  and  becomes  very  dark  on  the  addition  of  an 
alkali  or  of  a  temporarily  bluish-green  color  with  perchloride  of  iron. 
Ammonia  nitrite  of  silver  is  instantaneously  reduced  when  added  to 
the  urine  with  a  deposit  of  metallic  silver. 

Alkaptonuria  is  usually  congenital.  Several  members  of  the  same 
family  will  have  it.     No  symptoms  attend  the  condition. 

Note. — Serum-globulin  is  converted  into  a  coagulated  proteid  when 
heat  is  applied  or  concentrated  nitric  acid  added  to  a  solution.  Globu- 
lin is  soluble  in  dilute  salt  solutions.  If  urine,  rich  in  globulin,  is 
added,  drop  by  drop,  to  a  large  volume  of  distilled  water,  the  globulin 
is  precipitated  as  the  percentage  of  salt  is  reduced  by  dilution.  Globu- 
lin is  also  precipitated  by  dialysis.  If  a  portion  of  urine  containing 
globulin  is  saturated  with  magnesium  sulphate  or  half  saturated  with 
ammonium  sulphate,  globulin  is  precipitated. 

Hills'  describes  the  method  as  follows  :  "  25-50  cubic  centimetres 
of  the  urine  are  made  neutral  or  slightly  alkaline  with  ammonium 
hydroxide,  and  the  precipitated  phosphates  removed  by  filtration.  An 
equal  volume  of  a  saturated  solution  of  ammonium  sulphate  is  then 
added,  the  mixture  shaken,  and  allowed  to  stand  for  some  time,  and 
finally  filtered.  The  precipitate  is  washed  with  a  half-saturated  solu- 
tion of  ammonium  sulphate  for  the  removal  of  the  last  traces  of  albu- 
min and  the  filtrate  and  precipitate  tested  for  albumin  and  globulin 
respectively,  as  previously  described.  The  formation  of  a  precipitate 
upon  the  addition  of  either  magnesium  or  ammonium  sulphate  is  not 
in  itself  evidence  of  the  presence  of  globulin." 

Microscopical  Examination  of  the  Urine.  Microscopical  examina- 
tion of  the  urine  is  chiefly  concerned  with  the  sediments,  and  these  are 
conveniently  divided  into  the  organized  and  unorganized. 

1  Boston  Medical  and  Surgical  Journal,  1899,  vol.  cxli  ,  No.  6. 


938 


SPECIAL  DIAGNOSIS. 


The  organized  deposits  in  the  urine  are  blood,  pus,  mucus,  epithelium, 
casts,  spermatozoa,  micro-organisms,  cancerous  and  tuberculous  matter, 
entozoa. 

The  unorganized  deposits  are  uric  acid  and  its  compounds,  oxalate  and 
carbonate  of  lime,  phosphates,  leucin  and  ty rosin,  cystin  and  cholesterin. 

Normal  urine  forms  a  slight  sediment,  consisting  of  epithelium  from 
different  parts  of  the  geni  to-urinary  tract,  principally  from  the  bladder 
in  males,  and  from  the  vagina  and  bladder  in  females.  There  are  also 
some  crystals  of  the  different  urinary  salts,  sometimes  mucus  and  a  few 
white  blood-cells,  and,  if  the  urine  has  stood  a  while,  especially  if  alka- 
line, more  or  fewer  bacteria.  It  may  accidentally  contain  extraneous 
matter,  derived  from  the  vessel  which  contains  it  or  from  the  air.  (Fig. 
206.) 


Extraneous  matters  found  in  urine:  a,  cotton-fibres;  b,  flax-fibres;  c,  bairs;  d,  air-bubbles! 
e,  oil-globules  ;  /,  wheat-starch  ;  g,  potato-starch  ;  h,  rice-starch  granules;  i,  i,i,  vegetable  tissue  ; 
k,  muscular  tissue  ;  I,  feathers. 


The  centrifugal  machine  has  now  become  an  important  adjunct  to 
the  rapid  and  accurate  microscopical  examination  of  the  urine.     There 


DISEASES  OF  THE  KIDNEYS.  939 

are  now  numerous  varieties  to  be  secured  at  the  instrument-stores,  some 
of  which  are  devised  solely  for  urinary  examination,  while  others  have 
additional  apparatus  for  examination  of  the  blood  and  sputum.  The 
majority  of  them  are  revolved  by  hand.  Electricity  can  be  readily 
applied  to  any  of  them  and  labor  be  saved  by  such  a  device.  The 
advantages  of  centrifugal  force  over  the  older  gravity  method  employed 
in  microscopical  examination  are  marked.  Some  few  of  them  can  be 
briefly  outlined  : 

1.  Centrifugalization  secures  complete,  rapid,  and  concentrated  sedi- 
mentation.    It  is,  therefore,  best  suited  to  microscopical  diagnosis. 

2.  Casts  or  other  organic  material,  if  present,  can  be  studied  care- 
fully before  they  are  macerated  or  partially  destroyed  by  bacteria  or 
changed  by  the  deposition  of  amorphous  or  crystalline  material.  This 
is  a  most  important  aid  to  correct  diagnosis. 

3.  Crystals,  if  present  at  the  time  of  urination,  can  be  discovered  and 
differentiated  from  those  that  normally  crystallize  out  after  some  hours. 

4.  Certain  bodies,  hyaline  casts,  for  instance,  because  of  their  rather 
light  specific  gravity,  do  not  settle  on  the  simple  standing  of  the  urine, 
and  thus  escape  detection.  These  with  all  other  substances  are  thrown 
down  with  the  centrifugal  machine. 

5.  Bacteria  are  discovered  with  greater  ease,  especially  the  tubercle 
bacillus. 

The  method  commonly  used  for  the  examination  of  the  urinary  sedi- 
ment is  as  follows :  The  urine  for  examination  (the  chemical  analysis 
having  previously  been  made)  is  decanted  until  there  remains  but  a 
small  amount  in  the  bottle,  which  amount  contains  any  sediment 
already  formed,  and  heavier  organic  materials.  This  is  then  poured 
into  one  of  the  tubes  of  the  centrifugal  machine  to  within  one-half 
inch  of  the  top ;  if  but  one  specimen  of  urine  is  to  be  examined,  fill 
both  tubes  with  the  same  urine.  If  there  is  not  sufficient  urine  to  do 
this,  fill  the  remaining  tube  or  tubes  with  water.  It  is  well  to  mark 
the  external  metal  shields  of  the  tubes  with  a  figure,  say  1  and  2,  or  a 
and  6,  so  that  the  urines,  if  different  specimens,  may  not  become  con- 
fused. 

The  tubes  are  then  rapidly  revolved  for  three  minutes,  then  removed 
from  the  machine  and  a  few  drops  of  the  sediment  withdrawn  with  a 
pipette  and  placed  upon  the  slide  for  examination  under  the  microscope. 
It  is  necessary  to  remember  that  care  must  be  exercised  in  removing 
this  sediment  from  the  tube.  The  straight  glass  pipette  without  a 
pointed  end  seems  to  give  the  best  results  in  securing  the  sediment. 
The  finger  is  placed  upon  one  end,  the  pipette  inserted  to  the  bottom 
of  the  tube  and  the  finger  is  then  elevated  just  enough  to  secure  a  few 
drops  of  the  sediment  that  has  been  cast  down  by  centrifugalization. 
If  the  urine  contains  but  the  normal  mucous  cloud,  a  very  small  whitish 
sediment  or  cloud  is  found  at  the  bottom  of  the  tube.  If  oxalate  of 
lime  is  present,  a  small  filmy  whitish  sediment  is  seen.  The  sediment 
of  amorphous  urates  is  pinkish,  fawn,  or  salmon  color.  Uric  acid 
appears  as  a  "  brick-dust "  sediment.  Pus  produces  a  heavy  yellowish 
sediment ;  phosphates  a  heavy  white  sediment,  which  is  sometimes 
yellowish-white   from   admixture   with    leucocytes.      Blood   in    small 


940 


SPECIAL  DIAGNOSIS. 


quantities  produces  a  rather  characteristic  brownish  deposit.  Large 
amounts  of  blood  appear  as  reddish  coagulse  at  the  bottom  of  the  tube. 
With  some  of  the  centrifugal  machines  the  various  urinary  salts  and 
the  amount  of  albumin  present  can  readily  be  estimated.  Such  instru- 
ments are  provided  with  graduated  tubes,  in  which  the  urine  and  the 
necessary  reagents  are  put  and  the  resulting  precipitate  rapidly  cast 
down. 

Fig.  207. 


Cellular  elements  from  the  urine.  1,  squamous  epithelium  ;  2,  red  blood-corpuscles;  3,  poly- 
nuclear  leucocytes  ;  4,  transitional  cells  ;  5,  epithelium  from  the  kidneys ;  6,  epithelium  from  the 
bladder ;  7,  micrococcus  aurese  ;  8,  yeast-fungi. 

In  this  manner  Purdy  estimates  the  chlorides,  sulphates,  and  phos- 
phates, and  also  the  amount  of  albumin  most  satisfactorily.  It  is  ques- 
tionable, however,  whether  the  estimation  of  the  salts  is  accurate. 


Organized  Sediments.  Blood.  If  the  blood  comes  from  the  kid- 
ney, it  is  usually  intimately  mixed  with  the  urine,  which  remains  of  a 
red  or  reddish-brown  color,  and  contains  possibly  tube-casts  and  renal 
epithelium.  The  blood-cells  appear  singly,  have  frequently  lost  their 
haemoglobin,  and  hence  look  like  pale-yellow  disks.     (See  Fig.  207.) 

Sometimes  blood  coagulates  in  the  ureters,  and  long,  cylindrical 
plugs  are  passed,  causing  symptoms  resembling  those  of  renal  colic. 
When  blood  comes  from  the  bladder  or  neck  of  the  bladder  (fissure) 
there  are  symptoms  of  frequent  micturition,  of  acute  pain  and  tenes- 
mus, and  the  blood  is  not  intimately  mixed  with  the  urine.  When 
from  the  neck  of  the  bladder,  it  often  occurs  in  a  few  drops  at  the  end 
of  micturition,  accompanied  with  great  pain  and  a  sense  of  faintness. 
Intermittent  hematuria,  according  to  Von  Jaksch,  points  directly  to 
calculus  or  tumor  of  the  bladder. 

Blood-cells,  when  unaltered,  are  unmistakable,  on  account  of  their 
woll-known  biconcave  appearance.  When  they  have  lost  their  color- 
ing-matter they  appear  as  circular,  very  pale  disks,  with  extremely 
faint  outline  and  feeble  refractive  power.     Absence  of  a  nucleus  serves 


DISEASES  OF  THE  KIDNEYS.  941 

to  distinguish  them  from  yeast-spores,  and  the  latter,  moreover,  are 
often  oval  in  shape.  They  are  less  likely  to  be  confounded  with  the 
ovoid  and  circular  shapes  of  oxalate  of  lime  crystals,  because  the  latter 
are  not  common,  and  can  be  seen  usually  in  their  more  common  forms 
as  octahedra  and  dumb-bells  in  the  same  urine. 

Pus.  The  sources  of  pus  in  the  urine  have  been  referred  to  already. 
The  pus-corpuscle  is  an  opaque,  spherical,  granular  cell,  usually  some- 
what larger  than  are  blood-cells.  In  dilute  urine,  or  urine  to  which 
water  has  been  added,  it  swells  sometimes  to  twice  its  original  size. 
At  the  same  time,  it  becomes  less  granular,  and  two,  three,  or  four 
nuclei  may  appear.  In  concentrated  urines  the  pus-cell  is  small.  The 
addition  of  acetic  acid  also  causes  it  to  swell,  and  brings  out  the  nuclei 
more  distinctly  and  rapidly.  Sometimes  the  pus-cells  are  discrete, 
sometimes  in  dense  clumps,  and  sometimes  nothing  but  a  dense  mass 
of  pus-cells  appear  in  the  field  of  the  microscope. 

It  cannot  be  decided  from  microscopic  examination  whether  a  cell 
is  a  pus-corpuscle,  a  mucus-corpuscle,  a  white  blood-cell,  or  an  inflam- 
matory leucocyte.  It  must  be  a  matter  of  inference  from  the  general 
characters  of  the  urine.  If  red  blood-cells  are  also  present,  the  proba- 
bility of  finding  white  blood-cells  is  increased,  but  pus-cells  are  not 
necessarily  excluded.  So,  too,  if  much  mucus  be  present  in  the  urine, 
the  doubtful  cell  may  be  a  mucus-corpuscle.  Some  clue  to  the  source 
of  the  pus  can  be  obtained  from  the  urine  itself.  Urine  containing  pus 
from  the  kidney  is  usually  acid,  whereas  in  cystitis  it  is  alkaline,  and 
almost  always  contains  phosphates,  mucus,  and  abundant  bacteria. 
Again,  pus  from  the  kidney,  or  kidney  pelvis,  is  apt  to  vary  greatly  in 
amounts,  or  be  discharged  intermittently ;  and  the  urine,  when  filtered 
free  from  pus-cells,  is  usually  still  albuminous.  Renal  epithelium  and 
casts  may  also  be  found. 

Casts.  Casts  are  the  most  important  of  the  urinary  deposits.  They 
vary  greatly  in  number  and  size.  Sometimes  in  acute  nephritis  they 
form  a  considerable  part  of  the  sediment,  but  usually  they  have  to  be 
sought  for  carefully  and  patiently.  A  few  words  as  to  the  method  of 
examining  for  them  may  not  be  superfluous. 

Sedimentation  by  the  centrifugal  machine  is  now  much  in  vogue.  If 
the  centrifugal  machine  cannot  be  employed,  proceed  as  follows  : 

Six  or  eight  ounces  of  the  urine  to  be  examined  should  be  allowed 
to  settle  in  a  bottle  as  soon  after  being  passed  as  possible.  The  bottle 
should  be  tightly  corked,  because  urine  exposed  to  the  air  decomposes 
very  quickly ;  it  should  be  sent  to  the  person  who  is  to  examine  it  as 
soon  after  being  passed  as  possible,  in  order  that  an  examination  may 
be  made  before  fermentative  changes  spoil  it  for  trustworthy  analysis. 
After  standing  twelve,  or  preferably  twenty-four  hours,  nearly  all  of  the 
solid  matter  will  have  collected  at  the  bottom  of  the  bottle.  The  super- 
natant clear  fluid  can  now  be  poured  off,  and  the  lower  portion  of  the 
urine  and  the  sediment  poured  into  a  conical  subsiding-glass.  If  the 
urine  is  febrile, there  maybe  by  this  time  a  large  deposit  of  amorphous 
urates,  which  will  obscure  the  search  for  casts  ;  they  may  lie  dissolved 
by  gentle  heating  without  destroying  the  casts,  and  the  clear  urine 
again  allowed  to  settle  for  a  few  hours.     So,  too,  if  phosphates  are 


942 


SPECIAL  DIAGNOSIS. 


abundant,  they  should  be  gotten  rid  of  by  gentle  heating  and  acidula- 
tion  with  two  or  three  drops  of  dilute  acetic  acid. 

After  the  urine  in  the  conical  subsiding-glass,  which  will  not  now 
amount  to  more  than  an  ounce  or  two,  has  stood  for  a  few  hours,  any 
casts  that  mar  be  present  will  have  fallen  into  the  bottom.  If  the 
urine  is  very  concentrated  (1030  or  more),  epithelium,  blood,  and  casts 
will  be  suspended  longer ;  hence,  it  may  be  well  to  dilute  the  urine 
before  allowing  it  to  settle. 

A  glass  tube,  with  an  internal  diameter  of  about  one-eighth  of  an 
inch,  and  with  one  end  drawn  out  fine,  is  the  most  convenient  thing 
for  collecting  the  sediment.  The  ordinary  glass  pipette,  with  a  rubber 
suction-bulb  at  one  end,  commonly  known  as  a  "  medicine-dropper," 
sometimes  ansAvers  admirably.  If  the  common  glass  tube  is  used,  the 
forefinger  of  the  right  hand  should  be  placed  over  the  open  upper  end, 
and  the  fine  lower  end  passed  down  to  the  bottom  of  the  glass.  The 
finger  is  then  removed  sufficiently  to  permit  a  few  drops  to  be  sucked 
in.  The  same  thing  is  attained  if  the  finger  is  entirely  removed  as  soon 
as  the  point  on  the  tube  reaches  the  bottom  of  the  conical  glass ;  but 
in  that  case  more  than  the  lowest  layers  of  the  sediment  or  urine  are 
sucked  up,  and  hence  all  but  a  few  drops  should  be  allowed  to  flow  out 
when  the  tube  is  removed  from  the  urine.  In  this  way  the  drops  pre- 
served for  microscopical  examination  will  contain  the  sediment  from 
the  very  bottom  of  the  glass.  In  this  sediment,  in  pale  urines  free 
from  much  urates,  phosphates,  and  pus,  the  casts  will  be  found,  if  any 
are  present  in  the  urine.  It  is  most  important  to  examine  the  bottom 
lavers  of  the  sediment  when  the  latter  is  scanty,  or  when  phosphates 
or  urates  have  begun  to  precipitate  after  the  urine  has  been  standing 
some  time.  If  the  urine  is  already  cloudy  with  phosphates,  urates,  or 
pus,  when  it  is  put  aside  to  settle,  any  casts  that  may  be  present  will  be 
carried  down  with  the  heavier  sediment,  and  will  be  found  intimately 
mixed  with  it,  or  even  on  top  of  the  other  sediment. 


Fig.  208. 


Epithelial  and  hyaline  casts. 


The  few  drops  preserved  for  microscopical  examination  are  now  depos- 
ited on  several  slides,  without  a  cover-glass,  and  examined  carefully 
for  casts  under  a  power  of  50  to  60  diameters.    Casts  may  be  numerous, 


DISEASES  OF  THE  KIDNEYS. 


943 


so  that  nearly  every  field  contains  one  dozen  or  more,  or  they  may  be 
very  few,  not  more  than  one  or  two  being  found  on  a  slide.  The  best 
routine  method  for  microscopical  examination  is  as  follows  :  place  a 
few  drops  of  the  urinary  sediment  upon  the  slide ;  spread  the  drops  in 


Fig.  209. 


Hyaline  casts  and  cylindroids  in  hypostatic  congestion  of  kidney.    Low  power. 

a  thin  layer;  use.no  cover-glass;  examine  with  the  low  'power — a  diam- 
eter of  50 — with  a  small  amount  of  light ;  the  whole  slide  can  be  care- 
fully searched  in  three  minutes,  and  casts  discovered  can  be  minutely 


Fig.  210. 


Hyaline  casts  from  a  case  of  acute  nephritis.    1,  plain  hyaline  cast ;  2,  granular  deposit  on  hyaline 
cast;  3,  cellular  deposit  (blood  and  epithelium). 

studied  with  the  higher  power.  When  but  few  casts  are  present,  several 
slides  can  be  rapidly  examined  with  the  low  power,  and  an  accurate 
estimation  of  the  number  made. 


944 


SPECIAL  DIAGNOSIS. 


All  the  pipettes  used  in  examining  urine  must  be  kept  clean.  They 
should  be  allowed  to  stand  in  water  which  is  frequently  changed,  and 
carefully  rinsed  in  running  water  before  being  used. 

Tube-casts  usually  indicate  acute  or  chronic  nephritis ;  but  they  are 
sometimes  found  in  cases  of  renal  calculi ;  in  icterus,  usually  without 
albuminuria;  in  diabetes,  and  sometimes  in  secondary  congestion  of 
the  kidney. 


Fig.  211. 


Granular  casts. 


Several  varieties  of  casts  are  found.  1.  Hyaline  casts,  as  their  name 
implies,  are  clear,  translucent  bodies,  which  refract  light  so  slightly  that 
they  are  easily  overlooked.  They  have  well-defined  margins,  the  ends 
being  frequently  rounded ;  they  are  rarely  very  long,  and  are  straight, 
or  but  slightly  bent.  They  are  rarely  equally  translucent  throughout ;  at 
some  part  more  or  less  granulation  will  generally  be  found.  They 
vary  in  diameter  from  that  of  a  white  blood-cell  to  six  or  eight  times 
as  large.  They  can  be  stained,  and  so  rendered  more  distinct,  by 
allowing  a  drop  of  gentian- violet  solution  to  flow  in  under  the  edge  of 
the  cover-glass.  (Figs.  209  and  210.)  2.  Granular  casts  are  hyaline 
casts  which  appear  granular  either  from  some  deposit  on  their  surface 
or  from  a  granular  change  of  the  cast  itself.  When  the  granulation 
does  not  interfere  with  the  translucency  the  casts  are  described  as 
"  pale  "  or  "  slightly  "  granular  ;  and  when  they  become  very  dark,  so  as 
to  resemble  closely  a  blood-cast,  they  are  called  "  dark  "  or  "  opaque  " 
granular  casts.  (Plate  XL VII.,  Fig.  1,1;  and  Figs.  210,  211.)  3. 
Waxy  casts  appear  to  the  eye  to  be  more  solid  in  structure  than  the 
hyaline  casts ;  they  also  appear  more  cylindrical  in  form,  are  more  or 
less  yellow  in  color,  and  are  apt  to  be  larger  than  hyaline  casts.  (Plate 
XLYIL,  Fig.  1,  2.)  4.  Fatty  casts  are  hyaline  or  faintly  granular 
casts  on  which  are  deposited,  in  spots,  minute  oil-drops.  They  are 
sometimes  called  "  oil-casts  "  if  the  oil-drops  are  very  abundant,  (Fig. 
212.)  5.  Blood-casts  are  either  made  up  of  a  mass  of  blood-cells  pressed 
together  into  a  cylindrical  shape,  or,  more  frequently,  a  hyaline  cast  is 


PLATE    XLVII. 


© 


v< 


1.     Hyaline  Casts  with  Granular  Matter  and  Epithelial  Cells 
deposited  upon  them.     2.     Amyloid  (waxy)  Cast. 

(Oc.  4.  ob.  D.)     Drawn  by  J.  D.  Z.  Chase. 


y 


-j 


.   .-       &»■  (& 
;4  ^f®<:^ 


»1 


W    Mr 


■ 


Blood-easts  from  Case  of  Acute  Nephritis. 

(Oc.  4.  ob.  D.)     Drawn  by  J.  D.  /.  Chase. 


DISEASES  OF  THE  KIDNEYS. 


945 


studded  with  blood-cells.  (Plate  XLVIL,  Fig.  2.)  6.  Epithelial  casts 
sometimes  seem  to  be  composed  entirely  of  epithelial  cells  closely  packed 
together.  Such  casts  are  relatively  rare,  and  very  beautiful.  Ordi- 
narily, just  as  in  the  case  of  blood-casts,  an  epithelial  cast  consists  of 


Fig.  212. 


Fatty  casts  from  a  case  of  chronic  parenchymatous  nephritis. 

a  hyaline  cast  more  or  less  covered  with  renal  epithelium.  (Plate 
XLVIL,  Fig.  1,  1;  and  Fig.  208.)  7.  Dr.  George  Johnson  has 
described  casts  composed  of  ^us-corpuscles.  In  two  cases  in  which 
they  were  found  in  the  urine  the  patients  were  found  at  the  autopsy  to 


Fig.  213. 


Cylindroids. 


have  multiple  abscesses  of  the  kidney.  8.  Cylindroids  are  very  common. 
In  general  appearance  they  resemble  hyaline  casts ;  but  they  are  apt  to 
be  much  longer,  bent,  twisted  or  split,  and  to  have,  on  close  examina- 

60 


946 


SPECIAL  DIAGNOSIS. 


tiom  a  striated  or  finely  ribbed  appearance.  Moreover,  the  diameter 
of  the  cast  frequently  varies  greatly  at  different  points  j  sometimes  it 
appears  constricted  in  several  places,  and  in  other  cases  one  end  tapers 
off  into  a  thread.  Often  cylindroids  consist  of  fine,  narrow,  ribbon-like 
threads.     (Figs.  209  and  213.) 

Spermatozoa.     Spermatozoa  are  easily  recognized  by  their  tadpole 
shape  and  by  the  vibratile  motion  of  their  long,  delicate  tails.     They 

Fig.  214. 


Human  semen,  a,  spermatozoa  ;  6,  cylindrical  epithelium  ;  c,  bodies  enclosing  lecithin  gran- 
ules ;  d,  squamous  epithelium  from  the  urethra ;  d',  testicle-cells  ;  e,  amyloid  corpuscles ;  /,  sper- 
matic crystals  ;  g,  hyaline  globules.    (Von  Jaksch.) 

are  found  in  the  urine  of  both  sexes  after  sexual  intercourse.  (Figs. 
214  and  215.) 

Many  continent  men  have  occasionally  nocturnal  emissions,  accom- 
panied by  erections  and  erotic  sensations.  These  cannot  be  looked 
upon  as  abnormal,  and  they  are  compatible  with  robust  health.  There 
are  other  persons,  neurotic,  anaemic,  and  generally  constipated  in  habit, 
who  have  emissions  at  night  two  or  three  times  a  week,  of  which  they 
are  unconscious  until  they  wake  and  find  themselves  wet.  Semen  may 
also  be  lost  during  micturition  and  defecation,  especially  when  much 
straining  is  required.  Such  a  condition  (spermatorrhoea)  is  abnormal. 
It  is  due  to  general  nervous  and  muscular  relaxation,  associated  with 
nervous  dyspepsia  and  anaemia,  and  aggravated  by  sedentary  life,  con- 
stipation, and  the  reading  of  salacious  literature  or  the  cultivation  of 
erotic  thoughts.  In  young  men,  it  sometimes  follows  habits  of  mastur- 
bation, which  have  been  broken  up  but  have  left  behind  a  hyperaesthetic 
condition  of  the  prostatic  portion  of  the  urethra,  with  or  without  dila- 
tation of  the  orifices  of  the  ejaculatory  ducts ;  or  a  stricture  of  gonor- 
rhoeal  origin  may  be  its  cause.  Students  and  overworked  and  over- 
strained business  and  professional  men  are  the  ones  most  frequently 
affected. 

However  caused,  the  condition  is  apt  to  beget  a  most  distressing  state 
of  despondency,  in  which  the  patient  imagines  all  possible  ills,  and  is 
liable  to  drift  into  a  hysterical,  melancholic,  even  suicidal  frame  of 
mind,  and  so  falls  a  victim  to  quacks. 

Epithelium.  Epithelium  from  the  kidney,  bladder,  and  genito- 
urinary passages  occurs  in  the  urine.  Epithelial  deposits  in  male  urine 
are  very  scanty,  unless  there  is  some  disease  of  the  kidney  or  bladder, 


DISEASES  OF  THE  KIDNEYS.  947 

or  a  catarrhal  condition  of  the  prostatic  urethra,  such  as  is  left  from 
an  old  gonorrhoea.  On  the  other  hand,  considerable  epithelium  may- 
be normally  present  in  the  urine  of  women,  being  derived  principally 
from  the  vagina  and  bladder. 

Vaginal   epithelium  consists  of  large,  flat  pavement-cells,  and   is 
readily  distinguished. 

Fig.  215. 


Spermatozoa  from  urine. 

The  type  of  epithelium  of  the  kidney,  kidney  pelvis,  ureter,  and 
bladder  is  the  same,  and  it  is  not  possible  to  distinguish  with  certainty 
the  cells  which  come  from  each.  If  the  cells  are  scanty,  Yon  Jaksch 
thinks  they  come  from  the  ureter.  He  has  found  them  in  moderate 
quantities  and  superimposed  upon  one  another. 

Renal  cells  closely  resemble  the  oval  polygonal  cells  from  the  deeper 
lavers  of  the  bladder,  but  they  have  a  relatively  larger  nucleus.  (See 
Fig.  207.) 

Lipuria.  Oil  is  found  in  the  urine  in  fatty  degeneration  of  the 
kidney  and  its  epithelium,  and  occasionally  in  the  urine  of  those  who 
are  taking  cod-liver  oil,  and  in  calculous  disease  of  the  pancreas. 
Tyson  suggests  that  it  may  come  from  cystic  cheesy  degeneration  of  the 
kidney. 

It  is  also  found  in  chronic  nephritis,  in  phosphorus-poisoning,  and  in 
diabetes  mellitus,  as  well  as  in  chyluria.  The  urine  is  turbid,  but 
clears  when  agitated  with  ether.  The  fat  may  be  separated  by  a  sedi- 
mentator,  and  can  be  recognized  by  its  refractive  properties. 

Staining  for  Fat.  Reeder  recommends  Soudan  Three  for  staining 
human  secretions  and  excretions,  to  determine  the  presence  of  fat. 
Large  fat-droplets  take  a  bright  red,  and  small  droplets  a  yellow  or 
orange  color.  Fat  can  thus  be  demonstrated  in  the  blood  in  lipaemia, 
lipuria,  and  chyluria.  By  this  method  fat  can  be  demonstrated  in  the 
stomach-contents  and  in  the  feces  of  adults  with  jaundice.  A  saturated 
solution  of  Soudan  Three  in  96  per  cent,  alcohol  is  employed.     Equal 


948  SPECIAL  DIAGNOSIS. 

parts  of  this  solution  and  96  per  cent,  alcohol  are  added  to  the  urine. 
In  urinary  sediments  the  fat-droplets  in  casts  stain  a  scarlet  red. 

Chyluria.  This  is  a  more  or  less  milky  condition  of  the  urine,  due 
to  the  presence  of  fat,  which  probably  gains  entrance  to  some  part  of 
the  urinary  tract  by  rupture  of  the  lymphatic  vessels.  A  case  has  been 
reported  by  Saundby,  in  which  a  young'unniarried  girl,  being  pregnant, 
compressed  her  abdomen  so  much,  in  order  to  conceal  her  condition, 
that  oedema  of  the  legs,  thigh,  vulva,  and  lower  parts  of  the  abdomen 
resulted.  After  her  confinement  the  urine  became  milky,  and  remained 
so  for  many  days.  It  contained  fatty  matters  and  cholesterin,  but  no 
albumin  or  sugar. 

Fat  and  albumin  appear  at  the  same  time  in  some  diseases.  They 
recur  at  long  intervals.  Red  and  white  blood-corpuscles  are  also  found 
in  small  amounts.     The  urine  coagulates  on  standing,  or  gelatinizes. 

Parasitic  chyluria  is  due  to  the  filaria  sanguinis  hominis,  whose 
embrvos  obstruct  the  lymphatics.  The  latter  may  be  foimd  in  the 
urine. 

Entozoa.  The  most  common  is  the  echinococcus  or  hydatid.  When 
this  infects  the  kidney  or  urinary  vessels,  hooklets  and  even  cysts  have 
been  passed  in  the  urine.  The  disease  is,  of  course,  extremely  rare  in 
this  country. 

The  filaria  sanguinis  hominis,  which  causes  parasitic  chyluria,  is  occa- 
sionally found  in  the  urine.     (See  Filaria.) 

The  Bilharzia  hcematobia  sometimes  lodges  in  the  urinary  tract  and 
causes  hematuria.     It  is  peculiar  to  Egypt. 

Distoma  Hcematobium.  Common  in  Egypt  and  Abyssinia.  Eggs 
collect  in  great  masses  in  the  urinary  passages,  and  lead  to  inflamma- 
tion, ulcers,  stenosis,  etc.  Eggs  found  in  the  urine  alone  make  the 
diagnosis  possible. 

Strongylus  Gigas.  Very  rare.  Symptoms  of  pyelitis.  (The  parasite 
is  of  the  size  of  an  earth-worm.) 

Intestinal  worms  may  creep  into  the  bladder  through  fistulous  or 
other  openings,  and  be  discharged  through  the  urethra. 

Micro-organisms.  Normal  urine  contains  no  micro-organisms  at  the 
time  it  is  voided.  As  the  result  of  exposure  to  air,  however,  they  may 
develop  in  great  abundance.  The  non-pathogenic  organisms  found  are 
classed  as  mould-fungi  (hyphomycetes),  yeast-fungi  (blastomycetes),  and 
fission-fungi  (schizomycetes). 

Mould-fungi,  according  to  Von  Jaksch,  are  rarely  found  in  foul 
normal  urine.  Yeast-fungi  are  also  rare  in  normal  urine.  Fission- 
fungi  are  found  in  urine  undergoing  ammoniacal  decomposition. 

Sarcinse,  usually  smaller  than  those  of  the  stomach,  are  occasionally 
met  with — especially,  according  to  Roberts,  where  there  is  some  dis- 
order of  the  urinary  organs,  renal  pains,  painful  micturition,  cystitis,  etc. 

Under  the  name  bacteriuria,  Roberts  and  others  have  described  cases 
in  which  the  urine  contained  bacteria  at  the  time  of  being  voided.  He 
makes  four  groups  :  (1)  Cases  in  which  the  presence  of  bacteria  is  asso- 
ciated with  incipient  putrefactive  changes  in  the  urine  ;  (2)  cases  associ- 
ated with  ammoniacal  fermentation  of  the  urine ;  (3)  cases  in  which 
common  forms  of  bacteria  are  present  without  decomposition  of  the 


PLATE    XLVIII 


Uric  Acid. 

A.  Common  forms.    B.  Amorphous  urates. 
(Ob.  D.  and  A.,  Oc.  4.)    Drawn  by  J.  D.  Z.  Chase. 


FIO.   2. 


Combination  of  Uric  Acid  and  Calcium  Oxalate. 

(Oc.  4.  1  >b.   D.l     Drawn  by  J.  D.  Z.  Chase. 


DISEASES  OF  THE  KIDNEYS.  949 

urine ;  and  (4)  cases  in  which  micrococcus-chains  are  voided  in  the 
urine. 

The  pathogenic  organisms  which  are  more  or  less  closely  associated 
with  infectious  diseases,  septic  processes,  and  tuberculosis  are  found 
at  times  in  the  urine,  and  can  be  demonstrated  by  the  proper  stain ing- 
methods. 

Fig.  216. 
< 

Vibriones  in  urine.    (Roberts.) 

Dock  has  given  an  admirable  account  of  the  occurrence  of  the  tri- 
chomonas in  the  genito-urinary  passages.  This  parasite  belongs  to  the 
flagellate  infusoria.  The  prominent  symptoms  caused  in  Dock's  case 
were  painful,  difficult,  and  frequent  urination,  followed  by  hematuria. 
The  urine  contained  pus,  epithelium  of  all  kinds,  and  a  number  of  bodies 
slightly  larger  than  pus-corpuscles  of  a  peculiar  amyloid  appearance — 
the  trichomonades. 

Morbid  Growths.  The  urine  very  rarely  contains  the  elements  of 
morbid  growths.  Von  Jaksch  says  he  never  has  found  them  in  any 
way  reliable  in  the  case  of  tumors  of  the  kidney.  The  detection  of 
cancer-cells  or  pigmented  cells,  such  as  occur  in  melanotic  cancers, 
may  confirm  the  diagnosis  if  the  clinical  symptoms  point  to  cancer. 
Tumor-elements  are  most  likely  to  be  found  in  ulcerating  tumor  of  the 
bladder. 

Unorganized  Sediments.  Uric  Acid.  Uric  acid  is  present  in  small 
quantities  (eight  to  ten  grains  a  day)  in  normal  urine.  It  is  increased 
in  febrile  and  wasting  diseases,  such  as  phthisis  ;  in  diseases  of  the 
liver  and  spleen  (leukaemia),  and  in  malarial  fever,  diabetes,  scurvy, 
rhachitis,  and  following  an  attack  of  gout.  Excessive  use  of  milk  is 
said  to  increase  it.  Its  excretion  is  also  increased  by  certain  drugs — 
colchicum,  corrosive  sublimate,  salicylic  acid,  and  euonymin. 

It  is  diminished  in  ansemia,  chlorosis,  and  during  a  paroxysm  of  gout ; 
in  chronic  nephritis  ;  by  certain  drugs — large  doses  of  quinine  (Ranke), 
caffein,  sodium  chloride  and  sodium  carbonate,  lithia,  and  iodide  of 
potash.     (Plate  XLVIIL,  Figs.  1  and  2.) 

According  to  Roberts,  a  deposit  of  uric  acid  occurring  some  twelve 
to  twenty-four  hours  after  the  urine  has  been  passed  has  no  patholog- 
ical significance.  If  the  deposit  occurs  within  three  or  four  hours  after 
the  urine  has  been  passed,  it  is  certainly  not  natural.  It  is  frequently 
observed  in  convalescence  from  febrile  complaints,  especially  articular 
rheumatism ;  also  in  the  middle  periods  of  chronic  B right's  disease,  in 
chorea,  in  certain  types  of  diabetes,  and  in  enlargement  of  the  spleen. 
If,  however,  the  uric  acid  is  precipitated  before  the  urine  cools,  or  im- 
mediately afterward,  it  is  probable  that  the  same  precipitation  may  occur 
within  some  part  of  the  urinary  passages,  and  so  form  a  calculus. 


950 


SPECIAL  DIAGNOSIS. 


Urates.  Amorphous  urates  appear  under  the  microscope  as  opaque 
granular  particles,  which  dissolve  upon  heating,  and  respond  to  the 
murexid  test.  The  deposit  is  more  or  less  dense,  and  is  sometimes 
arranged  so  as  to  resemble  granular  casts. 


Fig.  217. 


Sodium  urate. 

a  a.  From  a  gouty  concretion.  6  b.  Arti- 
ficially prepared  by  adding  liq.  sodse  to  the 
amorphous  urate  deposit.    (Roberts.) 


Ammonium  urate  spontaneously 
deposited. 
a.  Spheres  and  globular  masses,    b. 
Dumb-bells,  crosses,  rosettes.    (Rob- 
erts.) 


Sodium  urate  appears  as  spherules  or  globules,  from  which  project 
short  spines,  either  straight  or  curved.  It  occurs  most  frequently  in 
concentrated  acid  urines,  such  as  are  passed  by  children  with  acute 
febrile  diseases.     (Fig-  217.) 


Fig.  218. 


Ammonium  urate. 


Ammonium  urate  resembles  sodium  urate.  It  is  frequently  asso- 
ciated with  phosphatic  deposits,  and  is  precipitated  from  alkaline 
urines.  Sometimes  it  appears  in  the  shape  of  dumb-bells.  (Figs.  217 
and  218.) 

Phosphates.  Phosphates  appear  in  the  urine  as  ammonio-magne- 
sium  phosphate  and  as  the  crystalline  and  amorphous  phosphate  of  lime. 


DISEASES  OF  THE  KIDNEYS. 


951 


They  are  precipitated  in  alkaline  or  faintly  acid  urines,  which  produce 
a  cloud  upon  being  heated ;  the  cloud  is  distinguished  from  albumin, 
as  already  pointed  out,  by  the  fact  that  it  disappears  when  the  urine  is 


Fig.  219. 


Triple  phosphates. 


acidulated  with  acetic  or  nitric  acid.  Ammonio-magnesium  phosphate 
is  easily  recognized  by  its  rhombic  prisms — "  coffin-lid  "  shape.  Other 
shapes  are  'produced  by  modification  of  the  primary  one,  chiefly  by 
bevelling  of  the  edges  and  hollowing  out  of  the  sides.     These  crystals 


Calcium  phosphate  crystals. 


are  usually  large,  and  are  frequently  found,  together  with  amorphous 
phosphates,  bladder  epithelium,  and  pus,  in  cases  of  cystitis. 

Amorphous  phosphate  of  lime  consists  of  fine  granular  particles  much 
resembling  amorphous  urates,  but  distinguished  from  them  by  not  dis- 


952  SPECIAL  DIAGNOSIS. 

appearing  upon  the  application  of  heat,  but  instantly  dissolving  when 
the  urine  is  acidulated. 

Crystalline  phosphate  of  lime  is  a  not  infrequent  deposit.  It  is 
found  as  narrow-wedged  crystals,  occasionally  grouped  together  in  the 
form  of  stars,  sheaves,  or  bundles,  with  their  apices  at  a  common 
centre. 

According  to  Roberts,  this  deposit,  in  quantity,  is  an  accompaniment 
of  some  grave  disorder.  He  has  found  the  stellar  phosphates  in  cancer 
of  the  pylorus,  once  in  phthisis,  and  more  than  once  in  patients  ex- 
hausted by  obstinate  rheumatism.  It  may,  however,  occur  in  health, 
when  the  urine  is  rich  in  lime  and  its  acidity  greatly  reduced. 

In  one  or  two  cases  of  renal  colic  the  writer  has  observed  numerous 
shining  particles,  which,  upon  microscopical  examination,  have  been 
shown  to  be  an  opalescent  film,  covered  with  small,  sharp  phosphatic 
(probably  calcium)  crystals.     (Fig.  221.) 

Fig.  221. 


Opalescent  film  in  a  case  of  renal  colic. 

Oxalate  of  Lime.  Oxalate  of  lime  occurs  in  the  form  of  small  octa- 
hedral crystals,  or,  more  rarely,  as  dumb-bells,  and  in  the  form  of  ovals 
or  disks.  It  is  precipitated  almost  always  from  acid  urines.  (Plate 
VI.,  Fig.  2 ;  and  Fig.  222.) 

Oxaluria.  According  to  Beneke,  oxaluria  has  its  proximate  cause  in 
an  impeded  metamorphosis,  an  insufficient  activity  of  that  stage  which 
changes  oxalic  acid  into  carbonic  acid. 

When  oxalates  are  constantly  found  in  the  urine  a  condition  of  pro- 
found hypochondriasis  is  found  to  exist,  but  it  has  no  necessary  relation 
to  the  oxaluria.  An  increase  of  oxalates  in  the  urine  is  found  in  dia- 
betes, especially  when  there  is  diminution  in  the  amount  of  sugar.  It 
is  in  excess  in  certain  forms  of  indigestion.  Its  constant  passage  may 
be  attended  by  pains  in  the  back  and  loins.  Flatulent  and  nervous 
dyspepsia  usually  accompany  the  increase,  and  neurasthenia  also  may 
be  present. 


DISEASES  OF  THE  KIDNEYS. 


953 


Cystin.  Cystin  occurs  in  the  form  of  hexagonal  prisms,  either  as 
irregular  masses  or  superimposed  one  upon  another,  so  as  to  form 
truncated  pyramids.  It  is  a  very  rare  sediment,  but  appears  to  be 
most  common  in  children  and  young  male  adults.  Several  members 
of  the  same  family  have  been  known  to  pass  it.  Its  chief  clinical  sig- 
nificance arises  from  the  fact  that  rarely  it  is  the  basis  of  calculi. 


Fig. 222 . 


<- 


fa    7 


v\ 


&> 


<> 


m> 


&3  o 


Calcium  oxalate. 


Leucin  and  Tyrosin.  Leucin  and  tyrosin  are  generally  described 
together,  though  the  former  is  not  spontaneously  deposited  from  urine. 
It  appears  in  the  form  of  spheres,  which  refract  light  strongly  and  have 
a  radiating  arrangement.     (Fig.  223.) 


Fig. 223. 


Crystals  of  leucin  (different  forms).  (Crystals  of  creatinin  chloride  of  zinc  resemble  the  leucin 
crystals  depicted  at  a.)  The  crystals  figured  toward  the  right  consist  of  comparatively  impure 
leucin.    (From  Charles  :  Chemistry.) 

Tyrosin  has  been  found  as  a  sediment,  of  a  light  greenish-yellow  color, 
in  typhoid  fever  and  acute  yellow  atrophy  of  the  liver.  It  appears  in 
the  form  of  tolerably  long,  needle-like  crystals,  or  as  bundles  and 
sheaves.  Frerichs  attaches  great  importance  to  leucin  and  tyrosin  in 
the  diagnosis  of  acute  yellow  atrophy  of  the  liver.     (Fig.  224.) 


954 


SPECIAL  DIAGNOSIS. 


Cholesterin.  This  occurs  at  times  in  fatty  degeneration  of  the  kid- 
neys, jaundice,  chyluria,  diabetes,  and,  according  to  Pohl,  in  the  urine  of 
epileptics  treated  with  bromide  of  potash.     (Fig.  225.) 


Fig.  224. 


Tyrosin  crystals. 


Melanuria.  Melanin  is  held  in  solution  or  suspended  in  small  gran- 
ules. The  urine  is  dark  in  color,  and  blackens  intensely  when  sulphuric 
acid  or  tincture  of  chloride  of  iron  is  added  to  it.  A  concentrated  solu- 
tion of  perchloride  of  iron  serves  to  detect  the  presence  of  the  substance. 


Fig.  225. 


Crystals  of  cholesterin. 


A  few  drops  added  to  the  urine  turn  it  gray.  If  a  few  drops  more  are 
added,  the  phosphates  are  precipitated  aloug  with  the  coloring-matter. 
Both  are  dissolved  by  an  excess  of  the  iron  solution.  Melanin  is  usually 
found  in  cases  of  melanotic  carcinoma. 


DISEASES  OF  THE  KIDNEYS.  955 

Catheterization  and  Exploration  of  the  Ureters. 

Examination  of  the  bladder,  the  ureters,  and  the  pelvis  of  the  kidney 
has  been  wonderfully  advanced  by  the  genius  of  Howard  Kelly.  The 
following  instruments  are  required  for  the  examination  of  the  bladder  : 
Female  catheter ;  urethral  calibrator ;  a  series  of  urethral  dilators  ;  a 
series  of  specula  with  obturators ;  common  head-mirror  and  a  lamp, 
Argand  burner  or  electric  light ;  long,  delicate  mouse-toothed  forceps  ; 
suction-apparatus  for  completely  emptying  the  bladder ;  ureteral 
searcher  ;  ureteral  catheter  with  a  handle ;  small  bran-bags  for  ele- 
vating the  pelvis. 

The  procedure  is  as  follows  :  Empty  the  bladder ;  measure  the  meatus 
urinarius  externus  ;  dilate  the  urethra  to  twelve  or  fifteen  millimetres ; 
insert  speculum  of  diameter  of  last  dilator  and  remove  obturator  ; 
elevate  the  hips  of  the  patient  about  a  foot  above  the  level  of  the 
table ;  inspect  with  light ;  remove  residual  urine  by  suction  or  with 
cotton  and  mouse-toothed  forceps. 

For  anaesthesia,  a  pledget  of  cotton  saturated  with  a  5  per  cent,  solu- 
tion of  cocaine  may  be  introduced  seven  minutes  before  dilatation.  On 
removal  of  the  obturator  the  bladder  becomes  distended  with  air.  The 
bladder  is  viewed  by  turning  the  speculum,  and  each  ureteral  orifice  is 
brought  into  view  by  turning  the  speculum  thirty  degrees  to  one  side 
or  the  other.  Kelly  says  :  "  The  orifice  appears  as  a  dimple  or  a  little 
pit,  or,  in  inflammatory  cases,  as  a  round  hole  in  a  cushioned  eminence  ; 
at  other  times  as  a  x\_  with  the  point  directed  outward  ;  again,  it  may 
be  scarcely  visible  even  to  a  trained  eye,  appearing  as  a  fine  crack  in 
the  mucosa,  and  occasionally  is  so  obscure  as  to  be  recognized  only  by 
the  jet  of  urine  as  it  escapes,  or  by  a  slight  difference  in  the  color  of 
the  mucous  membrane  at  that  point.  In  rare  cases  it  has  the  form  of 
a  truncated  cone  with  gently  sloping  sides  ;  this  appearance  is  most  apt 
to  be  developed  in  the  knee-breast  position.  The  bladder  mucosa  is 
usually  of  a  slightly  deeper  rose  color  around  the  ureter,  and  in  the 
presence  of  an  inflammatory  process  it  even  appears  deeply  injected/1 

Catheterization  of  the  Ureters.  The  catheters  are  sterilized  ;  they  are 
stiffened  with  a  wire  stylet.  The  orifice  is  exposed,  and  then  the  outer 
end  of  the  catheter  being  held  over  the  shoulder  by  an  assistant,  the 
conical  end  is  introduced  and  pushed  up  the  ureter,  while  at  the  same 
time  the  stylet  is  being  removed.  The  speculum  is  removed  and  again 
introduced  beside  the  first  catheter.  The  remaining  ureter  is  then  cath- 
eterized ;  both  are  properly  designated  and  allowed  to  drain  into  test- 
tubes  plugged  with  sterilized  cotton  and  fixed  in  a  block  of  wood.  By 
catheterization,  aspiration,  and  exploration  of  the  ureters  with  a  bougie, 
the  source  of  pyemia  anywhere  from  the  urethral  orifice  to  the  renal 
pelvis  can  be  found  ;  renal  calculi  diagnosticated  ;  strictures  of  the 
ureter  located ;  hydronephrosis  distinguished  from  soft  malignant 
growths  ;  and  the  functional  value  of  each  kidney  determined. 

Kelly  suggests  the  following  guide  to  the  ureteral  orifice  :  "  A.  point 
is  marked  on  the  cystoscope  5 }  cm.  from  the  vesical  end,  and  from  this 
point  two  diverging  lines  are  drawn  toward  the  handle  with  an  angle 
of  sixty  degrees  between  them.     The  speculum  is  introduced  up  to  the 


956  SPECIAL  DIAGNOSIS. 

point  of  the  V,  and  turned  to  the  right  or  left  until  one  side  of  the 
V  is  in  line  with  the  axis  of  the  body ;  then  by  elevating  the  endo- 
scope until  it  touches  the  floor  of  the  bladder  the  ureteral  orifice  will 
usually  be  found  within  the  area  covered  by  the  orifice  of  the  speculum." 
By  means  of  a  searcher,  or  sound,  the  suspected  orifice  is  further  ex- 
amined. 

Objective  Symptoms  due  to  Impairment  of  the  Function 
of  the  Kidney. 

Uraemia.  Under  symptoms  due  to  impairment  of  the  functions  of 
the  kidney  belong  the  various  manifestations  of  uraemia.  Diseased 
kidneys  do  not  eliminate  the  products  of  tissue-waste,  which  are  poison- 
ous materials.  The  toxic  matter  is  retained  within  the  blood,  and 
produces  toxaemia,  which  may  be  acute  or  chronic.  In  acute  uraemia 
the  manifestations  develop  suddenly  and  continue  but  a  short  period 
of  time,  with  alarmingly  active  symptoms  until  death  or  recovery.  In 
chronic  uraemia  the  onset  is  gradual.  The  manifestations  may  be  lim- 
ited to  one  or  two  conditions,  as  headache  or  morning  nausea,  or  they 
may  include  the  more  pronounced  symptoms  of  uraemia. 

Nervous  Symptoms.  1.  Headache.  The  pain  is  situated  in  the 
occipital  region,  and  may  extend  down  the  neck.  It  is  severe  and  of 
a  bursting  character.  It  may  be  associated  with  giddiness.  In  both 
acute  and  chronic  nephritis  it  is  often  the  first  manifestation.  It  may 
be  associated  with  eye-symptoms.  It  may  be  present  on  waking,  and 
continue  only  through  the  morning  hours.  In  acute  uraemia  it  persists 
throughout  the  attack.  Numbness  and  tingling  of  the  fingers  are  often 
complained  of  at  the  same  time. 

2.  Delirium.  The  delirium  may  be  mild.  This  is  usually  the  case 
in  the  typhoid  state  or  if  a  subnormal  temperature  prevails.  It  is 
sometimes  attended  by  delusions.  There  is  often  subsultus,  and  pick- 
ing at  the  bedclothing.  The  delirium  may  amount  to  true  mania,  and 
the  patient  may  exhibit  other  maniacal  symptoms.  On  the  other 
hand,  the  patient  may  be  noisy,  restless,  and  sleepless.  Melancholia 
and  delusional  insanity  may  develop  after  the  violent  nervous  symptoms 
of  uraemia  pass  off. 

3.  Convulsions.  A  convulsion  may  be  the  first  indication  of  disease 
of  the  kidneys,  or  it  may  succeed  a  few  days  of  persistent  headache, 
or  follow  an  attack  of  uraemic  vomiting.  The  convulsion  resembles 
epilepsy,  and  hence  is  known  as  an  epileptiform  convulsion.  If  the 
spasms  recur  in  rapid  succession,  the  interval  is  occupied  by  delirium 
or  coma.  If  they  are  infrequent,  the  patient's  mind  may  be  clear  in 
the  intervals.  Sometimes  a  focal  or  Jacksonian  epilepsy  occurs  instead 
of  the  true  epileptiform  convulsion.  The  temperature  is  usually  elevated. 
In  worn-out  subjects,  or  those  who  have  had  exhaustive  diarrhoea,  or 
are  debilitated  from  other  causes,  the  temperature  may  be  subnormal. 
A  temporary  blindness  often  follows  the  convulsion  (urcemie  amaurosis). 
Uraemic  deafness  may  occur. 

4.  Coma.  After  the  convulsion  the  mind  may  be  restored,  or  the 
patient  may  lapse  into  stupor,  followed  by  complete  coma.     Coma  may 


DISEASES  OF  THE  KIDNEYS.  957 

develop  without  convulsions,  or  immediately  succeed  a  general  convul- 
sion. Headache  or  eye-symptoms  may  precede  the  coma.  In  some 
instances  the  patient  lapses  into  a  typhoid  state,  in  which  the  tongue  is 
heavily  furred  and  the  breath  very  offensive.  Unless  the  coma  is  pro- 
found there  is  usually  some  twitching  of  the  muscles  of  the  hands  and 
face. 

5.  Local  palsies.  Dercum  was  among  the  first  to  call  attention  to  the 
occurrence  of  uraeniic  monoplegia  or  hemiplegia.  The  cases  resemble 
central  cerebral  disease.  The  nature  of  the  palsy  is  inferred  from  the 
results  of  the  examination  of  the  urine  and  the  condition  of  the  heart 
and  arteries.  Palsy  develops  suddenly,  or  may  occur  after  a  convul- 
sion. 

6.  Cramps  in  the  muscles  of  the  calves,  particularly  at  night,  are  of 
common  occurrence,  and  should  always  lead  to  an  examination  of  the 
urine. 

7.  Pruritus,  local  or  general,  is  another  nervous  symptom  which  may 
be  of  uraemic  origin. 

8.  Pain  in  the  upper  abdomen,  particularly  in  the  median  line,  is  a 
frequent  precursor  of  more  severe  uraemic  symptoms.  It  is  of  uraemic 
origin  itself.  It  may  be  seated  in  either  of  the  upper  quadrants,  and 
thence  extend  to  the  lower  portion  of  the  abdomen. 

Uremic  Dyspxcea.  Modifications  of  the  breathing  often  accom- 
pany symptoms  of  uraemia.  The  dyspnoea  may  be  constant.  It  may 
occur  in  paroxysms,  or  both  types  may  alternate.  A  common  type  in 
the  uraemia  of  chronic  nephritis  is  the  Cheyne-Stokes  breathing. 
Paroxysmal  dyspnoea  usually  occurs  at  night,  and  resembles  asthma 
in  every  respect.  Cheyne-Stokes  breathing  continues,  even  through 
the  period  of  coma,  although  not  necessarily  associated  with  it.  (See 
page  456.) 

In  addition  to  ursemic  dyspnoea,  the  occurrence  of  inflammatory 
pulmonary  complications  may  be  the  first  indication  that  the  condition 
of  the  urine  should  be  inquired  into.  Bronchitis,  pneumonia,  and 
pleurisy  are  common  complications. 

Gastrointestinal,  Symptoms  of  Uraemia.  Several  forms  are 
seen.  1.  Loss  of  appetite  is  common.  It  is  attended  with  absolute 
distaste  for  food  after  a  small  portion  is  taken.  2.  Nausea,  which 
may  be  continuous,  or  more  frequently  limited  to  the  early  morning. 
3.  Vomiting  may  be  paroxysmal,  occurring  chiefly  in  the  early  morn- 
ing, or  it  may  be  sudden  in  onset,  uncontrollable,  and  continue  until 
nervous  symptoms  of  uraemia  develop.  Urea  is  found  in  the  vomit. 
The  matter  ejected  is  profuse,  of  a  low  specific  gravity,  and  at  first 
acid  in  reaction.  If  chronic,  it  may  become  alkaline.  The  odor  is 
often  sufficient  to  cause  its  recognition.  4.  Constipation  is  generally 
the  rule  in  the  course  of  chronic  Bright' s  disease.  5.  Diarrhoza.  One 
of  the  manifestations  of  uraemia  is  the  occurrence  of  sudden,  profuse 
serous  purging.  This  may  be  so  extreme  as  to  cause  collapse,  or  may 
usher  in  coma  and  convulsions.  6.  Hiccough,  although  a  muscular 
affection,  is  usually  associated  with  gastric  disturbances. 

Latent  uraemia  was  first  recognized  by  Sir  William  Roberts.  It  is 
seen  in  its  most   characteristic  form  in  calculus    suppression.     The 


958  SPECIAL  DIAGNOSIS. 

patient  for  several  days  will  have  subnormal  temperature,  myosis, 
occasional  vomiting,  and  toward  the  end  twitching  of  the  voluntary 
muscles  and  slight  drowsiness.  After  the  end  of  five  or  ten  days 
coma,  convulsions,  or  dyspnoea  ensue. 

Cardiovascular  Symptoms  of  Nephritis.  The  symptoms  are 
the  effects  of  the  retention  of  morbid  products.  First,  the  heart  and 
bloodvessels.  The  poison  which  is  not  excreted  circulates  throughout 
the  system.  One  of  its  effects  is  irritation  of  the  vasomotor  nerves  of 
the  bloodvessels.  Excitation  of  these  nerves  causes  peripheral  con- 
traction of  the  smaller  vessels.  At  once  the  flow  of  blood  is  obstructed, 
so  that,  on  account  of  the  contraction,  hypertrophy  of  the  heart  rapidly 
ensues.  The  first  prominent  symptom,  therefore,  is  due  to  changes  in 
the  heart-muscle. 

Hypertrophy  of  the  Heart.  The  most  pronounced  change  is  hyper- 
trophy. The  persistent  spasm  of  the  peripheral  vessels  causes  in- 
creased arterial  tension.  The  blood-pressure  is  raised  and  causes 
increased  accentuation  of  the  aortic  second  sound.  High  tension  in 
the  artery  is  recognized  by  the  peculiar  character  of  the  pulse  and  by 
means  of  the  sphygmograph. 

Dilatation  of  the  Heart.  Unfortunately,  hypertrophy  of  the  heart 
cannot  always  be  kept  up.  If  it  fails,  we  then  have  a  second  con- 
dition of  the  heart  which  is  frequently  found  in  renal  inflamma- 
tions ;  it  is  dilatation.  The  state  of  the  coronary  arteries  predisposes 
to  this  condition  of  the  heart-muscle.  The  previously  mentioned 
arterial  tension  favors  the  development  of  chronic  endarteritis  with 
general  atheroma.  The  coronary  arteries  take  part  in  this  process. 
The  endarteritis  hinders  cardiac  nutrition,  dilatation  of  the  heart- 
muscle  follows,  and  later  comes  the  development  of  two  other  condi- 
tions, atrophy  and  myocarditis. 

Here  may  be  mentioned  other  relations  of  the  heart  and  kidneys  : 
a.  We  have  renal  disease  following  forms  of  cardiac  disease.  In  dila- 
tation of  the  heart  passive  congestion  of  the  particular  organ  takes 
place.  The  kidney  very  quickly  becomes  the  seat  of  such  congestion. 
In  the  course  of  simple  dilatation,  or  of  valvular  heart-disease,  the 
secondary  dilatation,  passive  congestion,  and  chronic  inflammation 
develop  slowly.  Embolism  may  also  occur,  b.  Renal  disease  and 
cardiac  disease  may  develop  at  the  same  time  from  a  common  cause, 
as  alcoholism,  gout,  or  endarteritis. 

In  addition  to  high  arterial  tension  and  accentuation  of  the  aortic 
second  sound,  the  objective  symptoms  of  atheroma  of  the  aorta  and 
arteries  are  present  with  the  chronic  inflammations  of  the  kidney. 
These  vascular  changes  need  not  be  again  rehearsed.    (See  Endarteritis.) 

It  is  important,  however,  to  bear  in  mind  that  they  frequently  occur 
together,  and  also  that  in  all  instances  of  arterial  disease  the  condition 
of  the  urine  must  be  inquired  into.  It  need  not  be  said  that  symptoms 
due  to  rupture  of  the  bloodvessels,  particularly  in  the  brain,  or  to  an- 
eurism, necessarily  may  be  present  in  the  course  of  renal  inflammation. 

Gastro-intestinal  Symptoms.  Fermentative  dyspepsia,  gastralgia, 
chronic  gastritis,  enteritis,  and  ulcerative  colitis  are  of  common  occur- 
rence. 


DISEASES  OF  THE  KIDNEYS.  959 

Hemorrhages.  The  arteries  are  very  liable  to  rupture,  causing 
epistaxis,  retinal  hemorrhage,  hemorrhages  from  the  bowels  and  lungs, 
and  hemorrhages  underneath  the  skin.  Frequent  hemorrhages  in  large 
amounts  from  any  portion  of  the  body  should  call  attention  to  the 
condition  of  the  urine. 

Ophthalmoscopic  Changes.  The  eye-ground  should  always  be 
examined ;  indeed,  the  patient  himself  by  his  complaints  often  directs 
attention  only  to  the  eye,  the  examination  of  which  discloses  the  pres- 
ence of  an  albuminuric  retinitis.  The  changes  may  occur  in  the  acute 
or  chronic  forms  of  nephritis,  although  they  are  more  common  in  the 
latter.  1.  A  diffuse,  slight  opacity  and  swelling  of  the  retina,  due  to 
oedema.  2.  White  spots  or  patches  of  various  sizes,  for  the  most  part  the 
result  of  degenerative  processes.  3.  Hemorrhages.  4.  Inflammation 
of  the  intraocular  end  of  the  optic  nerve.  5.  Atrophy  of  the  retina  and 
nerve  may  sometimes  result  from  and  succeed  the  inflammatory  changes. 
These  changes  may  affect  one  eye  only  (Gowers).  It  must  not  be  for- 
gotten that  temporary  blindness  may  occur  independently  of  retinitis. 

Dropsy.  Dropsy  may  occur  in  all  forms  of  nephritis.  It  is  most 
common  in  acute  varieties,  but  it  is  also  present  in  chronic  diffuse  neph- 
ritis with  exudation.  Renal  dropsy  usually  begins  in  the  face.  It  may 
develop  suddenly  in  acute  forms.  In  the  marked  forms,  oedema  of  the 
eyelids  may  continue  for  a  long  time.  All  varieties  may  be  found,  from 
local  oedema  to  extreme  anasarca.  The  serous  cavities  are  also  filled. 
The  oedema  is  usually  associated  with  a  diminished  amount  of  urine. 
Its  improvement  is  attended  by  increased  diuresis.  Dropsy,  in  chronic 
disease,  is  usually  due  to  dilatation  of  the  heart.     (See  page  100). 

The  Cutaneous  Symptoms,  and  Appearance  of  the  Face, 
In  inflammatory  affections  of  the  kidney,  the  appearance  of  the  skin 
and  expression  of  the  face  are  often  characteristic,  and  point  at  once  to 
an  examination  of  the  urine.  The  face  is  pallid,  and  of  an  ivory  white- 
ness. In  the  chronic  form  the  pallor  gives  way  to  an  ashen-gray  or 
sallow  complexion.  In  chronic  nephritis  the  skin  becomes  dry  and 
harsh,  and,  rarely,  is  covered  with  a  powdery  substance,  giving  it  the 
appearance  of  frost  on  the  skin.    The  powdery  substance  is  due  to  urea. 

Petechia;.  In  the  later  stages  of  chronic  inflammatory  affections 
hemorrhages  under  the  skin  and  in  the  mucous  membrane  are  seen. 

Anaemia.  Anaemia  is  a  frequent  symptom  in  all  forms  of  nephritis  ;. 
it  is  usually  marked.  It  is  associated  with  the  peculiar  pallor  just 
described,  and  attended  by  all  the  other  usual  symptoms. 

General  Symptoms.  The  cause  of  renal  disease,  as  far  as  symp- 
toms pointing  to  the  kidneys  are  concerned,  is  often  latent.  Instead 
of  renal  symptoms,  a  generally  depraved  state  of  the  system  may  be 
seen,  with  emaciation  and  weakness.  Lassitude  without  cause  demands 
an  examination  of  the  urine. 

Diabetic  Coma.  Acetonemia  is  a  toxemia  which  develops  in  the 
terminal  stages  of  diabetes.  It  is  due  to  an  accumulation  of  acetone 
in  the  blood.  It  is  also  called  diabetic  coma.  It  develops  acutely.  A 
sudden  onset  is  attended  by  sharp  pain  in  the  stomach  with  nausea,  and 
frequently  vomiting.  At  the  same  time  there  is  severe  dyspnoea.  The 
breathing  is  irregular  and  of  a  panting  character,  with  inspiratory  and 


960  SPECIAL  DIAGNOSIS. 

expiratory  dyspnoea.  There  may  or  may  not  be  cyanosis.  The  patient 
is  obliged  to  sit  up  in  bed  on  account  of  the  air-hunger.  Restlessness 
begins  at  once.  Delirium  develops  within  the  first  hour.  In  a  few 
hours  coma  sets  in.  The  temperature  is  subnormal ;  the  pulse  is  irreg- 
ular, and  soon  becomes  weak  and  thready.  The  odor  of  acetone  is 
detected  on  the  breath. 

Congestion  of  the  Kidney. 

Congestions  of  the  kidney  are  acute  and  chronic,  and  depend  upon 
changes  in  the  circulation,  whereby  blood  accumulates  in  the  kidney. 

Acute  congestion  of  the  kidney  is  caused  by  the  action  of  irritant 
poisons  •  it  follows  surgical  operations,  particularly  if  prolonged,  and 
may  follow  extirpation  of  one  kidney.  Diseased  kidneys  are  apt  to 
become  the  seat  of  active  congestion. 

Symptoms.  The  urine  is  diminished  in  amount,  or  may  be  suppressed 
entirely.  Only  a  small  amount  is  passed  at  frequent  intervals,  or  it  can 
be  secured  by  the  catheter  alone.  Albumin  is  present  in  considerable 
amount,  and  blood  and  epithelial  casts  are  numerous.  Death  may  take 
place,  with  symptoms  of  uraemia. 

Chronic  Congestion  of  the  Kidney.  It  is  also  called  passive  conges- 
tion. This  form  of  congestion  is  usually  a  part  of  general  venous  stasis, 
due  to  disease  of  the  heart  or  lungs,  as  valvular  disease  of  the  heart, 
with  secondary  dilatation  or  pulmonary  emphysema.  It  is  quite  com- 
mon. 

Symptoms.  The  urine  is  diminished  in  amount ;  dark  in  color ;  of 
high  specific  gravity,  ranging  from  1020  to  1030.  Uric  acid  and 
urates  are  increased.  Urea  to  the  amount  of  from  10  to  12  grains  to 
the  ounce  is  passed  in  twenty -four  hours.  At  first  there  is  no  further 
change,  but,  subsequently,  albumin  appears  in  small  amounts  in  an 
intermittent  manner.  Later,  it  is  constant  and  increased  in  amount. 
Hyaline  casts  are  found  in  the  urine,  and  a  few  red  blood-cells. 

The  condition  is  recognized  by  its  association  with  congestion  in  other 
organs ;  by  the  diminution  in  the  amount  of  urine,  its  high  specific 
gravity ,  and  excess  of  uric  acid  and  urates.  This  form  of  congestion 
is  serious,  because  it  leads  to  chronic  nephritis.  The  latter  is  recog- 
nized by  the  usual  changes  in  the  urine. 

Inflammations  of  the  Kidney. 

The  inflammations  of  the  kidney  are  divided  in  accordance  with  the 
activity  of  the  process  and  the  degree  of  exudation  or  cell-proliferation 
that  attends  the  inflammation.  We,  therefore,  have  the  following 
varieties : 

Acute  exudative  nephritis  (acute  Bright' s  disease). 

Acute  productive  or  diffuse  nephritis  (acute  Blight's  disease). 

Chronic  productive  or  diffuse  nephritis  with  exudation  (chronic 
tubular  nephritis). 

Chronic  productive  or  diffuse  nephritis  without  exudation  (chronic 
interstitial  nephritis). 

Suppurative  nephritis. 


DISEASES  OF  THE  KIDNEYS.  961 

Tubercular  nephritis. 

Acute  Exudative  Nephritis  or  Glomerulo-jstephritis.  In 
this  form  of  nephritis  there  are  congestion,  exudation  of  plasma,  trans- 
udation of  red  and  white  blood-cells,  and  changes  in  the  epithelium. 

Causes.  It  may  occur  without  definite  cause,  save  exposure  to  cold, 
and  at  times  even  without  such  history.  It  occurs  in  most  of  the  infec- 
tious diseases.  It  is  of  common  occurrence  after  scarlet  fever,  and  in 
the  course  of  pregnancy  and  in  septicaemia.  It  occurs  in  diphtheria, 
erysipelas,  and  pneumonia  frequently.  It  is  the  expression  of  a  pecu- 
liar type  of  typhoid  fever.  It  may  complicate  dysentery  and  acute 
tuberculosis.     It  forms  one  of  the  modes  of  termination  of  diabetes. 

Symptoms.  The  course  of  the  disease  may  be  mild,  presenting  only 
changes  in  the  urine,  or  there  may  be,  in  addition  to  decided  changes 
in  the  character  of  the  urine,  local  and  general  symptoms. 

In  mild  cases  the  urine  is  diminished  in  amount ;  micturition  is  fre- 
quent ;  the  color  of  the  urine  is  increased,  and  the  specific  gravity  is 
usually  high.  A  small  amount  of  albumin  is  found,  and  a  few  epithe- 
lial and  blood-casts,  and  sometimes  blood.  At  the  termination  of  the 
disease  the  casts  are  hyaline. 

In  severe  cases  the  disease  is  ushered  in  by  chill,  attended  and  fol- 
lowed by  pain  in  the  loins,  with  fever,  headache,  and  much  restlessness. 

The  urine  may  be  passed  more  frequently  than  usual,  but  in  small 
amounts ;  or  micturition  may  diminish  in  frequency  or  cease  entirely. 
Examination  of  the  urine  reveals  the  characteristic  changes.  The 
quantity  of  the  urine  is  lessened ;  the  specific  gravity  is  normal  or 
increased.  There  is  a  large  amount  of  albumin,  and  an  abundance 
of  hyaline,  granular,  epithelial,  and  blood-casts.  Free  white  and  red 
blood-cells,  and  epithelium  from  the  pelvis  and  tubules  are  found. 

The  fever  continues ;  the  pain  in  the  loins  is  sometimes  very  severe, 
and  may  be  taken  for  lumbago,  unless  an  examination  of  the  urine  is 
made.  Within  the  first  forty-eight  hours  the  characteristic  symptoms 
that  follow  the  chill  and  that  attend  the  urinary  changes  are  headache, 
sleeplessness,  more  or  less  stupor,  muscular  twitchings,  or  general  convul- 
sions. Eye-symptoms  may  be  present.  Instead  of  cerebral  symptoms, 
dyspnoea  may  be  marked.  With  both,  nausea  and  vomiting  are  of 
common  occurrence.  The  heart's  action  is  increased  in  force  and  fre- 
quency. The  left  ventricle  rapidly  becomes  hypertrophied.  The  aortic 
second  sound  is  accentuated.  The  pulse  is  hard  and  exhibits  the  char- 
acteristic features  of  high  tension.  From  the  onset  of  the  first  symptom, 
or  within  the  first  week,  two  other  striking  phenomena  arise.  They  are, 
first,  the  occurrence  of  dropsy  ;  second,  the  occurrence  of  ancemia. 

Dropsy  or  oedema  is  one  of  the  most  constant  symptoms.  It  appears 
first  in  the  face,  especially  the  eyelids.  It  may  be  limited  to  this  region. 
It  is  worse  in  the  morning.  From  the  face,  in  bad  cases,  it  extends  to 
the  lower  extremities  and  to  the  scrotum,  and  thence  all  over  the  body. 
Anasarca  is  the  name  applied  to  the  general  dropsy  ;  the  connective 
tissue  is  infiltrated  with  serum.  It  is  recognized  by  the  pallor  of  the 
swollen  surface ;  the  pitting  on  pressure ;  the  absence  of  heat  and  of 
pain.     (See  page  148.) 

Effusion  may  take  place  into  the  serous  cavities,  either  the  pleura, 

61 


962  SPECIAL  DIAGNOSIS. 

pericardium,  or  peritoneum,  causing  the  symptoms  due  to  effusion- 
In  some  instances  there  is  oedema  of  the  mucous  membranes,  as  the 
conjunctiva,  the  soft  palate,  and  the  glottis. 

Dyspnoea  may  be  a  pronounced  symptom,  due  either  to  uraemia 
(uraemic  asthma)  or  oedema  of  the  glottis,  effusions  into  the  pleura,  or 
to  bronchitis.  If  dilatation  of  the  heart  occurs,  dyspnoea  may  arise, 
due  to  that  or  to  the  secondary  oedema  of  the  lungs. 

With  or  without  the  occurrence  of  nausea  or  vomiting  there  is  always 
loss  of  appetite,  and  usually  constipation. 

The  fever  is  usually  moderate  and  irregular  in  type.  Prostration  is 
common ;  often  there  is  emaciation.  Symptoms  of  urcemia  may  occur 
at  any  time. 

Exudative  nephritis  with  excessive  pus  formation  is  of  sudden  onset, 
characterized  by  high  fever  and  extreme  prostration.  There  is  rapid 
emaciation  and  the  early  development  of  the  typhoid  state.  This  is 
preceded  by  delirium,  headache,  and  stupor,  with  great  restlessness. 
There  is  but  little,  if  any,  dropsy.  Large  numbers  of  red  and  white 
blood-cells  and  the  usual  casts  are  found  in  the  urine.  There  is  not  so 
much  diminution  in  the  urine  as  is  usually  seen.  The  disease  may 
arise  without  apparent  cause,  or  complicate  scarlet  fever  or  diphtheria. 

This  form  is  very  fatal,  and  resembles  acute  meningitis,  from  which 
it  is  diagnosticated  by  the  change  in  the  urine. 

Acute  Productive  or  Diffuse  Nephritis.  In  this  form  there 
is  an  overgrowth  of  connective  tissue,  and  excessive  growth  of  the 
capsule-cells  in  the  glomeruli,  in  addition  to  the  lesions  of  the  first 
form.  The  whole  kidney  is  not  necessarily  affected,  but  only  portions 
at  a  time.  Symptoms:  The  onset  is  sudden.  The  subjective  symptoms 
previously  described  are  present  in  a  marked  degree.  Nervous  symp- 
toms (uraemia)  are  most  pronounced.  Droptsy  develops  rapidly  and  to 
an  extreme  degree.  There  is  rapid  development  of  anosmia  and  loss  of 
flesh.    The  remaining  symptoms  tally  with  those  of  the  first  affection. 

The  urine  is  scanty,  bloody,  and  of  high  specific  gravity.  The  micro- 
scopical appearances  are  like  those  of  acute  exudative  nephritis.  If 
convalescence  is  established,  the  urine  becomes  more  abundant,  with  a 
corresponding  fall  in  the  specific  gravity.  The  albumin  and  casts  may 
appear  for  a  time,  but  eventually  disappear. 

Diagnosis.  The  diagnosis  of  acute  nephritis  of  either  form  is  based 
upon  the  examination  of  the  urine.  Etiological  associations  are  of 
value.    The  more  pronounced  cases  follow  scarlet  fever  and  pregnancy. 

In  the  latter  condition  it  usually  advances  slowly.  There  may  be 
no  symptoms  until  the  occurrence  of  uraemia.  In  some  instances  the 
disease  resembles  typhoid  fever.  In  cases  in  which  the  onset  is  sud- 
den, with  early  uraemic  symptoms,  it  must  not  be  mistaken  for  epilepsy, 
delirium,  or  mania. 

Chronic  Productive  or  Diffuse  Nephritis  with  Exudation. 
In  chronic  inflammations  the  formation  of  new  tissue  always  takes 
place.  They  are  divided,  therefore,  into  exudative  and  non-exudative 
inflammations.  The  exudation  is  from  the  vessels.  Causes :  This  form 
usually  follows  acute  productive  nephritis  and  chronic  congestions  or 
degenerations  of  the  kidney.     It  develops  in  the  course  of  syphilis, 


DISEASES  OF  THE  KIDNEYS.  963 

tuberculosis,  endocarditis,  disease  of  the  bones,  and  prolonged  suppura- 
tion. Frequent  exposure  to  cold  and  wet,  a  residence  in  damp  dwell- 
ings, and  the  alcoholic  habit  are  causal  conditions.  It  usually  occurs 
in  middle  life,  more  frequently  in  men.  When  it  occurs  as  a  primary 
disease  it  is  usually  found  in  young  adults.  Symptoms :  The  disease 
develops  slowly.  General  symptoms  may  first  be  observed.  Dropsy 
may  develop  at  first  and  continue  throughout  the  disease,  or  recur  at 
long  intervals.  The  appearance  of  the  patient  is  striking.  The  skin 
is  of  a  peculiar  pallor  and  is  pasty  in  appearance.  The  sclerotics  are 
very  white.  The  anaemia  which  gives  rise  to  the  pallor  is  profound, 
and  often  closely  resembles  that  of  pernicious  anaemia.  The  anaemia 
is  due  to  diminution  in  the  haemoglobin  and  reduction  in  the  number 
of  red  blood-cells. 

Headache  and  sleeplessness  are  common  symptoms.  Pronounced  acute 
uraemia  does  not  often  occur.  Chronic  urcemia  may  prove  fatal  by  the 
patient  lapsing  into  a  typhoid  state,  in  which  delirium  alternates  with 
stupor. 

The  urine  is  variable  in  quantity  and  character.  It  must  not  be  for- 
gotten that  the  course  of  the  disease  and  the  urinary  symptoms  are  often 
quite  variable  in  chronic  nephritis.  The  urine  may  be  normal  in  amount, 
but  during  the  exacerbations  it  is  scanty  or  suppressed.  The  specific 
gravity  and  the  amount  of  urea  lessen.  In  the  most  rapid  cases  it 
varies  between  1012  and  1020.  In  chronic  cases  it  falls  as  low  as  1005 
and  even  1001.  In  the  later  stages  the  amount  of  the  urine  and  the 
specific  gravity  may  both  be  increased.  Albumin  is  present'  in  large 
amounts.  When  the  disease  is  most  active,  and  the  dropsy  at  its 
height,  the  quantity  of  albumin  is  very  large.  In  the  quiescent  period 
of  the  disease  the  amount  is  lessened.  Casts  are  abundant,  both  epithe- 
lial, fatty,  and  granular ;  red  blood-cells  are  often  found. 

Retinitis  albuminurica  is  frequently  developed  in  the  course  of  the 
disease. 

Dyspnoea  is  a  common  symptom.  The  dyspnoea  may  be  due  to  any 
one  of  the  many  causes  previously  described  which  produce  this  symp- 
tom in  the  course  of  nephritis.  It  is  frequently  limited  to  sudden 
attacks  which  develop  in  the  night  or  early  morning.  There  is  often 
some  bronchial  catarrh. 

Nausea  and  vomiting  are  common  symptoms.     The  appetite  is  lost. 

Hypertrophy  of  the  left  ventricle  takes  place  in  all  cases,  except  in 
those  who  had  been  previously  weakened  by  other  disease.  The  right 
ventricle  is  often  hypertrophied  also.  The  second  aortic  sound  is 
accentuated,  and  the  pulse  is  of  high  tension.  Symptoms,  such  as 
headache  and  vertigo,  arise  on  account  of  the  profound  ancemia. 

The  disease  is  characterized  in  its  course  by  remissions  and  exacerba- 
tions. During  the  exacerbations  any  one  of  the  prominent  symptoms 
that  occur  in  renal  inflammations  may  be  present.  (Edema  is  the  one 
symptom  which  occurs  most  frequently,  and  is  likely  to  continue  the 
longest.  The  disease  lasts  from  three  months  to  three  years,  and  may 
pass  into  the  second  variety  of  chronic  inflammation. 

Course  of  the  Disease.  Delafield  has  well  outlined  the  course.  The 
constant   symptoms   are  anaemia,   dropsy,   and  albuminuria.      1.  The 


964  SPECIAL  DIAGNOSIS. 

symptoms  may  be  continuous  and  progressive  in  severity,  death  taking 
place  at  the  end  of  one  or  two  years,  on  account  of  dropsy  or  uraemia. 
2.  The  symptoms  may  continue  for  several  months,  and  the  patient 
finally  improve.  Recurrent  attacks  take  place,  the  symptoms  being 
more  severe  with  each  attack.  In  the  intervals  of  the  attacks  there  is 
a  small  amount  of  albumin  in  the  urine.  3.  The  patient  may  appar- 
ently recover,  but  the  urine  continues  to  be  of  low  specific  gravity,  and 
contains  some  albumin.  A  fatal  attack  of  uraemia,  or  an  apoplexy,  or 
the  onset  of  an  acute  disease  may  cause  an  exacerbation  of  the  renal 
symptoms.  4.  The  symptoms  may  persist  in  a  mild  degree  for  years, 
the  patient  at  the  same  time  feeling  comparatively  well.  5.  Spasmodic 
dyspnoea  may  be  the  first  and  only  symptom  for  a  long  time. 

Chronic  Productive  or  Diffuse  Nephritis  without  Exuda- 
tion. This  is  the  form  of  nephritis  which  is  also  called  interstitial 
nephritis,  granular  kidney,  or  cirrhosis  of  the  kidney. 

The  kidneys  are  diminished  in  size,  the  capsules  are  adherent,  and 
the  surface  roughened.  There  is  an  overgrowth  of  connective  tissue 
with  atrophy  of  the  epithelium  and  of  the  tubules,  and  dilatation  of 
some  of  the  tubes,  forming  cysts. 

Causes.  This  form  of  nephritis  follows  chronic  congestion  of  the 
kidney,  and  is  also  caused  by  alcohol,  lead,  gout,  syphilis,  malaria,  and 
by  chronic  endarteritis.  The  latter  condition,  as  well  as  cirrhosis  of 
the  liver  and  pulmonary  emphysema,  frequently  develops  hand-in-hand 
with  the  nephritis.  This  form  of  nephritis  is  notably  prevalent  in 
several  generations  of  different  families,  so  that  an  hereditary  history 
is  often  readily  obtained. 

Symptoms.  The  onset  of  the  disease  usually  occurs  late  in  life, 
although  well-defined  cases  may  occur  as  early  as  the  twenty-fifth 
year.  The  progress  at  first  is  very  insidious,  and  the  disease  may  have 
advanced  to  an  extreme  stage  without  the  occurrence  of  a  single  symp- 
tom. Death,  indeed,  may  be  due  to  other  causes  ;  or  a  person  in 
apparently  perfect  health  may  suddenly  manifest  symptoms  of  uraemia, 
or  may  develop  apoplexy  or  some  other  usual  accompaniment  of  inter- 
stitial nephritis. 

The  urine  is  increased  in  amount,  clear  in  color,  and  of  low  specific 
gravity.  The  albumin  is  small  in  amount,  or  may  be  absent.  Repeated 
examinations  extending  over  a  considerable  period  of  time  may  dis- 
close its  presence.  Hyaline  casts  are  present  in  small  numbers.  In 
some  cases  it  may  be  necessary  to  examine  a  dozen  or  fifteen  slides 
before  they  are  found.  Sometimes  there  are  a  few  red  blood-cells. 
Rarely  the  urine  is  bloody  at  irregular  periods  in  the  course  of  the 
disease,  or  actual  haernaturia  may  take  place.  With  the  exception  of 
the  state  of  the  urine,  the  only  symptom  present  may  be  the  loss  of 
flesh  and  strength.  At  the  same  time  the  skin  becomes  dry  and  harsh. 
CEdema,  however,  is  not  usually  present  unless  there  is  dilatation  of 
the  heart.  Special  symptoms  are  due  to  uraemia,  to  changes  in  the 
heart  and  arteries,  and  to  neuroretinitis. 

The  Heart.  The  left  ventricle  hypertrophies.  The  aortic  second 
sound  is  accentuated.  The  pulse  is  of  high  tension.  The  arteries 
become  more  prominent,  and  present  all  the  signs  of  endarteritis.     In 


DISEASES  OF  THE  KIDNEYS.  965 

the  later  stages,  as  nutrition  fails,  dilatation  of  the  heart  takes  place, 
with  regurgitation  at  the  mitral  valve,  and  the  development  of  a  train 
of  symptoms  due  to  these  changes.  Among  others  we  find  general 
malaise,  palpitation  of  the  heart,  dyspnoea,  oedema,  and  visceral  conges- 
tions. 

Urcemic  Symptoms.  These  symptoms  may  occur  at  any  time  in  the 
course  of  the  disease.  Headache  is  most  common  and  constant.  It 
may  occur  early  in  the  morning  only,  or  continue  throughout  the  day. 
It  may  be  continuous  and  cause  sleeplessness.  General  neuralgic  pains 
may  be  present  instead  of  severe  headache.  Muscular  twitchings  or 
general  convulsions  may  be  other  pronounced  symptoms,  or,  instead, 
delirium,  mild  or  violent,  stupor,  and  coma  may  come  on.  These 
symptoms  occur  suddenly  or  develop  very  gradually.  In  acute  uraemia 
with  the  above-mentioned  cerebral  symptoms  there  is  peripheral  spasm 
of  the  arteries,  causing  high  arterial  tension,  and  there  is  elevation  of 
the  temperature.  The  fever  may  rise  to  103°  or  104°,  but  is  usually 
about  102°,  and  is  irregularly  continuous.  After  the  patient  lapses 
into  deep  coma,  if  the  attack  is  fatal,  the  tension  of  the  pulse  is  lost, 
and  it  is  increased  in  frequency  and  diminished  in  strength.  In  chronic 
uraemia  the  cerebral  symptoms  develop  gradually.  The  temperature  is 
likely  to  be  subnormal,  particularly  if  diarrhoea  or  other  debilitating 
influence  is  coincident.     The  pulse  is  rapid  and  feeble. 

Pulmonary  symptoms  due  to  uraemia  are  quite  common.  They  may 
be  the  first  expression  of  uraemia.  This  is  seen  in  all  forms  of  nephritis. 
The  most  marked  symptom,  is  dyspnoea,  which  is  spasmodic  and  of 
short  duration.  The  attacks  may  occur  frequently,  and  are  usually 
increased  by  exertion  and  aggravated  by  a  recumbent  posture.  The 
shortness  of  breath  may  occur  in  the  early  morning  hours,  or  may  con- 
tinue throughout  the  day. 

Pulmonary  symptoms,  other  than  those  of  uraemia,  may  be  due  to  an 
intercurrent  bronchitis,  pneumonia,  or  pleurisy.  Chronic  bronchitis  or 
oedema  of  the  lungs  may  be  present,  on  account  of  dilatation  of  the  right 
heart.  The  chief  pulmonary  symptoms  that  point  to  these  conditions 
are  dyspnoea  and  cough. 

Spasmodic  dyspnoea  is  the  first  and  sometimes  the  only  symptom  for 
a  long  time.  Later  the  renal  symptoms  become  pronounced,  pointing 
to  the  true  nature  of  the  disease. 

Gastro-intestinal  Symptoms.  Catarrhal  gastritis  almost  always  com- 
plicates nephritis.  In  addition,  gastric  symptoms  due  to  uraemia,  and 
hence  to  oleficient  action  of  the  kidney,  ensue.  The  most  common  is 
the  occurrence  of  morning  nausea  or  of  morning  vomiting ;  the  occur- 
rence of  spasmodic  vomiting  at  irregular  periods,  or  the  occurrence  of 
violent,  acute  vomiting,  which  is  followed  in  two  or  three  days  by  other 
symptoms  of  uraemia.  The  patients  are  usually  constipated.  When 
the  disease  is  complicated  with  cirrhosis  of  the  liver,  intestinal  catarrh 
is  common,  and  intestinal  ulceration  with  conseojuent  diarrhoea  is  fre- 
quently found.  The  onset  of  uraemia  may  be  characterized  by  violent 
and  profuse  serous  purging,  which  of  itself  may  cause  collapse  and  death. 

Neuroretinitis  is  a  freopient  complication  of  nephritis,  and  may 
advance  more  rapidly  than   other  complications,  so  that  dimness  of 


966  SPECIAL  DIAGNOSIS. 

vision,  blindness,  or  other  eye-symptoms  may  cause  the  patient  to 
consult  an  oculist  before  attention  is  called  to  the  condition  of  the 
kidneys.  The  occurrence  of  this  complication  points  at  once  to  the 
necessity  of  an  examination  of  the  urine. 

It  is  common,  in  the  course  of  an  interstitial  nephritis,  to  have  acci- 
dents due  to  the  condition  of  the  arteries  that  accompanies  this  disease. 
On  account  of  the  atheroma,  aided  by  the  hypertrophied  heart,  rupture 
of  the  vessels  frequently  takes  place.  Apoplexy  is,  therefore,  of  com- 
mon occurrence,  and  hemorrhage  into  other  organs  sometimes  occurs. 

The  renal  disease  is  often  not  suspected  until  after  the  patient  has 
had  an  attack  of  apoplexy.  The  course  of  this  form  of  nephritis  is 
varied  very  much  by  the  occurrence  of  complications,  notably  em- 
physema, endocarditis,  or  cirrhosis  of  the  liver. 

Catarrhs.  There  is  always  a  tendency  to  chronic  inflammations  of 
the  mucous  membranes,  and  to  acute  inflammations  of  serous  mem- 
branes in  the  course  of  chronic  diffuse  nephritis.  It  is  necessary, 
therefore,  when  local  inflammations  of  this  character  are  present,  to 
make  thorough  and  repeated  examinations  of  the  urine,  especially  in 
a  patient  over  forty  years  of  age,  with  a  history  of  one  of  the  causal 
factors  previously  mentioned. 

Course  of  the  Disease.  Several  clinical  forms  of  interstitial  nephritis 
are  observed.  In  the  latent  form  the  disease  may  have  advanced  to 
an  extreme  degree  without  any  symptoms  of  renal  disease  during  life, 
death  taking  place  from  an  intercurrent  disease  or  accident.  On  the 
other  hand,  palpitation  of  the  heart  may  be  the  only  symptom  com- 
plained of,  and  the  observer  finds  a  hard  pulse,  general  atheroma,  and 
hypertrophy  of  the  left  ventricle  with  accentuation  of  the  second  sound. 
Apart  from  this  the  patient  may  enjoy  very  good  health.  The  danger 
lies  in  the  occurrence  of  pneumonia  or  inflammation  of  a  serous  mem- 
brane. Often  the  local  inflammatory  symptoms  are  slight  or  masked 
by  the  symptoms  of  renal  disease,  which  develop  rapidly. 

In  another  group  of  cases  some  special  symptom  only  may  be  com- 
plained of.  In  some  instances  it  may  be  gastric  catarrh,  in  some  eye- 
symptoms  alone  may  be  present,  while  in  others  hemicrania  or  other 
forms  of  headache  are  observed.  With  the  headache  there  is  usually 
vomiting.  Again,  we  may  have  constant  neuralgia  or  persistent  muscu- 
lar rheumatism  as  the  only  symptom.  Xose-bleed  is  a  symptom  which 
may  be  the  only  indication  of  chronic  nephritis,  particularly  if  the 
epistaxis  occurs  frequently. 

In  other  cases  the  course  is  not  latent,  but  characterized  by  a  series 
of  attacks  at  varying  intervals. 

During  the  attacks  the  symptoms  resemble  the  acute  form  of  neph- 
ritis, with  acute  urasmia,  the  occurrence  of  dyspnoea  and  loss  of  appetite, 
nausea  and  vomiting.  The  tension  of  the  arteries  is  higher  at  the 
time  of  the  attacks.  The  urine  contains  albumin,  and  is  of  low  specific 
gravity  during  the  time  of  the  attack  ;  during  the  interval  the  albumin 
is  found  at  irregular  times. 

Suppurative  Xepheitis  (Abscess  of  Kidney).  Infectious  matter 
is  conveyed  to  the  kidney  either  through  the  blood,  as  in  pyaemia  and 
ulcerative  endocarditis  (rarely  dysentery  and  actinomycosis),  or  by  the 


DISEASES  OF  THE  KIDNEYS.  967 

ureters,  as  when  it  follows  pyelitis  or  cystitis.  A  wound  may  infect  the 
kidney  directly. 

Symptoms.  The  symptoms  are  those  of  primary  disease,  and  the 
affection  is  usually  only  recognized  post-mortem.  Or  the  symptoms 
are  merely  those  of  suppuration.  Pus  is  seen  in  the  urine  only  on 
rupture  of  the  abscess  into  the  pelvis  of  the  kidney. 

Tubercular  Nephritis.  Fever,  emaciation,  anaemia,  and  pros- 
tration characterize  the  course  of  the  disease.  Tuberculosis  is  usually 
found  elsewhere.  There  may  be  no  other  symptoms.  Sometimes 
hydronephrosis  is  present.  A  tumor  is  often  present.  It  may  be  in 
the  loins,  or  may  be  in  front,  above,  and  a  few  inches  to  the  right 
or  left  of  the  umbilicus.  The  urine  is  normal  or  contains  pus  and 
detritus  or  even  bacilli.  The  finding  of  the  latter  is  necessary  often 
to  establish  a  diagnosis.  In  all  instances  of  pyuria  renal  tuberculosis 
should  be  suspected.  Catheterization  of  the  ureters  may  disclose  the 
organ  affected.  The  urine  should  then  be  centrifugal] zed  and  the 
sediment  examined  for  bacilli,  and,  as  Reynolds  points  out,  a  portion 
inoculated  in  guinea-pigs.  The  tuberculin  test  may  be  employed. 
The  testicles  and  bladder  should  be  carefully  examined  for  primary 
tuberculosis. 

Tuberculosis  of  the  kidney  presents  symptoms  like  those  of  pyelitis, 
renal  calculus,  or  a  new  growth.  It  is  almost  impossible  to  distinguish 
any  one  of  the  four  until  an  interval  has  elapsed.  In  all  cases  the 
patient  suffers  from  dull  pain,  sometimes  with  a  bearing-down  sensa- 
tion. Hsematuria  occurs,  and  the  patient  is  liable  to  attacks  of  renal 
colic.  These  symptoms  may  continue  until  a  tumor  can  be  made  out. 
Even  before  this  pain  will  be  elicited  on  palpation,  which  may  extend 
all  along  the  urinary  tract.  With  the  occurrence  of  the  tumor  the 
general  symptoms  of  tuberculosis  arise.  Further  diagnosis  is  based 
upon  the  results  of  the  urinary  examination. 

The  Degenerations. 

Degeneration  may  be  either  acute  or  chronic.  The  process  is  always 
secondary,  due  to  the  action  of  inorganic  poisons,  as  arsenic  or  phos- 
phorus, or  the  poison  of  infectious  disease,  or  is  produced  as  the  effect 
of  chronic  disease  of  the  organs,  or  by  disturbance  of  the  circulation. 

In  acute  degeneration  of  the  kidneys  the  urine  is  unchanged,  or  its 
quantity  is  diminished.  It  contains  a  little  albumin,  or  the  albumin  is 
present  in  large  amount,  with  casts  and  blood-corpuscles. 

There  may  be  no  symptoms  except  changes  in  the  urine,  or  symptoms 
of  uraemia  may  develop  at  once.  Dropsy  and  hypertrophy  of  the  heart 
do  not  occur. 

Chronic  degenerations  in  the  kidneys  follow  chronic  congestion,  or 
are  produced  by  alcoholism  or  syphilis.  They  occur  in  the  course  of 
pulmonary  phthisis,  and  of  chronic  suppuration  ;  they  may  develop  in 
the  course  of  gout  or  malarial  cachexia.  Symptoms:  In  the  simpler 
forms  there  may  be  no  clinical  symptoms  whatsoever.  In  others 
there  is  loss  of  flesh  and  strength,  the  development  of  anaemia,  and,  in 
rare  instances,  the  development  of  the  typhoid  state. 


968  SPECIAL  DIAGNOSIS. 

The  changes  in  the  urine  vary.  It  may  be  abundant,  scanty,  or 
suppressed.  The  specific  gravity  is  not  changed,  but  albumin  and 
casts  are  found. 

Amyloid  degeneration  of  the  kidney  is  associated  with  similar  degen- 
eration in  other  organs.  It  occurs  in  the  course  of  phthisis,  of  chronic 
suppurations,  of  syphilis,  of  chronic  dysentery,  and  is  thought  to  occur 
hi  the  malarial  cachexia,  or  with  gout.  Symptoms  :  The  degeneration 
may  be  present  without  clinical  symptoms.  If  symptoms  arise,  they 
are  due  to  the  anaemia  and  cachexia  that  attend  the  primary  disease, 
and  to  the  involvement  of  the  other  organs  in  the  same  process,  as  the 
liver,  spleen,  and  intestines.  Purely  says  dyspepsia  is  prominent  and 
diarrhoea!  attacks  are  common.  The  liver  and  spleen  become  enlarged 
during  the  course  of  the  disease  in  the  majority  of  cases.  QEdema  may 
be  present,  although  it  is  more  frequently  absent.  Ureemia  is  of  rare 
occurrence.  In  the  uncomplicated  degenerations  there  is  no  hypertrophy 
of  the  left  ventricle,  and  albuminuric  retinitis  is  a  rare  complication. 

The  Urine.  It  may  be  diminished,  normal,  or  increased,  usually  the 
latter ;  it  varies  from  time  to  time  in  the  same  case,  depending  upon 
complicating  symptoms,  as  diarrhoea,  which  causes  diminished  amount 
of  urine.  It  is  usually  very  pale.  The  specific  gravity  is  not  constant. 
It  ranges  from  1008  to  1014.  Albumin  is  constantly  present,  and  usu- 
ally in  considerable  amount.  Hyaline  casts  and  white  blood-cells  are 
always  found.  When  other  casts  are  present  nephritis  probably  com- 
plicates the  condition.  The  chief  distinctive  feature  of  the  casts  is  their 
large  size  and  hyaline  character. 

The  diagnosis  of  amyloid  disease  is  based  upon  the  presence  of  the 
cause  ;  changes  in  the  urine  ;  and  signs  of  similar  disease  in  other  organs. 


CHAPTEK    VIII. 

DISEASES   OF   THE   NERVOUS   SYSTEM. 

The  Data  Obtained  by  Inquiry. 

The  Social  History.  This  includes  a  knowledge  of  the  patient's 
occupation,  whether  he  or  she  is  married  or  not,  the  conditions  under 
which  he  may  live,  as,  for  example,  in  cases  of  great  wealth,  there  is 
perhaps  more  tendency  or  at  least  more  opportunity  to  dissipation  ;  in 
conditions  of  poverty  the  patient  may  have  been  insufficiently  nourished, 
or  have  suffered  from  continual  anxiety.  The  most  important  factor  is 
probably  the  occupation.  Occupations,  from  a  clinical  stand-point,  may 
be  divided  into  those  that  require  mental  exertion,  those  that  require 
physical  exertion,  and  those  that  expose  the  workmen  to  the  possibility 
of  Various  forms  of  intoxication. 

The  Family  History.  This  is  perhaps  of  more  importance  in 
connection  with  nervous  diseases  than  in  connection  with  those  of  any 
other  system.  By  neurotic  heredity  we  mean  the  fact  that  in  certain 
families  a  tendency  to  the  development  of  various  forms  of  nervous 
disease  exists,  which  may  be  manifested,  however,  only  in  certain  mem- 
bers of  a  given  generation.  Various  terms  are  employed,  to  indicate 
the  nature  of  the  inheritance.  Direct  inheritance  means  that  the  child 
suffers  from  exactly  the  same  disease  as  its  parent.  If  both  parents 
have  the  same  disease,  the  child  is  likely  to  have  it  more  severely,  and 
this  is  spoken  of  as  cumulative  inheritance.  By  indirect  inheritance  is 
meant  the  condition  in  which  collateral  ancestry  and  not  the  parents 
have  had  the  disease.  Both  the  parents  of  the  child  may  appear  to  be 
healthy,  and  the  grandparents  have  suffered  from  the  same  disease,  and 
this  is  called  atavistic  inheritance.  By  similar  inheritance  is  meant  the 
occurrence  in  the  offspring  of  a  disease  similar  to  that  from  which  the 
parents  have  suffered.  Examples  of  such  diseases  are  Huntington's 
chorea,  Goldflam's  periodic  paralysis,  etc.  By  dissimilar  inheritance  is 
meant  the  development  in  the  offspring  of  a  form  of  nervous  disease 
differing  from  that  which  existed  in  the  parents,  as  an  epileptic  child 
born  of  parents  suffering  from  neurasthenia,  hysteria,  or  insanity.  The 
indications  of  neurotic  heredity  are  manifold.  Inquiries  must  be  made 
in  regard  to  cases  of  insanity,  to  cases  of  epilepsy,  to  instances  of  suicide, 
to  peculiarities  of  character,  to  criminal  tendencies,  to  addiction  to  the 
use  of  drugs,  such  as  alcohol  or  opium  ;  to  congenital  deformities,  or  to 
congenital  diseases,  such  as  deaf-mutism,  etc.  Charcot  has  called  atten- 
tion to  the  fact  that  certain  of  the  so-called  rheumatic  manifestations 
may  occur  in  the  antecedents  of  a  patient  suffering  from  nervous  disease. 

The  History  of  Previous  Diseases.  This  is  of  considerable  im- 
portance.   The  infectious  diseases  are  sometimes  followed  by  peripheral 


970  SPECIAL  DIAGNOSIS. 

neuritis  or  lesions  in  the  central  nervous  system,  or  they  may  produce 
an  early  tendency  to  arterio-sclerosis.  It  is  of  importance  to  know 
whether  the  foetal  existence  of  the  patient  was  normal,  and,  if  possible, 
to  obtain  data  concerning  the  condition  of  the  mother  during  this  period. 
Inquiry  should  be  made  regarding  the  nature  of  the  birth  ;  the  existence 
of  infantile  spasms,  at  what  age  they  occurred,  when  they  ceased,  if  at 
all,  and  if  there  was  any  suspected  reason  for  their  development.  It 
should  be  noted  when  the  child  first  walked,  when  it  first  was  able  to 
talk,  the  rapidity  of  its  intellectual  development  and  progress  at  school, 
whether  the  character  was  normal,  if  there  were  night  terrors  or  noc- 
turnal enuresis.  In  boys  the  physician  should  endeavor  to  discover  if 
there  is  any  history  of  severe  injury,  particularly  to  the  head,  whether 
the  boy  had  the  opportunity  for  free  exercise  or  was  restricted  in  this 
respect ;  if  his  habits  were  good ;  if  he  smoked  early ;  if  he  was  over- 
worked at  school  or  obliged  to  work  hard  during  early  adolescence. 
In  the  case  of  females  the  physician  should  inquire  at  what  period 
puberty  occurred,  and  whether  there  has  been  any  difficulty  with  men- 
struation. The  existence  of  luetic  infection  is  often  difficult  to  eluci- 
date. Occasionally  it  will  be  admitted,  but  more  frequently  it  is  neces- 
sary to  discover  the  fact  by  indirect  questioning. 

The  History  of  the  Disease  Itself.  As  in  other  conditions, 
the  patient  should  be  questioned  regarding  the  duration  of  the  disease, 
its  earliest  manifestations,  whether  exacerbations  and  remissions  have 
occurred,  and  the  nature  of  its  course.  It  is  important  to  inquire  for 
slight  symptoms  that  are  usually  overlooked  by  the  patient,  such  as 
the  ocular  disturbances,  ptosis,  paralysis  of  the  external  rectus  in  loco- 
motor ataxia,  a  tendency  to  extravagance  in  paresis,  the  manifestations' 
of  nocturnal  epilepsy,  etc. 

The  Subjective  Symptoms.  The  data  obtained  by  inquiry  in- 
clude the  subjective  sensations  of  the  patient.  These  are  chiefly  of 
two  kinds — pain  and  paresthesia.  In  addition,  the  patients  sometimes 
complain  of  a  general  feeling  of  restlessness,  of  irritability,  of  inability 
to  think  consecutively,  or  various  other  forms  of  indefinite  general  and 
intellectual  disturbance.  Pain  is,  however,  such  an  important  symptom 
in  general  disease  that  it  has  been  discussed  in  the  section  upon  Gen- 
eral Diagnosis. 

Paresthesia  may  be  defined  as  subjective  sensations,  either  resem- 
bling those  normally  occurring  as  a  result  of  excessive  stimulation  of 
the  sensory  nerves,  or  of  a  peculiar  nature.  They  are  exceedingly 
various  in  their  character,  and  may  be  sharply  localized  or  indefinitely 
distributed.  To  them  belong  chiefly  itching,  tingling,  formication, 
numbness,  subjective  sensation  of  heat  or  of  cold,  of  moisture,  of 
pressure,  or  of  tearing  or  rending.  Sometimes  the  paresthesia?  are 
very  slight  in  character,  and  may  escape  the  notice  of  the  patient  until 
his  attention  has  been  directed  to  them  ;  in  some  cases  they  become  so 
severe  as  to  cause  intense  suffering  and  temporary  helplessness.  They 
usually  indicate  some  functional  or  organic  disturbance  of  a  nerve- 
trunk,  and  are,  therefore,  as  a  rule,  limited  to  the  distribution  of  some 
particular  nerve.  The  functional  forms,  however,  may  be  produced 
by  external  conditions,  such  as  pressure  upon  the  bloodvessels  leading 


DISEASES  OF  THE  NERVOUS  SYSTEM.  971 

to  a  local  anaemia,  exposure  to  cold,  to  heat,  and  the  like.  A  peculiar 
type  of  this  condition  is  known  as  rneralgia  paraesthetica,  and  is  char- 
acterized by  paresthesias  in  the  distribution  of  the  external  cutaneous 
nerve  of  the  thigh.  In  this  disease,  and  occasionally  in  other  forms  of 
paresthesia,  the  subjective  symptoms  are  associated  with  objective 
disturbances  of  sensation. 

The  Data  Obtained  by  Observation. 

These  include  nearly  all  the  important  symptoms  of  nervous  disease, 
and  are,  therefore,  of  paramount  importance.  They  are  disturbance  of 
sensation,  of  motion,  of  reflex  actiou,  of  appearance  and  of  contour, 
disturbances  of  the  special  senses,  of  the  functional  activity  of  the 
various  organs  of  the  body,  and  alteration  of  the  condition  of  nutrition. 

Sensation.  New  varieties  of  sensation  appear  to  be  discovered  every 
year,  and  it  is  therefore  tedious  and  sometimes  impossible  to  analyze  all 
that  have  been  already  described.  Sensations  may  be  described  as  those 
which  are  relatively  simple — that  is,  involving  but  a  single  variety  of 
perception,  and  those  that  are  complex. 

Simple  Sensations.  Tactile  sensation,  or  the  sense  of  touch,  is 
usually  spoken  of  as  aesthesia.  It  is  the  ability  to  know  when  some 
external  object  has  come  in  contact  with  the  skin.  Hypercesthesia  is  an 
increased  sensitiveness  to  contact ;  and  hypcesthesia,  decreased  sensitive- 
ness ;  ancesthesia,  total  loss  of  the  ability  to  perceive  objects  touching 
the  skim  No  satisfactory  instrument  for  the  measurement  of  the  touch 
sense  has  as  yet  been  devised.  In  general,  it  may  be  tested  either 
directly  with  the  end  of  some  hard,  blunt  object,  or,  when  still  acute, 
with  a  camel's-hair  brush  or  cotton  point.  The  patient  should  close 
his  eyes,  or,  what  is  better,  permit  them  to  be  bandaged,  and  should 
then  be  instructed  to  indicate  by  some  word  or  motion  the  moment 
contact  takes  place.  The  investigator  must  be  careful  not  to  use  force, 
and  the  instrument  employed  should  not  be  so  sharp  nor  so  rough  as  to 
produce  pain.  From  time  to  time  the  patient  should  be  asked  whether 
he  were  touched  when  contact  has  not  been  made,  although  some  move- 
ment indicating  the  approach  of  the  instrument  to  the  skin  has  been 
performed.  Frequently  in  prolonged  examinations  the  attention  becomes 
fatigued,  and  the  patient  no  longer  recognizes  whether  he  is  touched 
or  not,  and  answers  at  random.  Hypercesthesia,  may  occur  in  a  variety 
of  conditions.  Its  most  common  cause  is  functional  exaltation  or  irri- 
tability of  the  nerves,  which  may  occur  in  neuralgia  or  neuritis.  It  also 
occurs  in  organic  disease  of  the  cord,  and  is  then  limited  to  the  area  of 
distribution  of  the  spinal  segment  just  above  the  destructive  lesion. 
This  is  spoken  of  as  the  zone  of  hyperesthesia.  It  is  also  occasionally 
present  in  functional  conditions,  such  as  neurasthenia  and  hysteria,  and 
may  be  merely  the  result  of  some  local  irritation  of  the  skin.  The 
degree  of  tactile  perception  varies  considerably  in  different  persons. 
Hypcesthesia  may  occur  in  a  variety  of  conditions — in  neuralgia,  in 
partial  lesions  of  the  spinal  cord,  particularly  disease  of  the  posterior 
columns,  and  rarely  in  central  lesions  of  various  kinds,  particularly 
those  occurring  in  the  parietal  lobe,  in  the  end  of  the  posterior  limb  of 


972  SPECIAL  DIAGNOSIS. 

the  internal  capsule,  and  in  the  pons.  It  also  occurs  in  functional 
nervous  conditions,  and  is  quite  common  among  the  insane.  Anaes- 
thesia results  from  solutions  of  continuity  of  the  sensory  nerves,  from 
destructive  lesions  of  the  cord,  or  from  central  lesions.  It  is  also  the 
commonest  form  of  hvsterical  stiorua.  Organic  anaesthesia  mav  be  dis- 
tinguished  from  functional  anaesthesia  by  its  distribution.  If  caused 
by  nerve  injury,  it  will  exist  in  the  region  supplied  by  that  particular 
nerve.  If  caused  by  disease  of  the  spinal  cord,  the  area  of  anaesthesia 
will  be  segmental  in  type — that  is,  bounded  by  two  nearly  horizontal 
lines  passing  about  the  body.  In  unilateral  lesions  of  the  spinal  cord 
the  anaesthesia  is  limited  to  the  opposite  side  of  the  body.  In  central 
disease  the  anaesthesia  is  commonly  unilateral,  and  corresponds  to  the 
paralyzed  side,  if  paralysis  is  present.  If  due  to  a  lesion  of  the  cortex, 
however,  it  may  be  limited  to  one  extremity,  where  it  is  usually  asso- 
ciated with  paralysis. 

Pain  sense,  or  algesia,  is  the  ability  to  perceive  pain  of  any  kind. 
Various  instruments  have  been  devised  for  testing  its  intensity. 
Among  the  best  is  that  suggested  by  Ivulbin,  consisting  of  a  needle 
which  is  thrust  into  the  skin  for  varying  distances  ;  the  amount  of  press- 
ure required  and  the  degree  of  penetration  being  indicated  on  a  scale. 
Even  this,  however,  is  far  from  accurate,  and  for  clinical  purposes  it 
is  sufficient  to  use  a  needle  or  pinch  a  small  fold  of  skin  between  the 
finger-nails.  In  case  of  very  pronounced  disturbance  of  the  pain-sense 
it  is  sometimes  possible  to  use  the  actual  cautery  or  to  thrust  a  needle 
entirely  through  a  thick  fold  of  the  skin.  A  faradic  current  is  also 
frequently  employed,  and  to  a  certain  extent  is  accurate,  if  data  can  be 
obtained  by  comparing  the  healthy  with  the  diseased  side  of  the  body. 
As,  however,  it  appears  that  there  is  a  special  form  of  sensation  for  the 
induced  current,  its  results  cannot  be  relied  upon  implicitly.  Hyper- 
algesia is  increased  susceptibility  to  painful  impressions,  so  that  the 
lightest  contact  may  cause  exquisite  agony.  It  occurs  in  inflammation 
and  in  those  conditions  associated  with  hyperesthesia.  A  variety  of 
hyperalgesia  is  tenderness — that  is,  pain  elicited  by  simple  pressure. 
It  is  most  frequently  associated  with  local  inflammation,  and  occurs 
along  the  course  of  the  nerves  in  neuritis  and  neuralgia.  Hypalgesia, 
or  decreased  susceptibility  of  pain,  occurs  as  a  result  of  partial  lesion 
of  the  nerves,  or  of  the  central  portion  of  the  spinal  cord,  and,  occa- 
sionally, as  a  result  of  focal  lesions  in  the  brain.  It  is  also  very  com- 
mon among  idiots,  immediately  after  epileptic  attacks,  and  in  cases  of 
hysteria.  Hypalgesia  may  also  be  acquired  as  a  result  of  constant 
exposure  to  a  mild  form  of  irritation,  as,  for  example,  in  those  accus- 
tomed to  going  bare-footed.  Analgesia  is  an  exceedingly  important 
symptom.  It  results  from  total  destruction  of  the  nerve  ;  from  disease 
of  the  central  gray  matter  of  the  spinal  cord,  such  as  occurs  in  trans- 
verse myelitis,  syringomyelia  ;  in  tumors  of  the  cord ;  and  from  focal 
disease  of  the  brain,  particularly  if  situated  in  the  parietal  lobe,  and 
the  posterior  limb  of  the  internal  capsule.  It  also  occurs  in  a  great 
variety  of  functional  conditions,  and  may  be  general  in  the  form  of 
insanity  known  as  primary  stupor.  It  is  a  very  common  lesion  in 
hysteria,  and  in  this  disease  the  area  of  distribution  mav  assume  the 


DISEASES  OF  THE  NERVOUS  SYSTEM.  973 

most  curious  forms,  being  limited  to  one-half  of  the  body,  or  tracing 
geometrical  figures  on  various  parts  of  the  skin.  It  may  also  be  pro- 
duced by  hypnotic  suggestion.  Organic  analgesia  is  frequently  associ- 
ated with  trophic  changes,  either  as  a  result  of  the  inability  of  the  part 
to  defend  itself  against  irritation,  or  as  a  result  of  the  intimate  associa- 
tion of  the  sensory  and  trophic  nerve-fibres. 

Visceral  pain  may  be  elicited  by  strung  pressure  upon  the  testicles, 
ovaries,  or  breasts,  or  a  violent  blow  upon  the  abdomen.  It  is  usually 
characterized  by  intense  prostration  and  nausea.  Visceral  analgesia 
occurs  in  some  cases  of  locomotor  ataxia  and  occasionally  in  hysteria. 

The  heat  sense,  or  thermocesthesia,  enables  us  to  recognize  the  differ- 
ence in  temperature  between  various  bodies.  It  is  usually  tested  by 
filling  two  test-tubes,  one  with  hot  and  one  with  cold  water,  and  apply- 
ing them  in  irregular  alternation  to  the  region  under  investigation. 
The  difference  in  temperature  between  the  two  tubes  is  a  rough  test 
of  the  delicacy  of  the  sense.  In  health  a  difference  of  1°  C.  can  be 
recognized  upon  the  more  sensitive  portions  of  the  body  (the  ante- 
rior surface  of  the  forearms,  the  skin  of  the  face,  and  the  chest).  A 
rougher  test  is  the  use  of  metal  and  wooden  objects.  The  former  con- 
duct heat  more  rapidly  from  the  surface,  and  therefore  give  rise  to  a 
sensation  of  cold.  The  heat-sense  is  rather  complicated,  and  is  not  yet 
thoroughly  understood.  There  seem  to  be  special  points  upon  the  skin 
where  the  nerves  for  heat  and  cold  terminate.  (Goldscheider.)  There 
may  be  loss  of  perception  for  cold  objects,  while  the  perception  for  hot 
objects  remains  unimpaired,  or  the  reverse  may  be  present.  Sometimes 
the  patient  calls  all  objects  warm  and  at  other  times  he  calls  them  cold. 
Hyperthermocesthesia  is  practically  of  no  value  as  a  clinical  sign,  for  our 
methods  of  testing  the  delicacy  of  the  sense  are  at  present  imperfect, 
and  hypothermocesthesia  is  also  difficult  to  detect,  and  probably  belongs 
to  the  category  of  conditions  in  which  one  of  the  sensations  is  more  or 
less  impaired.  Thermoancesthesia,  or  complete  loss  of  the  heat-sense, 
is  very  important  clinically.  It  occurs  in  neuritis  or  destructive  lesions 
of  the  nerve,  and  in  central  disease  of  the  spinal  cord,  such  as  transverse 
or  pressure  myelitis,  tumor,  and  especially  in  syringomyelia.  As  a 
result  of  being  most  frequently  associated  with  cord  disease,  the  thermo- 
anaesthetic  area  is  usually  segmental.  The  heat-sense  may,  in  connection 
with  other  forms  of  sensation,  be  diminished  in  functional  nervous 
disease. 

The  above  three  forms  of  simple  sensation  are  those  usually  regarded 
as  of  the  greatest  clinical  importance.  They  may  be  equally  affected, 
or  one  or  two  may  be  preserved  and  the  others  diminished  or  lost. 
The  latter  condition  is  known  as  dissociation  of  sensation.  It  occurs 
in  neuritis,  but  is  exceedingly  rare.  It  also  occurs  in  various  forms  of 
myelitis,  particularly  pressure  myelitis.  It  is  the  most  characteristic 
symptom,  and  for  a  long  time  was  considered  pathognomonic  of  syringo- 
myelia. In  this  form  of  dissociation  tactile  sense  is  preserved,  and  the 
temperature  and  pain  senses  arc  lost.  When  the  tactile  sense  is  lost,  and 
the  pain  sense  still  present,  the  condition  is  termed  anaesthesia  dolorosa. 

Simple  sensations  of  perhaps  less  clinical  importance  than  the  fore- 
going are  trichocesthesia,  or  the  consciousness  that  a  cutaneous  hair  has 


974  SPECIAL  DIAGNOSIS. 

been  touched.  This  is  really  the  sensation  perceived  when  tactile  sense 
is  tested  with  the  cotton  point ;  the  latter  is  felt  very  well  upon  the 
forearm,  on  the  back  of  the  hand,  and  not  on  the  palm,  where  sen- 
sation is  distinctly  more  acute.  Von  Bechterew  calls  attention  particu- 
larly to  the  fact  that  trichosesthesia  and  tactile  sense  are  not  equally 
delicate  in  various  parts  of  the  body.  The  former  is  most  readily 
tested  by  touching  the  individual  hairs  with  a  small  needle  or  cotton 
point.  More  elaborate  apparatus  of  no  particular  value  has,  however, 
been  devised. 

The  Sensation  of  Locality.  When  any  part  of  the  surface  of  the  body 
is  touched  we  can,  under  normal  conditions,  tell  the  location  of  the 
point  of  contact.  This  varies,  however,  consideraoly  in  various  parts 
of  the  body,  being  more  accurate  on  the  lips  and  less  on  the  skin  of 
the  back  between  the  shoulder  blades,  where  an  error  of  from  6  cm. 
to  7  cm.  is  still  within  the  normal  limits.  It  may  be  very  much  dis- 
turbed without  any  loss  of  the  delicacy  of  the  touch  sense.  It  may  be 
tested  by  making  contact  with  the  finger  or  any  blunt  object.  Another 
method  formerly  much  used  by  clinicians,  and  still  employed  by  psy- 
chologists, is  the  use  of  the  cesthesiometer,  an  instrument  consisting 
essentially  of  two  points  that  can  be  placed  at  a  measured  distance 
from  each  other.  It  has  been  found  that  in  normal  persons  these  can 
be  detected  as  two  points  at  the  tip  of  the  tongue  when  separated  only 
1  mm. ;  but  may  still  be  felt  as  one  on  the  back  when  separated  as  much 
as  65  mm.  This  method  is  extremely  inaccurate,  for  the  reason  that 
it  is  difficult  to  apply  the  points  with  the  same  degree  of  force.  More- 
over, experiments  have  shown  that  the  skin  readily  becomes  educated 
and  able  to  discriminate  points  much  closer  together  than  is  normal 
for  the  part  that  is  being  tested. 

Allochiria.  This  is  a  general  term  applied  to  the  false  localization  of 
sensory  stimuli.  In  some  cases  the  sensation  may  be  felt  not  at  the 
point  where  it  was  applied,  but  at  exactly  the  corresponding  point  on 
the  opposite  side  of  the  body.  This  occurs  particularly  in  hysteria. 
In  organic  disease  of  the  spinal  cord  mistakes  of  localization  are  not 
uncommon — thus,  in  hypsesthesia  of  the  arm,  irritation  at  the  hand 
may  be  referred  to  the  shoulder,  and  the  same  is  true  of  the  lower 
extremity. 

When  there  exists  a  hypsesthesia  it  is  of  course  difficult  for  the 
patient  to  localize  as  accurately  as  is  possible  when  sensation  is  normal. 

The  Electro-cutaneous  Sense.  This  is  really  the  degree  of  resistance 
to  the  irritation  of  the  induced  current.  It  varies  considerably  in 
different  individuals,  and  in  the  same  individual  under  different  con- 
ditions and  in  different  parts  of  the  body.  It  is  perhaps  most  delicate 
on  the  skin  of  the  face,  and  least  delicate  on  the  back  and  the  outer 
surface  of  the  thighs.  It  is  curiously  affected  in  certain  nervous  dis- 
eases ;  thus,  in  the  periodic  paralysis  of  Goldflam  it  is  almost  completely 
abolished  during  the  attack.  In  meralgia  paraesthetica  it  is  also,  as  a 
rule,  greatly  diminished.  In  all  cases  of  muscular  degeneration  the 
electric  current  is  better  supported  than  Avhen  the  muscles  react.  It 
is  also  greatly  diminished  when  there  is  oedema  of  the  skin  or  much 
subcutaneous  fat.     It  sometimes  persists,  however,  when  tactile  an?es- 


DISEASES  OF  THE  NERVOUS  SYSTEM.  975 

thesia  is  present.  In  tetany  it  is  greatly  exaggerated  (Erb's  sign),  and 
this  constitutes  one  of  the  cardinal  symptoms  of  the  disease,  and  it  is 
also  increased  in  some  of  the  functional  nervous  conditions.  It  is  best 
tested  by  using  a  simple  faradic  battery,  employing  as  the  electrode 
for  contact  either  the  wire  brush  or  the  naked  wire.  No  satisfactory 
system  of  measurement  has  as  yet  been  devised,  but  it  is  of  advantage 
to  use  invariably  the  same  battery,  and  to  note  the  position  of  the  inner 
coil  with  reference  to  the  outer  one. 

Pressure  Sense.  The  clinical  significance  of  this  has  not  yet  been 
determined.  It  is  certain,  however,  that  it  undergoes  considerable 
variation  as  the  result  of  various  pathological  changes.  It  may  be 
tested  roughly  by  making  various  degrees  of  pressure  with  the  finger 
or  a  blunt  object  upon  the  surface  of  the  skin,  the  limb  being  so  placed 
that  it  is  impossible  for  the  patient  to  make  muscular  resistance.  It 
may  be  tested  more  accurately  by  using  a  series  of  little  blocks  that 
can  be  piled  one  on  top  of  the  other,  or  by  filling  a  vessel  more  or  less 
completely  with  shot  or  mercury. 

Functional  Modifications  of  the  Various  Forms  of  Sensa- 
tion. Delayed  Sensation.  The  perception  of  the  various  forms  of 
stimulation  that  are  appreciated  in  consciousness  as  sensations  may 
be  delayed  for  some  time  after  the  stimulus  has  been  applied.  This 
is  spoken  of  as  delayed  sensation,  and  the  interval  may,  in  extreme 
cases,  be  several  seconds.  It  is  not  known  where  this  delay  takes 
place,  whether  in  the  sensory  bodies  of  the  skin,  or  in  the  nerves,  or  in 
the  central  nervous  system.  This  symptom  is  manifested  particularly 
in  tabes  dorsalis,  but  may  occur  in  functional  nervous  disease  and  in 
various  forms  of  organic  central  disease.  It  has  also  been  noted  in 
peripheral  neuritis.  The  delay  can  occur  for  one  sensation  alone,  as 
the  pain  sense,  even  when  tactile  sense  is  normal. 

Complex  Sensations.  These  are  probably  very  numerous,  but 
only  two  have  been  so  carefully  studied  that  they  are  valuable  for 
clinical  purposes.  These  are  the  so-called  position  or  muscular  sense, 
and  the  stereognostic  sense.  By  the  position  or  muscular  sense  we  mean 
the  ability  to  perceive  and  recognize  the  position  of  the  limbs  or  of  the 
body — that  is,  whether,  for  example,  the  joints  are  in  a  state  of  flexion 
or  extension,  supination,  pronation,  or  rotation  ;  whether  the  spine  is 
bent  or  erect,  and  the  position  of  the  head  with  reference  to  the  trunk. 
It  probably  depends  upon  the  complex  co-ordination  of  the  perceptions 
received  from  the  muscles,  joints,  periosteum,  tendons,  and  skin.  It 
may  be  tested  in  a  variety  of  ways.  The  patient  should  be  instructed 
to  close  his  eyes  or  have  them  bandaged  ;  the  finger  is  carefully  grasped 
on  either  side  and  flexed  or  extended.  After  each  movement  the  patient 
indicates  its  direction.  After  the  fingers  have  been  tested  the  same 
process  is  employed  for  the  wrist,  elbow,  and  shoulder.  Similar  methods 
may  be  used  for  the  feet,  and  the  head  may  be  rotated  to  the  right  or 
the  left,  bent  forward,  laterally,  or  backward.  Another  method  is  to 
take  one  arm,  bend  it  into  some  particular  position,  and  instruct  the 
patient  to  imitate  the  position  with  the  other  arm  ;  the  same  thing  being 
done  with  the  legs ;  or  the  patient  may  be  instructed  to  describe  the 
position  in  which  his  arm  has  been  placed,  without  attempting  an  imi- 


976  SPECIAL  DIAGNOSIS. 

tation.  This  sense  is  lost  when  for  any  reason  there  is  total  anaesthesia 
of  the  part,  and  may  disappear  as  an  isolated  symptom  in  case  of  disease 
of  the  posterior  columns  or  in  the  ataxia  due  to  central  lesions.  By 
the  stereognostic  sense  we  mean  the  ability  to  recognize  the  shape, 
consistency,  surface,  and  nature  of  any  object  placed  in  the  hand  or 
brought  in  contact  with  the  skin  of  any  part  of  the  body.  This  sen- 
sation is  most  readily  tested  by  directing  the  patient  to  keep  the  eyes 
firmly  closed ;  then  to  select  a  number  of  small  objects,  such  as  a 
pencil,  match-safe,  coin,  key,  etc.,  and  place  them  in  his  hand  and 
direct  him  to  name  them  or  describe  them.  This  sense  depends  upon 
a  variety  of  perceptions.  The  size  of  the  object  is  recognized  by  a 
combination  of  the  locality  and  muscle  senses ;  the  nature  of  its  surface 
by  the  tactile  sense ;  its  consistency  chiefly  by  the  pressure  sense,  per- 
haps aided  by  the  pain-sense ;  its  nature — that  is,  whether  of  metal, 
wood,  or  any  other  substance — largely  by  the  temperature  sense.  The 
stereognostic  sense  is  always  abolished  when  tactile  sense  is  absent. 
Occasionally  in  hysteria  the  patient  may  declare  himself  unable  to 
perceive  touch  when  the  stereognostic  sense  is  intact,  but  this  is  an 
exception.  It  may,  however,  be  lost  when  tactile  sense  is  still  preserved, 
especially  if  the  locality  sense  and  the  muscle  sense  have  been  greatly 
impaired.  When  due  to  organic  causes  its  absence  usually  indicates  a 
lesion  in  the  parietal  lobe  or  in  the  projection  fibres  coming  from  this 
region.  It  occurs  frequently  in  hemiplegia,  in  cerebral  monoplegia, 
and  occasionally  in  peripheral  palsy,  involving  two  forms  of  sensation. 
It  has  also  been  observed  as  a  transient  symptom  after  brain  shock 
without  disturbance  of  any  other  sense. 

Disturbance  of  Motility.  These  may  be  grouped  under  a  number 
of  heads.  First,  loss  of  power,  which  may  be  either  partial,  paresis  ; 
or  complete,  paralysis.  Second,  impairment  of  movement,  inco-ordina- 
tion,  or  ataxia.  Third,  closely  allied  to  this,  tremor.  Fourth,  excessive 
muscular  movement,  spasm,  or  convulsions. 

Paralysis.  This  is  a  loss  of  power  in  the  muscles.  It  may  be 
true,  in  which  the  loss  of  power  is  due  to  some  disease  of  the  muscle 
itself  or  the  nervous  influence  controlling  it ;  or  false,  when  it  is  due 
merely  to  an  inhibition  of  the  muscnlar  function  produced  by  a  disease 
of  the  muscle  or  joint  that  causes  pain  upon  movement.  Paralysis  is 
classified,  according  to  the  part  affected,  into  monoplegia,  when  one 
extremity  is  involved ;  hemiplegia,  when  half  the  body  is  involved  ; 
paraplegia,  when  two  symmetrical  extremities  are  involved ;  para- 
plegia, cruralis,  if  the  legs  are  affected ;  paraplegia  brachialis,  if  the 
arms  are  affected  (this  term  is  usually  restricted  clinically  to  paralysis 
of  both  legs) ;  diplegia,  when  two  extremities  are  affected  without 
involvement  of  the  trunk.  Clinically,  this  is  sometimes  restricted, 
although  incorrectly,  to  paralysis  of  both  arms  {diplegia  brachialis)  or 
of  both  sides  of  the  face  {diplegia  facialis).  Grossed  paralysis  is  a  term 
applied  to  paralysis  of  one  side  of  the  face  and  the  opposite  side  of  the 
body.  Local  paralysis  is  the  term  used  when  only  small  groups  of 
muscles  are  affected.  Multiple  paralyses  is  employed  when  several 
parts  of  the  body  are  involved  at  the  same  time.  Paralysis  is  also 
classified,  according  to  the  cause,  into  cerebral  paralysis,  spinal  parol- 


DISEASES  OF  THE  NERVOUS  SYSTEM.  977 

ysis,  neural  paralysis,  and  muscular  or  myopathic  paralysis.  Paralysis 
is  also  classified,  according  to  the  type,  into  spastic  paralysis,  in  which 
the  muscle  tone  is  increased  and  the  reflexes  are  exaggerated,  and  con- 
tractures are  either  present  or  likely  to  ensue,  and  flaccid  paralysis,  in 
which  the  muscle  tone  is  diminished,  in  which  there  is  no  resistance  to 
passive  movement,  and  the  reflexes  are  abolished.  Spastic  paralysis  is 
usually  due  to  some  lesion  in  the  central  motor  neuron — that  is,  between 
the  motor  cortex  and  the  terminations  of  the  fibres  of  the  pyramidal 
tracts  in  the  anterior  cornua  of  the  spinal  cord.  The  lesion,  therefore, 
may  be  situated  in  the  cortex,  the  corona  radiata,  the  internal  capsule, 
the  pons,  the  pyramids  of  the  medulla,  and  the  lateral  columns  of  the 
cord.  Spastic  paralysis  must  not  be  confused  with  the  contractures 
that  ensue  after  degeneration  of  the  muscles,  as  in  infantile  palsy, 
neuritis,  etc.  In  these  cases  the  limbs  are  in  a  state  of  permanent 
flexion.  The  resistance  to  extension  and  to  passive  movement  is  not 
due  to  increased  muscular  tone,  but  to  an  actual  shortening  of  the 
muscle  and  its  tendons,  which  can  only  be  overcome  by  rupture  of  one 
or  the  other.  Flaccid  paralysis  may  be  produced  by  cerebral  lesions, 
but  is  more  commonly  due  to  lesions  of  the  peripheral  motor  neurons 
— that  is,  from  the  anterior  cornua  of  the  cord  to  the  muscle  itself. 
It  may,  therefore,  be  produced  by  destruction  of  the  ganglion  cells,  by 
injury  to  the  anterior  roots,  or  the  peripheral  nerves,  or  disease  of  the 
muscle.  Flaccid  paralysis  frequently  occurs  as  the  result  of  functional 
conditions — for  example,  it  is  the  type  of  paralysis  that  is  usually 
observed  in  hysteria.  As  the  trophic  centres  influencing  the  muscle 
are  either  cut  off  or  destroyed,  atrophy  of  the  latter  usually  takes  place 
{atrophic  paralysis),  which  is  characterized  by  decrease  in  bulk,  altera- 
tion of  the  electrical  reactions,  and  fibrillary  twitchings.  Monoplegia, 
or  paralysis  of  one  limb,  may  be  caused  by  small  lesions  in  the  cerebral 
cortex  or  the  corona  radiata.  It  is  rarely  produced  by  lesions  of  the 
internal  capsule,  where  the  fibres  are  placed  closely  together,  or  of 
the  spinal  cord,  unless  the  gray  matter  of  the  latter  is  involved.  It 
occurs  in  circumscribed  forms  of  infantile  paralysis,  in  lesions  of  the 
peripheral  nerves,  particularly  the  roots  of  the  plexuses,  but  rarely  in 
disease  of  the  muscles  alone,  the  lesions  in  this  case  being  more  widely 
distributed.  Monoplegia  also  occurs  in  hysteria  and  in  the  pseudo- 
paralysis due  to  localized  disease  of  the  muscles  or  joints.  Hemiplegia 
is  commonly  due  to  a  lesion  of  the  opposite  side  of  the  central  convolu- 
tions. This  lesion  may  either  be  extensive  and  destroy  the  motor  por- 
tion of  the  cortex  or  corona  radiata,  or  more  circumscribed,  involving 
the  internal  capsule,  the  crura,  the  pons,  or  the  medulla.  Spinal  lesions, 
also,  if  unilateral,  which  is  rare,  and  situated  above  the  fourth  cervical 
segment,  may  produce  paralysis  of  the  same  side  of  the  body.  ( Vide 
Brown-Sequard's  syndrome.)  In  hemiplegia  due  to  lesion  of  the  cere- 
brum, the  muscles  of  the  trunk,  and  those  supplied  by  the  upper 
branch  of  the  facial  nerve  commonly  escape.  The  lower  half  of  the 
face,  the  arm  and  leg,  and  the  side  of  the  body  opposite  the  affected 
hemisphere  are  paralyzed.  If  due  to  lesion  of  the  pons  below  the 
decussation  of  the  facial  fibres  —that  is,  in  the  posterior  half — the  arm 
and  leg  of  the  opposite  side  and  the  lower  half  of  the  face  on  the 

62 


978  SPECIAL  DIAGNOSIS. 

same  side  are  paralyzed  (crossed  paralysis,  pontine  palsy).  Lesions  of 
the  medulla  ordinarily,  in  addition  to  the  motor  tracts,  involve  other 
important  nuclei  and  tracts.  Spinal  hemiplegia  is  characterized  by 
the  absence  of  facial  involvement.  Hysterical  hemiplegia  can  only  be 
recognized  in  some  cases  by  the  discovery  of  the  other  stigmata  of  that 
disease.  The  form  of  paralysis  in  organic  hemiplegia  is  ordinarily 
spastic,  and  usually  in  the  course  of  time  pronounced  contractures 
occur.  Paraplegia  cruralis  is  usually  produced  by  a  lesion  of  the  spinal 
cord.  If  this  lesion  is  situated  above  the  lumbar  portion  of  the  cord, 
the  type  of  paralysis  is  spastic ;  if  in  the  lumbar  or  sacral  region,  or 
involving  the  cauda  equina,  there  is  often  abolition  of  the  reflexes  and 
flaccidity  of  some  of  the  muscles.  Paraplegia,  therefore,  occurs  in  trans- 
verse or  pressure  myelitis,  in  tumor  of  the  spinal  cord,  in  hemorrhage 
into  the  spinal  cord,  and  as  a  result  of  traumatism.  It  is  occasionally 
produced  by  multiple  neuritis  of  the  legs,  particularly  that  form  known 
as  Landry's  paralysis,  or  in  alcoholic  neuritis,  by  bilateral  cerebral 
lesions,  and  occasionally  as  a  functional  condition.  Paraplegia  brachi- 
alis  is  a  rare  condition  occurring  chiefly  as  the  result  of  a  localized 
meningitis  in  the  cervical  enlargement,  particularly  pachymeningitis 
hypertrophica  cervicalis.  As  the  result  of  the  destruction  of  the  ante- 
rior roots  there  is  atrophy  and  degeneration  of  the  muscles,  and  the 
paralysis  is  flaccid.  It  may  also  occur  in  syringomyelia,  and  more 
rarely  as  a  result  of  traumatic  injury  to  both  sides  of  the  brachial 
plexus.  Diplegia  facialis  is  almost  invariably  the  result  of  bilateral 
facial  palsy — that  is,  either  neuritis  or  an  injury  to  the  facial  nerve 
after  it  leaves  the  medulla.  The  paralysis  is,  therefore,  flaccid  in 
type,  characterized  by  the  loss  of  the  normal  folds,  and  the  inability  to 
close  the  eyes  and  drooping  of  the  corner  of  the  mouth. 

Multiple  palsies  are  usually  due  to  some  general  condition  affecting 
the  peripheral  neurons — thus,  in  multiple  infantile  palsy  the  anterior 
cornua  of  the  gray  matter  of  the  spinal  cord  are  involved  in  various 
situations.  The  paralysis  is  usually  flaccid  and  incomplete — that  is, 
certain  groups  of  muscles  escape.  In  polyneuritis  due  to  intoxication 
or  infection  there  may  be  paralysis  either  of  certain  groups  of  muscles, 
particularly  the  extensors,  or  of  the  entire  limb.  This  occurs  most 
frequently  in  poisoning  by  lead,  arsenic,  and  alcohol,  or  in  infectious 
diseases,  as  beri-beri  and  diphtheria.  The  paralysis  is  nearly  always 
flaccid ;  there  is  muscular  atrophy,  and  the  reactions  of  degeneration 
ultimately  appear.  Local  palsies  are  usually  due  also  to  lesions  of  the 
peripheral  neurons.  Occasionally,  however,  a  very  small  lesion  in  the 
cortex  will  produce  this  condition.  They  are  commonly  the  result  of 
some  trauma  injuring  a  single  nerve- trunk.  The  paralysis  is,  of  course, 
flaccid,  and  the  reactions  of  degeneration  are  present. 

A  congenital  absence  of  complete  atrophy  of  the  muscle  gives  rise 
to  myopathic  paralysis.  In  either  case  the  diagnosis  must  usually  be 
made  by  careful  anatomical  examination,  as  in  the  course  of  a  very 
short  time  the  patient  learns  to  compensate  the  defect  of  the  individual 
muscle  by  the  excessive  action  of  others  in  its  neighborhood.  The 
muscles  most  frequently  affected  by  congenital  absence  are  the  pec- 
torals, although  many  others  also  may  be  involved.     Total  atrophy 


DISEASES  OF  THE  NERVOUS  SYSTEM.  979 

occurs  in  various  myopathies,  but  with  extreme  slowness.  In  a  special 
type  of  muscular  atrophy  (type  of  Duchenne-Aran)  atrophy  occurs  in  in- 
dividual muscles  or  in  small  groups,  and  compensation  is  usually  acquired 
for  a  considerable  time  until  the  progress  of  the  disease  renders  it  no 
longer  possible. 

Paresis  is  a  term  used  to  indicate  partial  loss  of  power  in  the  volun- 
tary muscles.  In  addition  to  the  causes  given  for  paralysis,  it  may  be 
produced  by  exhaustion.  Paresis  is  of  two  kinds — that  in  which  the 
muscle  is  unable  to  exert  its  normal  force  at  any  time,  and  that  in 
which  the  muscle  may  exert  its  normal  force  for  a  brief  period  and 
then  rapidly  becomes  exhausted  and  insufficient.  In  the  former  there 
is  some  deformity,  such  as  foot-drop  or  wrist-drop.  In  the  latter  the 
symptoms  do  not  appear  until  some  effort  has  been  made.  Paresis 
may  also  be  temporary,  as  after  fatigue ;  stationary,  as  in  cases  of 
injury  to  the  central  nervous  system ;  or  progressive,  as  in  the  myop- 
athies. In  the  latter  condition  the  muscles  waste  and  lose  their 
power,  but  reactions  of  degeneration  do  not  occur,  and  there  are  no 
fibrillary  twitchings.  Ultimately,  the  condition  may  go  on  to  absolute 
paralysis.  The  power  of  the  muscle  may  be  tested  very  accurately  by 
means  of  the  dynamometer.  This  consists  of  a  steel  spring  with  a 
staff  on  one  side  and  a  sliding  index  on  the  other.  The  patient  com- 
presses the  spring  in  the  palm  of  the  hand,  and  the  amount  of  pressure 
is  indicated  in  pounds  or  kilogrammes  upon  the  index.  By  various 
mechanical  devices  the  dynamometer  may  also  be  employed  for  the 
other  muscles  of  the  body.  Care  should  be  taken  when  it  is  used  that 
the  patient  is  not  permitted  to  throw  his  weight  against  it.  In  using 
the  instrument  it  is  chiefly  important  to  regard  not  so  much  the  abso- 
lute power  as  the  difference  between  the  two  sides,  the  degree  of  mus- 
cular force  normally  present  varying  very  greatly  in  different  indi- 
viduals. Clinically,  it  is  often  sufficient  to  have  the  patient  squeeze 
the  physician's  hand  first  with  one  hand  and  then  with  the  other ;  even 
moderate  differences  being  readily  detected  by  this  means.  The  patient 
may  also  be  instructed  to  resist  passive  movements,  such  as  the  exten- 
sion of  the  flexed  arm ;  the  flexion  of  the  extended  arm ;  the  lateral 
movement  of  the  head  ;  the  opening  of  the  eyelids,  or  the  various 
movements  of  the  lower  extremities. 

Intermittent  claudication  is  a  term  applied  to  indicate  the  occurrence 
of  transient,  partial,  or  complete  paresis  or  lameness.  Sometimes  the 
patient  will  suddenly  be  unable  to  continue  locomotion,  and  fall  to  the 
ground ;  at  others,  one  limb  will  become  weak,  causing  a  m-onounced 
limp  and  necessitating  the  aid  of  a  crutch ;  while  in  other  instances 
there  is  simply  discomfort  upon  continued  locomotion.  This  symptom 
occurs  in  various  forms  of  functional  nervous  diseases ;  thus  the  peri- 
odic paralysis  of  Goldflam,  meralgia  paraesthetica,  and  as  an  idiopathic 
condition  in  diabetes  and  arterio-sclerosis. 

Disturbances  of  movement,  characterized  by  excessive  or  perverted 
muscular  activity,  consist  of  ataxia,  tremor,  and  spasm.  By  ataxia 
is  meant  the  inability  to  co-ordinate  perfectly — that  is,  to  give  each 
muscle  its  due  share  in  the  performance  of  any  action.  As  a  result 
the  movements  are  irregular  and  imperfect.     Various  types  of  ataxia 


980  SPECIAL  DIAGNOSIS. 

have  been  distinguished  :  Spinal  ataxia,  in  which  the  disturbances  of 
motion  are  more  pronounced  when  the  eyes  are  closed,  and  which  is  due 
to  disease  of  the  posterior  columns ;  cerebellar  ataxia,  in  which  the  dis- 
turbances are  equally  severe  when  the  eyes  are  opened  or  closed,  but 
disappear  when  the  patient  lies  down ;  cerebral  ataxia,  in  which  there 
is  loss  of  muscular  sense  and  marked  persistent  inco-ordination  of 
movement,  occurs  as  a  result  of  injury  to  the  parietal  lobe ;  pseudo- 
ataxia,  due  to  the  weakness  of  certain  groups  of  muscles,  so  that  they 
do  not  properly  oppose  the  action  of  other  groups.  Finally,  there  is 
a  form  of  ataxia  apparently  due  to  anaesthesia  of  the  skin  and  loss  of 
the  muscular  sense,  in  which  the  patient  is  able  to  perform  movements 
perfectly  as  long  as  he  can  watch  the  part  with  the  eye,  but  as  soon 
as  the  eyes  are  closed  the  ataxia  appears  Ataxia  may  be  tested  in  a 
variety  of  ways.  Ataxia  of  the  upper  extremities  may  be  recognized 
by  directing  the  patient  to  touch  the  tip  of  the  nose  with  the  tip  of 
the  forefinger,  or  to  extend  the  arms  and  bring  the  tips  of  the 
forefingers  together  with  a  rapid  motion.  In  health,  after  one  or 
two  trials,  either  of  these  movements  can  be  done  perfectly.  When 
ataxia  is  present  they  are  carried  out  awkwardly,  and  the  forefingers 
are  only  brought  in  contact  with  each  other  or  the  tip  of  the  nose  after 
several  irregular  coarse  oscillations.  The  ataxia  of  the  legs  may  be 
tested  by  requesting  the  patient,  lying  upon  his  back,  to  touch  some 
object  held  above  his  feet  with  one  of  the  toes,  or  to  bring  the  heel  of 
one  foot  against  the  knee  of  the  other.  When  the  patient  is  erect  the 
ataxia  may  be  tested  by  getting  him  to  place  the  feet  together,  when 
there  may  be  some  swaying  that  is  usually  very  markedly  increased 
when  the  eyes  are  closed.  If  the  ataxia  is  very  slight  it  may  be  neces- 
sary to  get  the  patient  to  stand  on  one  foot  with  the  eyes  closed,  or 
to  attempt  to  step  backward  under  the  same  conditions.  Under  these 
circumstances  a  considerable  swaying  occurs  that  is  more  pronounced 
than  the  swaying  noticed  in  a  normal  person  attempting  to  perform 
the  same  movements.  If  the  ataxia  is  at  all  pronounced  it  produces  a 
characteristic  disturbance  in  the  gait.  (See  Ataxic  Gait.)  Ataxia  of 
the  head  is  difficult  to  detect.  Some  observers  contend  that  a  peculiar 
form  of  grimacing,  whenever  the  patient  attempts  to  move  the  lips  or 
the  eyes,  or  whenever  the  muscles  of  the  face  express  some  emotion,  is 
an  ataxic  condition  due  to  overaction. 

Tremor.  This  is  a  disturbance  of  motion  characterized  by  an  oscilla- 
tion of  the  part  or  parts  involved.  Tremor  may  be  of  various  kinds. 
It  may  be  fine  or  coarse,  constant  or  irregular.  It  may  disappear 
upon  voluntary  effort  or  only  be  apparent  when  motion  is  attempted 
(intention  tremor).  It  may  be  the  result  of  paralysis,  paralytic  tremor  ; 
of  poisoning,  toxic  tremor ;  of  some  functional  nervous  disease,  as  the 
hysterical  tremor  ;  or  spasm  of  the  muscle,  spasmodic  tremor  ;  or  it  may 
occur  as  a  family  peculiarity  without  any  discoverable  cause,  hereditary 
or  idiopathic  tremor.  Tremors  are  also  classified  as  rapid,  in  which  the 
movements  occur  more  than  five  times  per  second  ;  and  slow,  in  which 
the  oscillations  may  occur  at  intervals  of  several  seconds.  Nearly  all 
forms  of  tremor  are  increased  by  placing  the  muscles  upon  a  stretch. 
Tremor  can  usually  be  recognized  by  simple  inspection.     In  some  cases 


DISEASES  OF  THE  NERVOUS  SYSTEM.  981 

it  is  necessary  to  use  peculiar  methods  of  detecting  it.  Ordinarily  it  is 
sufficient,  in  order  to  detect  tremor  of  the  fingers,  to  get  the  patient  to 
extend  them  forcibly  and  keep  them  in  that  position.  If  the  tremor, 
however,  is  exceedingly  fine,  its  effect  may  be  exaggerated  by  attaching 
long,  light  rods  to  the  fingers,  such  as  straws.  This  procedure  is  often 
exceedingly  useful  in  cases  of  tremor  of  the  head  or  the  feet.  Tremors 
may  be  recorded  by  attaching  to  the  part  affected  rods  whose  ends  are 
furnished  with  a  pencil  or  stylet  which  writes  upon  a  moving  roll  of 
paper.  If  a  chronograph  marks  off  seconds  or  fractions  of  a  second 
at  the  same  time,  it  is  possible  to  measure  very  accurately  the  rate  of 
oscillation.  A  more  convenient  method  consists  hi  allowing  the  patient 
to  put  the  trembling  part,  for  example,  the  hand,  upon  a  small  drum 
which  conveys  each  movement  to  an  oscillatory  stylet  that  marks  upon 
a  piece  of  smoked  glass  or  paper.  Seconds  should  be  marked  at  the 
same  time.  Persistent  fine  tremor  occurs  particularly  in  paralysis 
agitans.  In  this  the  movements  in  the  fingers  are  those  of  flexion 
and  extension  and  of  opposition  in  the  thumb,  and  it  has,  therefore, 
been  spoken  of  as  the  pill-roller's  tremor.  It  also  occurs  not  infre- 
quently in  exophthalmic  goitre  and  as  hereditary  or  idiopathic  tremor. 
Irregular  tremors  occur  as  a  manifestation  of  ataxia,  often  with  cere- 
bral lesions  (the  paralytic  tremor),  and  after  intoxications,  as  alcohol 
and  tobacco.  The  hysterical  tremor  may  be  either  irregular  or  regular. 
Its  character  is  largely  influenced  by  surrounding  circumstances  ;  thus 
if  the  hysterical  patient  be  in  the  hospital  ward  and  have  an  oppor- 
tunity of  seeing  a  Case  of  paralysis  agitans,  the  tremor  peculiar  to  that 
condition  is  often  closely  reproduced.  Ordinarily,  however,  the  hys- 
terical tremor,  being  the  result  of  voluntary  and  variable  effort,  is 
irregular.  Intention  tremor  occurs  particularly  in  multiple  sclerosis. 
In  this  condition  no  tremor  is  observed  while  the  parts  are  at  rest,  but 
as  soon  as  voluntary  motion  is  attempted  a  violent  tremor  ensues,  and 
continues  until  the  effort  ceases.  Such  a  tremor  can  be  particularly 
well  elicited  by  asking  the  patient  to  convey  a  glass  of  water  to  his 
mouth.  The  movements  become  more  and  more  violent  as  the  lips  are 
approached,  and  frequently  more  or  less  of  the  water  is  spilled.  It  may 
also  be  tested  by  asking  the  patient  to  touch  with  the  forefinger  some 
object.  It  will  be  observed,  as  the  finger  approaches,  that  the  oscilla- 
tions become  more  vigorous  and  wider.  Intention  tremor  may,  of 
course,  be  present  in  other  parts  of  the  body.  Generalized  tremors 
are  spoken  of  as  convulsions  or  convulsive  movements  (q.  v.). 

Muscular  Spasm.  By  this  is  meant  a  condition  in  which  the 
muscle  is  involuntarily  but  forcibly  contracted,  either  persistently 
(tonic  or  tetanic  spasm)  or  rhythmically  (clonic  spasm).  Tonic  spasms 
are  characterized  by  the  vigorous  contraction  of  the  muscle,  which 
becomes  hard  and  painful.  If  only  one  group  of  muscles  is  affected, 
as,  for  example,  the  calf,  the  joint  controlled  by  this  group  is  placed  in 
the  position  normally  assumed  when  they  are  active.  If  all  the  muscles 
of  the  limb  or  even  antagonistic  groups  are  affected,  the  flexors  usually 
overcome  the  extensors.  This,  however,  is  not  invariably  the  case. 
When  all  the  muscles  of  the  body  are  involved,  the  powerful  muscles 
of  the  back  usually  arch  the  spinal  column,  and  there  is  a  more  or  less 


982  SPECIAL  DIAGNOSIS. 

severe  opisthotonos.  Tonic  spasms  can  usually  be  diagnosticated  by 
simple  inspection.  They  occur  particularly  in  tetanus,  strychnine- 
poisoning,  and  hysteria,  and  in  these  conditions  may  often  be  produced 
by  peripheral  irritation.  Localized  spasms  in  the  upper  extremities 
may  occur  as  a  result  of  disease  of  the  cord  above  the  cervical  enlarge- 
ment, or  of  the  brain,  producing  a  spastic  condition  of  the  muscles. 
This  is  rare.  A  more  common  type  is  the  peculiar  form  of  spasm 
seen  in  tetany,  consisting  in  the  closure  of  the  fingers  and  the  opposi- 
tion of  the  thumb,  giving  rise  to  the  so-called  obstetrical  hand.  Spasms 
in  certain  individual  muscles  of  the  hand  or  arm  occur  in  the  occupation 
neuroses.  Spasms  of  the  lower  extremities  are  also  occasioned  by  the 
various  conditions  giving  rise  to  spasticity  of  the  muscles.  An  idio- 
pathic form  of  spasm  not  infrequently  occurs  in  the  calf  muscles,  par- 
ticularly on  awakening.  It  appears  to  be  of  no  clinical  significance. 
Hysterical  spasms  are  of  various  types.  The  tonic  forms  may  affect  a 
single  limb  or  even  a  single  group  of  muscles,  and  may  persist  for  long 
periods  of  time,  giving  rise  either  to  extension  or  persistent  flexion  of 
the  limb.  In  the  latter  case  shortening  may  ultimately  ensue  and 
cause  persistence  of  the  deformity.  General  hysterical  spasms  usually 
can  be  recognized  by  the  fact  that  the  patient  assumes  some  extraor- 
dinary posture,  as  opisthotonos,  pleurosthotonos,  and  emprosthotonos. 
These  spasms  are  often  precipitated  by  pressure  upon  some  sensitive 
point  (hysterogenic  zone,  ovaria),  and  may  sometimes  be  abolished 
by  pressing  upon  the  same  or  a  corresponding  portion  of  the  body.  A 
peculiar  form  of  localized  tonic  spasm  is  that  occurring  in  the  masseters, 
known  as  trismus.  The  myotonic  reaction  is  frequently  spoken  of  as  a 
form  of  tetanic  spasm.  It  consists  of  a  sudden,  persistent  contraction 
of  the  muscle  or  groups  of  muscles  with  which  some  voluntary  move- 
ment has  been  attempted.  It  occurs,  as  far  as  is  known,  only  in  Thom- 
son's disease.  Clonic  spasms  are  of  various  types.  They  may  affect  a 
single  extremity,  half  the  body,  or,  in  rare  cases,  the  whole  body.  The 
movements  are  usually  rhythmical,  and  vary  greatly  in  different  cases. 
The  most  frequent  causes  of  clonic  spasms  are  the  injuries  to  the  brain. 
Focal  irritation  in  the  motor  region  will  produce  at  first  a  spasm  in  the 
part  innervated  by  that  area.  If  the  irritation  is  sufficiently  strong,  or 
acts  for  a  sufficiently  long  time,  its  influence  will  extend  to  the  adjacent 
areas  in  the  cortex,  and  a  general  unilateral  or  bilateral  convulsion  will 
ensue.  This  is  the  so-called  epileptiform  attack.  If  the  local  spasm 
is  distinct  and  precedes  by  some  time  the  development  of  the  general 
twitching,  it  is  spoken  of  as  focal,  or  Jacksonian  epilepsy.  As  a  result 
jf  the  violent  irritation  in  the  brain,  unconsciousness  usually  ensues, 
but  not  invariably.  Clonic  convulsions  may  possibly  be  of  local  origin, 
although  this  is  exceedingly  doubtful.  Ankle  clonus,  however,  and 
patellar  clonus  bear  a  certain  resemblance  to  this  symptom  of  disease. 
A  localized  form  of  clonic  spasm,  due  to  peripheral  irritation  in  all 
likelihood,  is  facial  tic,  characterized  by  occasional  or  successive  light- 
ning-like contractions  of  the  muscles  of  the  face.  Functional  con- 
vulsions, particularly  those  occurring  in  hysterical  patients,  are  very 
frequently  clonic  in  character.  Often  there  will  be  a  preliminary 
tetanic  spasm,  followed  in  a  short  time  by  the  development  of  clonic 


DTSEASES  OF  THE  NERVOUS  SYSTEM.  983 

movements.  These  assume  various  forms,  the  commonest  being  per- 
haps beating  with  the  limbs,  throwing  of  the  head  from  side  to  side, 
and  lateral  or  antero-posterior  movements  of  the  body.  The  attitudes 
and  movements  express  fear,  threat,  ecstasy,  eroticism,  or  other  emo- 
tional states. 

Allied  to  the  clonic  spasms,  but  bearing  also  close  affinity  to  tremors, 
are  the  irregular  movements  that  occur  in  chorea  and  athetosis.  The 
typical  movement  of  chorea  is  an  irregular  innervation  of  groups  of 
muscles  that  appears  to  be  voluntary  in  character,  but  that  is  not  under 
the  control  of  the  patient,  is  much  more  rapid,  as  a  rule,  than  a  volun- 
tary movement,  and  recurs  at  very  frequent  intervals.  Choreic  move- 
ments may  be  mild,  or  so  severe  that  they  produce  irregular  contortions 
of  the  body,  causing  the  patient  to  throw  himself  or  herself  from  side 
to  side,  and  often  producing  severe  bodily  injuries  and  even  death  by 
exhaustion.  Athetosis  is  a  name  given  to  a  peculiar,  slow,  irregularly 
rhythmical  movement  of  the  extremities,  generally  spoken  of  as  worm- 
like in  character.  It  is  ordinarily  most  marked  in  the  fingers.  In 
movement  these  are  gradually  extended  until  they  form  almost  a  right 
angle  with  the  back  of  the  hand,  and  then  slowly  flexed  and  extended 
again,  each  finger  moving  more  or  less  independently  of  the  others. 
At  the  same  time  there  is  movement  at  the  wrist-joint,  the  elbow,  and 
sometimes  of  the  trunk.  The  limbs  may  be  affected,  giving  rise  to  a 
curious,  staggering  gait  in  which  the  patient  seems  ever  to  be  about  to 
lose  his  equilibrium,  but  maintains  it  almost  by  a  miracle.  Frequently 
the  muscles  of  the  face  are  involved,  giving  rise  to  curious,  irregular 
grimaces  and  more  or  less  disturbance  of  speech  or  dysarthria.  The 
movements  are  usually  continuous.  Athetosis  is  a  very  common  sequel 
to  cerebral  lesions  occurring  in  early  childhood. 

The  term  convulsion  is  used  to  designate  general  spasm  with  loss  of 
consciousness.  It  is  often  employed,  however,  to  indicate  general  clonic 
spasm  of  the  whole  body,  even  if  consciousness  be  still  present.  This 
use  is  undesirable,  and  should  be  avoided.  General  convulsions  inva- 
riably indicate  some  disturbance  in  the  brain.  If  this  is  organic,  it 
may  be  either  some  chronic  disease  with  occasional  exacerbation  of 
cortical  irritation,  or  some  acute  injury  or  some  disease,  such  as  men- 
ingitis. If  it  is  some  functional  disturbance,  it  may  be  hysteria  or 
epilepsy.     (The  latter  is,  of  course,  usually  due  to  organic  lesions.) 

The  term  muscular  tone  means  that  condition  of  the  voluntary 
muscles  of  the  body  by  which  they  are  maintained  in  a  state  of  tension 
sufficient  to  enable  them  to  respond  promptly  to  nervous  innervation. 
Muscular  tone  varies  slightly  under  normal  conditions.  It  is  less  in 
profound  fatigue,  and  when  the  attention  is  distracted  by  external 
objects ;  it  is  more  marked  when  the  patient  concentrates  his  attention 
upon  the  part  being  tested.  It  is  invariably  diminished  after  lesions 
of  the  peripheral  motor  neuron,  in  cases  of  profound  cachexia,  in  coma, 
and  during  anaesthesia.  It  is  also  generally  decreased  in  lesions  of  the 
posterior  columns  of  the  spinal  cord.  It  is  increased  in  lesions  of  the 
central  motor  neuron  without  involvement  of  the  peripheral  neuron,  in 
neurasthenia,  hysteria,  and  in  conditions  affecting  the  brain  as  a  whole, 
such  as  meningitis,  brain  tumor,  etc.     It  must  be  remembered  that 


984  SPECIAL  DIAGNOSIS. 

flaccid  paralysis  does  not  necessarily  imply  diminished  muscle  tone ; 
thus  in  the  early  stages  of  hemiplegia  the  muscles  are  completely 
relaxed,  but,  nevertheless,  the  reflexes  are  usually  increased.  There 
are  two  methods  of  testing  this  quality  :  First,  passive  movements ; 
second,  the  tendon  reflexes.  In  the  former  the  limb  to  be  tested  is 
grasped  firmly,  and,  if  flexed,  is  suddenly  but  not  too  forcibly  ex- 
tended, or,  if  extended,  is  flexed.  If  the  muscle  tone  is  normal  there 
may  be  a  transient,  involuntary  resistance  at  first,  but  this  disappears 
very  soon,  and  then  the  limb  may  be  moved  in  any  position  with  com- 
paratively slight  effort.  Any  of  the  joints  may  be  tested  independently 
in  this  manner.  It  is  important  to  inform  the  patient  what  is  to  be 
done  and  what  is  to  be  tested.  In  children,  in  the  ignorant,  and  in  the 
insane  it  is  often  almost  impossible  to  overcome  the  tendency  to  volun- 
tary resistance,  which  is  usually  increased  by  the  anxiety  produced  by 
the  examinatiou.  Occasionally  it  is  necessary  to  take  some  measures 
to  distract  the  attention,  such  as  giving  the  patient  a  sum  in  arithmetic 
to  perform,  requesting  him  to  look  at  the  ceiling  or  some  particular 
object,  or  engaging  him  in  conversation.  Increase  of  the  muscle  tone 
is  determined  by  increased  resistance  to  passive  movements.  This  may 
be  so  great  that  it  is  almost  impossible  to  bend  the  limb  at  any  of  the 
joints,  or  so  slight  that  it  is  difficult  to  discriminate  it  from  the  normal 
condition. 

The  exaggerated  forms  are  usually  spoken  of  as  spasticity  of  the 
muscles,  and  when  associated  with  paretic  or  paralytic  conditions  the 
term  spastic  paralysis  is  employed.  Diminution  of  the  muscle-tone  is 
usually  difficult  to  detect  by  passive  movements  alone.  When  it  is 
entirely  lost  the  lhnb  is  spoken  of  as  flail-like.  The  joints  seem  to 
have  no  tendency  to  remain  in  one  position.  If  the  limb  is  shaken, 
with  every  movement  they  pass  from  extension  to  flexion,  or  vice  versa. 
Under  these  circumstances  the  passive  movements  are  entirely  unre- 
sisted, the  only  effort  necessary  being  that  required  to  overcome  the 
weight  of  the  limb  itself. 

The  Texdox  Reflexes.  These  were  first  described  by  TVestphal 
in  connection  with  the  reflexes  of  the  knee.  They  consist  essentially 
of  a  rapid  twitch  or  succession  of  twitches  in  the  muscle  when  the 
tendon  by  which  it  is  attached  to  some  bony  part  is  struck  a  sharp 
blow.  There  is  some  difference  of  opinion  regarding  the  true  nature 
of  the  stimulus  required  to  produce  them.  According  to  Gowers,  it  is 
a  simple  extension  of  the  muscle,  and  he,  therefore,  uses  the  term  myo- 
tome phenomenon.  Sternberg,  on  the  other  hand,  believes  that  he  has 
shown  that  they  are  the  result  of  vibrations  in  the  tendon,  which  are 
communicated  by  it  to  the  muscle.  Others  contend  that  they  are  pure 
reflexes  produced  by  the  mechanical  action  of  the  blow  upon  the  nerve- 
fibres  in  the  tendon  itself.  It  is  certain,  at  any  rate,  that  more  factors 
are  required  than  the  mere  tone  of  the  muscle,  and  that  afferent  im- 
pulses to  the  spinal  cord  and  efferent  impulses  from  it  are  necessary  to 
the  development  of  the  reflex;  and  that  it  is  furthermore  profoundly 
influenced  by  higher  centres  that  usually  have  an  inhibitory  action 
(upper  reflex  arc).  The  question  is  complicated  by  the  fact  that  in 
certain  cases  the  reflexes  may  be  elicited  by  tapping  the  bony  parts,  such 


DISEASES  OF  THE  NERVOUS  SYSTEM.  985 

as  the  periosteal  reflexes ;  by  irritating  the  skin  overlying  the  muscles, 
as  the  cutaneous  reflexes ;  or  by  tapping  upon  the  fascia  or  the  belly 
of  the  muscle  itself.  In  general,  it  may  be  said  that  all  conditions  pro- 
ducing increased  muscular  tone  produce  exaggeration  of  the  reflexes, 
and  that  all  conditions  diminishing  muscular  tone  diminish  the  reflexes. 
In  marked  contradiction  to  this,  however,  are  the  facts  that  attention  to 
the  reflex,  being  tested,  will  diminish  or  abolish  it  completely,  whereas 
distraction  of  the  attention,  which  ordinarily  diminishes  muscular  tone, 
increases  the  force  of  the  reflex.  Moreover,  in  certain  forms  of  pro- 
found coma,  where  the  muscle  tone  appears  to  be  at  a  minimum,  the 
reflexes  appear  to  be  often  greatly  exaggerated.  Thus,  in  uraemia  and 
diabetic  coma,  I  have  been  able  on  several  occasions  to  detect  exaggera- 
tion of  the  reflexes  when  the  limbs  were  flail-like  in  their  relaxation. 

The  individual  reflexes  of  the  head  are  practically  limited  to  the  chin- 
jerk.  This  is  elicited  by  having  the  patient  open  his  mouth  slightly, 
then  a  flat  object,  such  as  a  tongue  depressor,  or  the  handle  of  a  spoon,  is 
placed  upon  the  teeth  of  the  lower  jaw  and  sharply  tapped  with  the 
finger  or  hammer.  Under  normal  circumstances  there  will  be  a  slight 
upward  jerk  of  the  chin.  It  may  also  be  elicited  with  less  discomfort 
to  the  patient  by  placing  the  finger  beneath  the  lower  lip  and  upon  the 
mental  prominence  and  striking  it  sharply  with  the  hammer.  This  does 
not  always  result  in  a  reflex  under  normal  conditions,  but  is  quite  satis- 
factory for  the  purpose  of  testing  pathological  exaggeration.  The  chin- 
jerk  is  nearly  always  increased  in  neurasthenia  and  hysteria,  and  is 
sometimes  present  in  profound  coma.  In  the  conditions  of  general 
spasticity  that  are  occasionally  met  with  in  severe  infectious  disease  it 
is  also  usually  exaggerated.  Its  absence  does  not  appear  to  be  of  any 
pathological  significance.  Allied  to  the  tendon  or  peritoneal  reflexes 
is  the  phenomena  known  as  Chvostek's  sign.  This  occurs  only  in  tetany, 
and  consists  of  a  sudden  lightning-like  twitching  of  the  muscles  of  the 
face,  particularly  the  elevators  of  the  angles  of  the  lip  and  the  muscles 
of  the  eyelids.  It  is  elicited  by  striking  the  skin  below  the  zygomatic 
arch  just  in  front  of  the  ear  with  the  hammer.  It  was  formerly  sup- 
posed that  this  was  due  to  mechanical  irritation  of  the  trunk  of  the 
facial  nerve,  but  the  same  phenomenon  can  also  be  elicited  by  striking- 
over  the  malar  bone  or  in  the  region  of  the  infra-orbital  foramen.  No 
tendon  reflexes  have  as  yet  been  discovered  for  the  muscles  of  the 
trunk. 

In  the  arms  the  most  important  are  the  bicipital,  tricipital,  and 
the  supinator  reflexes.  The  bicipital  reflex  is  best  obtained  by  allow- 
ing the  patient  to  rest  the  perfectly  relaxed  arm  upon  some  support, 
for  example,  the  arm  of  the  investigator  in  a  semi-flexed  position. 
The  finger  or  thumb  is  then  placed  upon  the  tendon  of  the  biceps,  and 
struck  a  sharp  blow  with  the  hammer  or  the  finger,  as  in  percussing. 
In  nearly  all  normal  cases  a  slight  twitching  or  distinct  contraction  of 
the  biceps  can  be  obtained  in  this  manner.  Sometimes  it  is  possible, 
by  resting  the  arm  upon  a  support,  to  see  the  tendon  distinctly  and  to 
strike  it  directly,  but  this  is  usually  much  less  satisfactory.  The  tri- 
cipital  reflex  is  readily  obtained  by  holding  the  arm  semi-flexed  and 
relaxed,  and  then  striking  just  above  the  olecranon  process  of  the  ulna. 


986  SPECIAL  DIAGNOSIS. 

The  supinator  reflex  is  obtained  by  striking  the  radius  just  above  the 
styloid  process.  These  reflexes  are  particularly  distinct  in  hemiplegia, 
upon  the  paralyzed  side.  They  also  occur  in  the  general  conditions 
above  mentioned.  Their  absence  is  of  no  pathological  significance,  as 
it  is  often  impossible  to  obtain  them  in  normal  individuals.  In  addi- 
tion a  reflex  may  be  obtained  by  striking  the  bodies  of  the  extensor 
muscles  of  the  forearm,  giving  rise  to  extension  of  the  fingers.  A 
form  of  wrist  clonus  occasionally  occurs  that  may  be  elicited  by  sud- 
denly flexing  the  wrist-joint  either  dorsally  or  ventrally,  and  holding 
it  in  the  cramped  position.  The  hypothenar  reflex  is  the  contraction 
produced  in  the  palmaris  brevis  by  pressure  upon  the  pisiform  bone. 
It  does  not  appear  to  be  dependent  upon  any  diseased  condition.  Tap- 
ping upon  the  bodies  of  the  muscles  sometimes  gives  rise  to  a  sharp 
contraction.  This  is  particularly  observed  in  connection  with  the 
shoulder  muscles  (Striimpell)  and  pectoral  muscles.  An  important 
reflex,  the  abdominal  reflex,  is  elicited  by  drawing  the  end  of  a  blunt 
object  obliquely  across  the  skin  of  the  abdomen  downward  and  out- 
ward or  upward  and  inward,  the  object  being  to  make  it  cross  the  line 
of  the  intercostal  nerves  as  nearly  as  possible  at  a  right  angle.  This 
produces  contraction  in  the  muscles  innervated  by  these  nerves,  and 
is  due  to  the  stimulation  of  their  cutaneous  distribution.  It  may  be 
exaggerated  in  functional  nervous  conditions,  and  is  diminished  in 
cases  of  hemiplegia  and  anaesthesia  on  the  anaesthetic  sides.  Its  absence 
at  some  particular  point  occasionally  serves  as  an  additional  factor  in 
the  localization  of  lesions  of  the  spinal  cord.  Various  reflexes,  prob- 
ably periosteal  or  fascial  in  nature,  may  be  produced  by  tapping  upon 
the  spinous  processes  of  the  ilium.  As  far  as  is  known,  they  are  hot 
of  any  clinical  value. 

The  reflexes  of  the  lower  extremities  are  the  most  important  of 
all.  The  first  discovered,  the  knee-jerk,  is  invariably  present  hi  health, 
and  by  its  delicacy  and  constancy  is  the  most  valuable  reflex  for  clin- 
ical purposes.  It  may  be  elicited  in  a  variety  of  ways.  Perhaps 
the  best  method  is  to  have  the  patient  lie  upon  his  back  :  then  placing 
one  hand  under  the  knee  it  should  be  lifted  several  inches  from  the 
surface  of  the  bed  or  table  until  the  leg  and  thigh  form  an  obtuse 
angle  of  about  120°.  Then  with  the  finger,  the  side  of  the  hand, 
the  edge  of  the  stethoscope,  or  the  percussion  hammer1  it  is  struck  a 
sharp  blow.  The  patellar  tendon  should  be  struck  between  the  lower 
edge  of  the  patella  and  the  tuberculum  of  the  tibia.  The  stroke  should 
be  delivered  with  moderate  force,  and,  according  to  the  practice  of  most 
clinicians,  a  single  blow  is  sufficient,  but  sometimes  the  reflex  is  more 
certainly  elicited  if  several  strokes  are  given  in  quick  succession.  The 
most  obvious  and  vigorous  contraction  occurs  in  the  quadriceps  of  the 
same  side,  causing  the  leg  to  be  tipped  upward  suddenly  and  giving 
rise  to  the  name  knee-jerk.  In  addition,  the  adductors  of  the  same  side 
nearly  always  contract  slightly,  and  occasionally  the  flexor  muscles — 

1  There  are  various  forms  of  these — one  with  a  heavy  metal  head  and  short,  wooden 
handle,  the  end  of  the  metal  head  being  covered  with  leather ;  another,  composed  of  a 
wedge-shaped  piece  of  rubber  set  in  a  light  metal  handle ;  the  latter  is  probably  the 
better. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  987 

that  is,  the  biceps,  the  semi-tenclinosus,  and  the  semi-membranosus — 
also  contract.  Frequently  the  adductors  of  the  opposite  side  contract 
very  slightly  in  health,  and  sometimes  quite  vigorously  in  diseased 
conditions  {crossed-reflex).  Other  methods  of  obtaining  this  reflex  are 
to  allow  the  patient  to  sit  on  a  low  chair  with  the  leg  extended  forward, 
until  it  forms  a  blunt  angle  with  the  thigh,  with  the  heel  resting  upon 
the  ground.  The  patellar  tendon  is  then  struck  as  before.  Clinically 
it  is  usually  sufficient  when  the  patient  is  sitting  in  an  ordinary  chair 
to  have  one  leg  thrown  over  the  other,  and  hanging  loosely  and  freely. 
Occasionally  it  is  difficult,  on  account  of  extreme  relaxation  of  the 
muscles,  to  stretch  the  tendon  sufficiently  to  obtain  the  reflex  by  this 
method,  and  Gowers  suggests  that  under  these  circumstances  the  legs 
should  be  completely  flexed  upon  the  thighs.  It  is  often  difficult  to 
discover  the  tendon,  either  on  account  of  deformity  of  the  joint  or 
because  of  an  excess  of  fat  tissue.  In  one  case  that  I  have  observed, 
in  which  extensive  arthropathies  existed,  the  knee-jerk  was  present, 
but  obtained  with  great  difficulty,  on  account  of  the  distortion  of  the 
parts.  The  patellar  tendon  reflex,  therefore,  is  a  multiple  muscular 
reflex,  producing  phenomena  of  the  opposite  side,  the  so-called  bilateral 
reflex.  It  is  said  to  be  invariably  present  in  health,  but  its  intensity 
varies  considerably,  and  in  some  apparently  healthy  persons  without 
any  evidence  of  disease  of  the  spinal  cord  it  is  extremely  difficult  to 
elicit.  Under  these  circumstances  it  is  necessary  to  use  various  pro- 
cedures in  order  to  make  it  evident.  These  consist  either  in  requesting 
the  patient  to  look  at  the  ceiling,  in  order  to  distract  the  attention,  or 
to  perform  some  violent  muscular  effort,  such  as  an  attempt  to  pull  the 
hands  apart  when  they  are  clasped  together,  to  squeeze  the  dynamom- 
eter, etc.  Under  these  circumstances  the  knee-jerk,  if  obtained,  is 
spoken  of  as  reinforced.  It  is  always  important  to  have  the  muscles 
completely  relaxed,  and  to  prevail  upon  the  patient  not  to  think  of 
what  is  being  done.  The  knee-jerk  is  sometimes  rendered  more  pro- 
nounced by  emotion,  and  sometimes  inhibited,  as,  for  example,  by 
fright.  The  arc  of  the  knee-jerk  is  situated  in  the  first  lumbar  seg- 
ment of  the  cord,  but  probably  occasionally  deviates  slightly  from  this 
position,  being  either  higher  or  lower.  The  knee-jerk  is,  therefore, 
invariably  increased  in  any  disease  of  the  pyramidal  tracts  above  this 
point.  It  is  diminished  in  disease  of  the  efferent  or  afferent  fibres. 
Its  absence  in  tabes  dorsalis  was  noted  early,  and  has  long  been  con- 
sidered evidence  of  disease  of  the  posterior  columns.  Closely  allied  to 
the  knee-jerk  in  its  clinical  significance  and  mode  of  occurrence  is  the 
patellar  reflex.  This  is  elicited  usually  by  placing  the  finger  transversely 
above  the  patellar,  pushing  the  bone  forcibly  down,  and  then  striking 
the  finger  with  the  hammer.  Ordinarily  a  distinct,  pronounced  con- 
traction of  the  quadriceps  alone  is  produced.  In  order  to  elicit  this 
reflex  the  leg  must  be  extended  and  relaxed.  Patellar  clonus  occasion- 
ally occurs,  and  is  obtained  by  placing  the  thumb  and  forefinger  oil  the 
upper  edge  of  the  patella  and  pushing  it  forcibly  downward  and  keep- 
ing it  in  that  situation.  If  clonus  occurs  it  will  be  characterized  by  a 
series  of  rapid  contractions  of  the  quadriceps,  resulting  in  a  vertical 
oscillation  of  the  patella.     It  occurs  in  disease  of  the  spinal  cord,  and 


988  SPECIAL  DIAGNOSIS. 

not  infrequently  in  conditions  of  increased  tonicity  in  general  infectious 
diseases.1 

In  general  it  may  be  said  that  the  mechanical  effort  is  dependent 
upon  the  condition  of  the  nutrition  of  the  quadriceps  and  the  amount 
of  interference  of  the  opposing  muscles.  Exaggeration  of  the  knee- 
jerk  is  characterized  by  a  more  vigorous  effort  or  more  extensive  con- 
traction of  the  surrounding  muscles.  The  latter,  indeed,  may,  by  the 
involvement  of  the  flexors,  diminish  the  excursion  of  the  leg.  Some- 
times in  cases  of  profound  emaciation,  as  in  cachexia,  although  the 
knee-jerk  is  increased  and  the  muscle  apparently  contracts  vigorously, 
its  power  is  so  greatly  diminished  that  it  is  unable  to  move  the  leg. 
Elaborate  mechanisms,  therefore,  that  have  been  devised  for  meas- 
uring the  knee-jerk  do  measure  in  fact  only  the  amount  of  movement 
of  the  foot,  and  are  practically  worthless.  They  consist  essentially  of 
an  arc  of  a  circle  whose  radius  is  approximately  equal  to  the  length  of 
the  leg.  Either  a  pencil  or  a  small  readily  movable  index  is  placed 
against  the  foot,  and  the  knee-jerk  is  measured  by  the  number  of  de- 
grees marked  off  on  the  scale.  It  is  manifest  that  comparisons  are 
only  valuable  when  the  blow  is  of  exactly  the  same  force,  and  then 
only  when  the  experiments  are  performed  upon  the  same  individual 
within  a  limited  period  of  time.  In  order  to  obtain  a  constant  force 
of  blow  various  instruments  have  been  devised,  the  simplest  being 
weights  dropped  through  a  paper  cylinder  upon  the  patellar  tendon, 
and  the  more  complicated  having  springs  for  their  motive  power. 
Tendon  reflexes  may  also  be  obtained  by  tapping  upon  the  hamstring 
tendons.  They  are  of  no  particular  value.  Tapping  upon  the  inner 
condyle  of  the  tibia  often  produces  contraction  of  the  adductor  muscles, 
but  this  is  not,  as  a  rule,  as  pronounced  as  the  contraction  produced  by 
the  percussion  upon  the  patellar  tendon.  Next  in  importance  to  the 
patellar  reflex  is  the  Ackillis  tendon  reflex,  which  consists  of  the  contrac- 
tion of  the  gastrocnemius  and  soleus  muscles  when  the  Achillis  tendon 
is  struck.  It  is  most  readily  elicited  by  lifting  the  entire  leg  from  the 
bed  or  table,  and  holding  it  by  the  ball  of  the  foot,  which  is  gently 
pressed  upward.  The  tendon  is  thus  moderately  stretched,  and  may 
be  struck  directly.  In  nearly  all  healthy  individuals  this  reflex  is 
present,  but  is  absent  in  some,  and  its  absence  is  apparently  of  no  clin- 
ical significance.  Exaggeration  may  be  indicated  in  moderate  cases  by 
the  more  forcible  extension  of  the  foot.  In  more  pronounced  cases  it 
gives  rise  to  a  peculiar  and  characteristic  phenomenon,  known  as  ankle 
clonus.  This  may  be  elicited  by  tapping  the  tendon  once  vigorously  or 
several  times  in  succession  when  the  leg  is  held  in  the  manner  described, 
but  is  more  readily  produced  by  slightly  flexing  the  leg  and  thigh,  then 
grasping  the  ball  of  the  foot  firmly,  flexing  it  dorsally  with  considerable 
force,  and  holding  it  in  that  position.  When  ankle  clonus  exists  there 
will  be  violent  vibratory  oscillations  of  the  foot,  as  long  as  the  pressure 
upon  the  sole  is  continued,  that  vary  from  two  to  three  up  to  five  or 

1  Dr.  Mills  has  devised  an  ingenious  instrument,  consisting  of  a  metal  ring  with  a 
curved  handle,  by  which  the  patella  may  be  drawn  downward  and  the  jerk  or  clonus 
more  certainly  elicited. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  989 

ten  movements  per  second.  There  is  usually  a  rhythmical  increase  and 
decrease  in  the  rapidity ,  without  absolute  cessation  at  any  time.  Occa- 
sionally, in  very  mild  cases,  the  clonus  after  a  few  movements  becomes 
weaker,  and  rapidly  disappears.  Ankle  clonus  is  supposed  to  indicate 
the  existence  of  a  lesion  above  the  second  lumbar  segment  of  the  spinal 
cord  that  seriously  interferes  with  the  function  of  the  pyramidal  tract. 
For  a  long  time  there  has  been  doubt  as  to  whether  it  occurs  in  func- 
tional disease,  but  it  seems  now  to  be  established  that  it  does.  Its 
occurrence  in  functional  conditions  is,  however,  of  such  extreme  rarity 
that  when  it  is  present  organic  disease  should  always  be  suspected.  It 
is  most  characteristic  in  spastic  paraplegia,  either  due  to  transverse 
myelitis,  to  lateral  sclerosis,  or  to  syringomyelia.  It  also  occurs  after 
lesions  in  the  motor  regions  of  the  brain.  It  can  sometimes  be  elicited 
by  supporting  the  weight  of  the  leg  upon  the  toe.  Under  these  circum- 
stances it  develops  spontaneously  in  organic  conditions,  and  sometimes 
in  fatigue,  cold,  or  exhaustion.  It  may  also  be  produced  in  normal 
persons  who  continue  for  a  sufficient  length  of  time  voluntary  oscilla- 
tory movements  of  the  foot  supported  in  this  manner.  A  pseudo-ankle 
clonus  has  been  described  as  characterized  by  a  few  irregular  oscilla- 
tions that  soon  cease.  It  occurs  in  functional  disease  and  occasionally 
among  malingerers.  Tapping  upon  the  tendon  of  the  great  toe  occa- 
sionally produces  a  slight  contraction  of  that  member.  The  other 
reflexes  of  the  lower  extremities  are  front  tap,  dorsal  extension  of  the 
toes  upon  percussion  of  the  anterior  surface  of  the  tibia,  and  the  toe 
reflex — that  is,  slight  flexion  of  the  toes  when  the  skin  of  the  sole  is 
irritated.  This,  according  to  Babinsky,  is  replaced  by  a  dorsal  flexion 
of  the  toes  when  the  pyramidal  columns  are  involved,  and  disappears 
in  tabes  dorsalis.  The  plantar  reflex  properly  belongs  to  the  group  of 
cutaneous  reflexes.  It  is  characterized  by  the  involuntary  withdrawal 
of  the  foot  when  the  sole  is  irritated.  It  is  of  course  absent  in  cases 
of  anaesthesia,  and  is  greatly  exaggerated  in  functional  nervous  condi- 
tions, occasionally  giving  rise  to  a  peculiar  general  tremor  of  the  leg  or 
even  of  the  whole  body.  It  is  best  elicited  by  drawing  a  blunt  object 
(pencil,  handle  of  a  stethoscope)  across  the  surface  of  the  foot. 

Allied  to  the  reflexes  is  the  so-called  paradoxical  contraction  of  AVest- 
phal.  This  consists  in  a  persistent  spasm  of  the  muscle  when  its  two 
attachments  are  suddenly  brought  closer  together.  It  is  most  fre- 
quently observed  in  the  peroneal  muscles  of  the  leg,  and  may  be  elicited 
by  suddenly  flexing  the  foot  dorsally.  It  occurs  most  frequently  in 
various  functional  conditions,  and  has  also  been  observed  in  paralysis 
agitans. 

Next  to  the  functional  conditions  of  the  muscles,  which  is  indicated 
by  the  degree  of  motility  that  they  possess,  we  arc  interested  in  the 
state  of  their  nutrition.  It  may  be  suspected  that  this  is  impaired 
when  fibrillary  contractions  or  atrophy  are  present. 

Atrophy  of  the  muscles  may  usually  be  detected  by  simple  inspection. 
If  only  certain  groups  are  involved,  the  latter  will  appear  more  or  less 
distorted.  It  is  always,  however,  important  to  measure  the  injured 
limb  and  compare  it  with  the  sound  side  if  the  affection  is  unilateral. 
When  due  to  general  conditions,  such  as  the  muscular  dystrophies  or 


990 


SPECIAL  DIAGNOSIS. 


polyneuritis,  it  is  sometimes  more  difficult  to  be  certain  of  its  existence. 
A  general  atrophy  of  the  muscular  system  also  occurs  in  cachectic 
states,  such  as  the  cachexia  of  carcinoma.     Fibrillary  twitchings  occur 

Thev  are  characterised 


in  muscles  undergoing  degenerative  changes 


Fir.   226. 


M.  occipit. 

M.  retrah.  auric 
N.  auricul.  post. 

M.  splenitis 

N.  accessorius 

M.  sternooleidom. 

M.  cueullaris 

N.  axillaris  (M.  deltoid.) 

N.  thoracic,  long.  (M.  serr. 
ant.  maj. 

Plexus  brach. 


M.  temporal. 
M.  frontal. 

M.  corrugator  super- 

[cilii. 
M.  orbicul.  palp. 

>  Nasal  muscles. 

jM.  levat.  lab.  sup. 
M.  zygomaticus. 

M.  orbic.  oris. 

M.  masseter.  [talis. 
]M.  levator  menti  (men- 
M.  depressor  lab.  inf. 

(quadr.  meuti). 
M.  depressor  ang.  oris 

(triangul.  menti). 

N.  hypoglossus. 


Platvsnia 

M.  sterDohyoideus. 

M.  omohyoideus. 

pllrenicus. 

M.  sternotbyreoideus. 

Erb's  point  (M.  del- 
toid., biceps,  bracb. 
int.  supinator  long. 

N.  thoracic  ant.  (M. 
pect.  maj.). 


Motor  points  for  the  head  and  neck.     (Sahli.) 


by  the  sudden,  spasmodic  contraction  of  individual  fibres  in  the  mass 
of  the  muscle  itself,  giving  rise  to  a  curious  trembling  of  the  overlying 
skin  and  a  peculiar  sensation  to  the  palpating  hand,  as  if  minute  waves 
were  passing  through  the  muscular  substance.  They  often  occur  spon- 
taneously, and  in  degenerating  muscles  may  be  elicited  by  slight  median- 


DISEASES  OF  THE  NERVOUS  SYSTEM.  991 

ical  stimuli,  such  as  cold,  percussion,  or  shock.  Fibrillary  twitchings 
may  also  occur  in  healthy  muscles  that  have  either  been  chilled  (tremor 
or  shivering)  or  subjected  to  severe  fatigue. 

The  most  reliable  method  of  diagnosis  is  by  an  electrical  examina- 
tion. For  this  purpose  we  use  two  types  of  apparatus.  The  galvanic 
current  is  produced  by  the  galvanic  battery,  consisting  of  a  number  of 
cells,  each  containing  an  electro-positive  and  electro-negative  element 
and  filled  with  battery  fluid.  Long  wires  are  attached  to  the  battery, 
through  which  the  current  flows  when  they  are  brought  in  contact  or 
the  circuit  closed,  and  ceases  when  they  are  kept  apart  or  the  circuit 
opened.  The  free  end  of  the  wire  toward  which  the  current  flows 
from  the  cell  is  called  the  anode,  and  the  free  end  from  which  the 
current  passes  to  the  cell,  the  cathode ;  then,  if  any  substance  is  intro- 
duced between  these  ends  of  the  wire,  closing  the  circuit,  the  current 
passes  through  it  from  the  anode  or  positive  pole  to  the  cathode  or 
negative  pole.  It  is  customary  to  introduce  into  the  circuit  for  meas- 
uring the  amount  of  electricity  employed  a  galvanometer,  which  is 
graduated  in  milliamperes.1  As  it  is  important  to  employ  a  definite 
number  of  milliamperes,  the  apparatus  is  also  provided  with  a  rheostat, 
which  renders  it  possible  by  the  introduction  of  a  greater  or  less  degree 
of  resistance  to  regulate  the  amount  of  electricity  passing  through  the 
body.  The  free  ends  of  the  wire  are,  for  medical  purposes,  supplied 
with  electrodes.  These  consist  essentially  of  metal  disks  or  plates 
to  which  the  wire  is  attached,  provided  with  a  wooden  or  hard  rubber 
non-conducting  handle.  As  the  resistance  normally  offered  by  the 
skin  is  greatly  reduced  if  it  be  moistened,  the  ends  of  the  electrodes 
are  covered  with  cotton  or  gauze  and  moistened  by  immersion  in  either 
plain  or  salt  water.  The  area  of  the  cross-section  of  the  electrode  may 
vary  considerably.  Ordinarily,  it  is  customary  to  have  one  very  large 
electrode,  from  50  to  100  square  centimetres  in  area,  and  one  exactly 
3  square  centimetres  in  area.  (Stintzing's  standard  electrode.)  In 
addition,  for  therapeutic  purposes,  it  is  customary  to  have  for  the 
galvanic  and  faradic  apparatus  a  wire  brush  and  various  special  elec- 
trodes for  application  to  the  more  inaccessible  portions  of  the  body. 
If  a  muscle  or  nerve  is  to  be  investigated  the  large  electrode  is  thor- 
oughly moistened  and  placed  over  the  back  or  the  sternum.  It  is 
not  advisable  to  place  it  over  the  neck  nor  to  allow  the  patient  to  hold 
it  in  the  hand.  The  current  is  so  arranged  that  this  large  electrode  is 
at  first  the  anode  and  the  small  electrode  the  cathode.  The  cathode 
is  now  placed  over  the  muscle  or  the  nerve  to  be  stimulated,  locating 
it,  if  possible,  exactly  over  the  most  sensitive  (electrically)  point.  This 
is  most  readily  determined  by  comparison  with  the  figures  on  pages  990 
et  seq.  The  circuit  should  be  open  and  the  rheostat  so  placed  that  the 
minimum  amount  of  current  flows  through  the  body.     The  circuit  is 

1  One  milliampere  equals  0.001  of  an  ampere.  The  ampere  is  the  unit  adopted  for 
the  measure  of  the  amount  of  current.  It  is  determined  by  dividing  the  unit  of 
electromotive  force,  one  volt— that  is,  0.0  of  the  amount  of  current  liberated  by  a 
freshly  filled  Daniell  cell,  divided  by  1  ohm — that  is,  the  amount  of  current  required 
to  overcome  a  unit  of  standard  resistance,  or  a  column  pf  mercury  1.06  metres  in 
length  and  1  square  millimetre  in  cross-section. 


992 


SPECIAL  DIAGNOSIS. 


now  rapidly  opened  and  closed,  while  the  cathode  is  kept  in  position 
and  the  rheostat  gradually  moved  around  until  the  current  is  strong 
enough  to  produce  a  slight  twitching  of  the  muscle.  This  will  first 
occur  at  the  making  of  the  circuit,  and  is  spoken  of  as  cathodal  closing 
contraction,  or  CCC.  The  current  should  now  be  slightly  increased, 
and  by  means  of  a  switch  the  small  electrode  converted  into  the  anode 
and  the  other  into  the  cathode.  It  will  soon  be  observed  that  a  con- 
traction takes  place  both  at  opening  and  closing  the  current.  This  is 
spoken  of  as  the  anodal  closing  contraction,  or  ACC,  and  the  anodal 
opening  contraction,  or  AOC.     If  the  small  electrode  be  again  made 


Fig.  227. 


Rectus  abdominis. 
Intercostal  nerves. 


Serratus  magnus. 
Latissimus  dorsi. 


Intercostal  nerves. 


Transversus 
abdominis. 


Diagram  of  the  motor  points  of  the  trunk.    (Prom  Von  Ziemssen.) 


the  cathode,  it  will  be  found  that  there  is  a  vigorous  contraction  when 
the  current  is  closed,  but  none  when  it  is  opened.  Finally,  if  the  cur- 
rent is  made  still  stronger,  it  will  be  found  that  the  closure  of  the 
current  produces  at  the  cathode  no  longer  a  simple  lightning-like  con- 
traction, but  a  prolonged  cramp  of  the  muscle,  spoken  of  as  cathodal 
closing  tetanus,  or  CCTe.  The  contraction  produced  by  both  opening 
and  closing  the  current  at  the  anode  is  now  much  stronger  than  before, 
and  there  will  probably  appear  a  slight  contraction  at  the  opening  of 
the  cathode,  the  cathodal  opening  contraction,  or  COC  —that  is  to  say, 
with  gradual,  increasing  current  the  order  of  contraction  is  as  follows 
in  a  normal  muscle  :  cathodal  closing  contraction,  anodal  closing  con- 
traction, anodal  opening  contraction,  cathodal  closing  tetanus,  cathodal 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


993 


opening  contraction.  Under  ordinary  circumstances  the  healthy  mnscle 
contracts  suddenly  and  relaxes  almost  immediately.  Various  modi- 
fications of  these  phenomena  occur  in  diseased  conditions,  and  there  are 
considerable  quantitative  changes  between  the  different  muscles  in 
health.     Thus,  in  the  muscles  of  the  face  contraction  is  always  more 


Diagram  of  the  motor  points  of  the  arm,  under  side. 
1.  Musculocutaneous  nerve.     2.  Musculocutaneous  nerve, 
triceps.    6.    Median  nerve.     8.  Brachialis  anticus.      10.  Ulnar  nerve, 
nerve  to  the  pronator  teres. 


(From  Vox  Ziemssen.) 

3    Biceps.    4.  Internal  nerve  of 


12.    Branch  of  median 


rapid  than  in  those  of  the  thigh,  and  can  be  elicited  with  much  weaker 
currents.  In  disease  we  recognize  three  types  of  alteration :  First, 
quantitative  changes ;  second,  quantitative  qualitative  changes ;  third, 
pure  qualitative  changes.  Before  discussing  these  it  is  necessary  to 
describe  the  faradic  apparatus.  This  consists  essentially  of  a  coil  of 
wire  through  which  flows  an  electric  current,  that  forms  the  core  for  a 


Motor  points  of  the  arm,  outer  side.    (From  Von  Ziemssi  v  i 

1.  External  head  of  triceps.    2.  Musculo-spinil  nerve.    3.  Brachialis  anticus.    -1.  Supinator 

longus.    5.  Extensor  carpi  radialis  longior.    6.  Extensor  carpi  radialis  hrevior. 

second  coil  not  attached  to  it.  If,  now,  the  current  passing  through 
the  inner  or  primary  coil  is  interrupted,  there  will  be  generated,  at  each 
opening  of  the  current,  a  current  in  the  outer  or  secondary  coil,  going 
in  the  opposite  direction,  and,  at  each  closure,  a  current  going  in  the 
same  direction.     This  is  usually  the  stronger,  and,  if  the  interruptions 

63 


994 


SPECIAL  DIAGNOSIS. 


are  sufficiently  rapid,  dominates  the  reversed  current.  The  ends  of  the 
secondary  coil  are  attached  to  the  electrodes.  The  strength  of  the  cur- 
rent is  altered  by  moving  the  inner  coil  away  from  the  secondary  coil. 


Fig.  231. 


Motor  points  of  forearm,  inner  surface.  Motor  points  of  forearm,  outer  surface. 

(From  Vo.v  Ziemssen.) 

Fig.  230.— 1.  Flexor  carpi  radialis.  2.  Branch  of  the  median  nerve  for  the  pronator  teres.  3. 
Flexor  profundus  digitorum.  4.  Palmaris  longus.  5.  Flexor  sublimis  digitorum.  6.  Flexor 
carpi  ulnaris.  7.  Flexor  longus  pollicis.  8.  Flexor  sublimis  digitorum  (middle  and  ring  fingers). 
9.  Median  nerve.  10.  Ulnar  nerve.  11.  Abductor  pollicis.  12.  Flexor  sublimis  digitorum  (index 
and  little  finger).  13.  Opponens  pollicis.  14.  Deep  branch  of  ulnar  nerve.  15.  Flexor  brevis 
pollicis.  16.  Palmaris  brevis.  17.  Adductor  pollicis.  18.  Adductor  minimi  digiti.  19.  Lumbri- 
calis  (first).  20.  Flexor  brevis  minimi  digiti.  22.  Opponens  minimi  digiti.  24.  Lumbricales 
(second,  third,  and  fourth). 

Fig.  231.— 1.  Extensor  carpi  ulnaris.  2.  Supinator  longus.  3.  Extensor  minimi  digiti.  4.  Ex- 
tensor carpi  radialis  longior.  5.  Extensor  indicis.  6.  Extensor  carpi  radialis  brevior.  7.  Extensor 
secundi  internodii  pollicis.  8.  Extensor  communis  digitorum.  9.  Abductor  minimi  digiti.  10. 
Extensor  indicis.  11.  Dorsal  interosseus  (fourth).  12.  Extensor  indicis  and  extensor  ossis  meta- 
carpi  pollicis.  14.  Extensor  ossis  metacarpi  pollicis.  16.  Extensor  primi  internodii  pollicis.  18. 
Flexor  longus  pollicis.    20.  Dorsal  interossei. 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


995 


This  is  spoken  of  as  the  distance  between  the  coils,  and  is  measured  in 
inches  or  centimetres.  It  is  manifest  that  this  method  for  measuring 
is  not  absolute,  but  its  value  must  be  determined  for  each  particular 
machine.  This  can  only  be  done  by  the  physiological  test — that  is, 
measuring  the  force  required  to  produce  contractions  in  some  muscles 
and  then  comparing  it  with  the  known  value  for  this  muscle  obtained  by 
a  standard  machine,  and  obtaining  in  this  way  the  ratio.     The  current 


Fig.  232. 


Fig.  233. 


....5 


02 9 


Motor  points  of  thigh,  anterior  surface.  Posterior  surface. 

(From  Von  Ziemssen.) 

Fig.  232. — 1.  Tensor  vaginae  femoris  (branch  of  superior  gluteal  nerve).  2.  Anterior  crural  nerve. 
3.  Tensor  vaginse  femoris  (branch  of  crural  nerve).  4.  Obturator  nerve.  5.  Rectus  femoris.  6.  Sar- 
torius.  7.  Vastus  externus.  8.  Adductor  longus.  9.  Vastus  externus.  10.  Branch  of  crural  nerve 
to  quadriceps  extensor  cruris.    12.  Crureus.    14.  Branch  of  crural  nerve  to  vastus  externus. 

Fig.  233.— 1.  Adductor  magnus.  2.  Inferior  gluteal  nerve  for  gluteus  maximus.  3.  Semi-tendin- 
osus.  4.  Great  sciatic  nerve.  5.  Semi-membranosus.  6.  Long  head  of  biceps.  7.  Gastrocnemius 
(internal  head).  8.  Short  head  of  biceps.  10.  Posterior  tibial  nerve.  12.  Peroneal  nerve.  14.  Gas- 
trocnemius (external  head).    16.  Soleus. 


is,  of  course,  increased  when  the  secondary  coil  is  directly  over  the 
primary  one  and  diminished  when  the  primary  coil  is  withdrawn.  As 
the  current  in  the  secondary  coil  is  oscillatory — that  is,  going  first  in 
one  direction  and  then  in  the  other — it  is  not  theoretically  possible  to 
speak  of  an  anode  and  a  cathode.  Practically,  however,  the  current 
going  in  the  same  direction  as  that  of  the  primary  coil  is  the  stronger, 
and  a  difference  does  exist  between  the  two  ends  of  the  wire,  which  are 


996 


SPECIAL  DIAGNOSIS. 


usually  spoken  of,  therefore,  as  cathode  and  anode.  A  contraction  pro- 
duced by  the  faradic  stream  is  always  tetanic  in  health,  as  there  are  a 
series  of  stimulations  constantly  passing  through  the  muscle. 


Fig.  234. 


Fig.  235. 


Motor  points  of  the  leg,  outer  side.  Inner  side. 

(From  Von  Ziemssen.) 
Fig.  234.— 1.  Peroneal  nerve.  2.  Peroneus  longus.  3.  Gastrocnemius  (external  head).  4.  Tibi- 
alis anticus.  5.  Soleus.  6.  Extensor  longus  pollicis.  7.  Extensor  communis  digitorum  longus. 
8.  Branch  of  peroneal  nerve  for  extensor  brevis  digitorum.  9.  Peroneal  brevis.  10.  Dorsal  inter- 
ossei.  11.  Soleus.  13.  Flexor  longus  pollicis.  15.  Extensor  brevis  digitorum.  17.  Abductor 
minimi  digiti. 

Fig.  235.— 1.  Gastrocnemius  (internal  head).    2.  Soleus.    3.  Flexor  communis  digitorum  longus. 
4.  Posterior  tibial  nerve.    5.  Abductor  pollicis. 


Alterations  in  the  Reactions  of  the  Muscles  and  Nerves 
to  Electricity.  Reactions  of  Degeneration.  Quantitative 
alterations  consist  in  increase  or  decrease  of  the  susceptibility  of  the 
muscles  or  nerves  to  electrical  action.  They  may  be  determined  in 
case  the  lesion  is  unilateral  by  comparison  with  the  normal  side  of  the 
body  ;  in  case  the  lesion  is  bilateral,  only  by  comparison  with  a  stand- 
ard table,  such  as  has  been  furnished  by  Stintzing. 


If  the  deviation 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


997 


from  the  normal  is  slight,  the  error  has  very  likely  been  produced  by 
variation  or  alteration  in  the  resistance  of  the  skin.  Quantitative 
increase  in  the  electrical  reaction  occurs  chiefly  in  tetany,  for  which 
disease  it  is  almost  pathognomonic,  and  has  been  spoken  of  as  Erb's 
sign.  It  occurs  also  occasionally  in  the  early  stages  of  hemiplegia,  in 
paralysis  of  the  facial  nerve,  and  has  been  noted  in  certain  cases  of 
tabes  dorsalis.  Diminished  electrical  irritability  occurs  in  all  the  forms 
of  idiopathic  muscular  dystrophy.  It  also  occurs  in  those  forms  of 
atrophy  due  to  lesion  of  the  central  motor  neuron  without  involve- 
ment of  the  peripheral  motor  neuron.  It  also  occurs  in  those  atrophies 
secondary  to  disease  of  the  joints  and  loss  of  functional  activity  on  the 
part  of  the  muscle.  Diminished  reaction  may  occur  in  hysteria  and 
profound  neurasthenia,  and  has  been  observed  in  some  cases  of  loco- 
motor ataxia,  and  even  in  some  cases  of  progressive  spinal  muscular 
atrophy  of  exceedingly  slow  course.  It  also  occurs  in  certain  nervous 
diseases  whose  nature  is  not  yet  understood,  as  in  Goldflam's  periodic 
paralysis,  although  it  is  to  be  noted  that  there  are  other  alterations  in 
the  electrical  reactions  in  this  disease.  The  quantitative  qualitative  reac- 
tion consists,  first,  of  a  diminution  of  the  reaction  of  the  muscle  or  the 
nerve  to  the  faradic  current,  and  its  diminution  or  exaggeration  to  the 
galvanic  current,  with  distinct  alteration  of  the  order  in  which  the 
various  forms  of  galvanic  irritation  produce  contractions.  Cohn  dis- 
criminates three  types  of  this  form  of  degeneration  :  First,  the  complete 
reaction,  mild  in  character,  and  terminating  in  recovery ;  second,  the 
complete  reaction,  severe  and  incurable;  and,  third,  a  partial  reaction. 
He  gives  the  following  table  illustrating  the  various  stages  of  these  three 
forms  : 

Total  Reaction  of  Degenekation. 


Moderate  Form. 
Indirect  stimulation  (nerve). 


Direct  stimulation  (muscle). 


1st  stage,  1-8  days. 
2d  stage,  2-15  weeks. 


F. 
Diminished. 
Lost. 


G. 
Diminished. 
Lost. 


F. 
Diminished. 
Lost. 


3d  stage,  6-30  weeks.       Returning.        Returning.        Returning. 


4th  stage,  later. 


1st  and  2d  stages. 

3d  stage,  after  6  weeks. 


Subnormal.       Subnormal.       Subnormal. 


Progressive  Incurable  Form. 

As  first  and  second  stages  above. 
Lost.  Lost.  Lost. 


G. 
Diminished. 
Increased, con- 
traction slow. 

AOOCCC. 
Diminishing 

contraction 

more  rapid. 

AOC  =  or 

>CCC. 

Subnormal,  no 

qualitative 

changes 


Diminished 
or  lost. 
AOOCCC. 


1  By  direct  stimulation  is  meant  the  application  of  the  electrode  to  the  muscle  itself- 
By  indirect  stimulation  is  meant  the  application  of  the  electrode  to  the  motor  nerve- 
trunk.  The  latter  term  is  employed  because  irritation  of  the  nerve  can  only  be  detected 
by  the  activity  of  the  muscle,  and  the  stimulation  of  the  latter  is,  of  course,  in  this 
mode  of  application,  indirect. 


998 


SPECIAL  DIAGNOSIS. 


Partial  Reaction  of  Degeneration. 

Indirect  stimulation  (nerve).         Direct  stimulation  (muscle). 


F. 

G.                          F. 

G. 

1st  stage. 

1-8  days. 

Normal  or 

Normal  or        Normal  or 

Normal  or 

diminished. 

diminished,      diminished. 

diminished. 

2d  stage, 

2-5  weeks. 

Normal  or 

Normal  or        Normal  or 

Increased,  con- 

diminished. 

diminished.      diminished. 

traction  slow. 
AOCKCCC. 

3d  stage. 

6-12  weeks. 

All  normal  oi 

■  progressive  form. 

3d  stage, 

6  weeks. 

Diminished 

Diminished      Diminished 

Diminished 

or  lost. 

or  lost.              or  lost. 

or  lost. 
Contraction 
still  slow. 
AOC<CCC. 

The  following  points  in  these  tables  need  explanation.  The  faradic 
reaction  is  similar  to  that  which  occurs  in  the  normal  muscle,  but 
requires  a  much  stronger  current  to  produce  it.  The  galvanic  reaction 
of  the  nerve  is  similar  to  that  obtained  under  normal  conditions,  except- 
ing that  a  stronger  current  is  required.  The  contraction  is  lightning- 
like and  disappears  instantly.  The  direct  galvanic  stimulation  of  the 
muscle,  however,  produces  a  worm-like  contraction  very  different  from 
that  observed  in  the  normal  muscle,  and  is  ascribed  to  the  direct  stimu- 
lation of  the  muscle  itself  and  not  to  the  stimulation  of  thet  erminations 
of  the  motor  nerves.  This  often  occurs  with  a  much  weaker  current 
than  is  normally  required  to  produce  contraction  in  the  muscle.  It 
will  also  be  observed  that  the  cathodal  closing  contraction  is  no  longer 
the  first  to  appear,  but  it  is  replaced  by  the  anodal  opening  contraction, 
and  this  is  followed  by  the  anodal  closing  contraction,  cathodal  closing 
contraction  occurring  only  with  relatively  strong  currents.  If  regen- 
eration occurs  muscular  contractions  occur  in  response  to  weaker  faradic 
currents,  and  by  direct  galvanic  stimulation  they  become  more  light- 
ning-like in  character.  Gradually  the  cathodal  closing  contraction 
appears  in  response  to  weaker  currents,  and  finally  occurs  before  the 
anodal  opening  contraction.  If  recovery  does  not  take  place,  direct 
galvanic  stimulation  requires  stronger  and  stronger  currents,  and  there 
is  no  increase  in  the  rapidity  of  the  contraction.  The  cathodal  closing 
contraction  disappears,  and  finally  only  the  anodal  contraction  remains, 
which  is  exceedingly  slow  and  worm-like.  When  the  muscle-tissue  has 
been  completely  replaced  by  connective  tissue  all  reactions  naturally 
cease.  The  partial  reaction  of  degeneration  is  very  similar  to  the  mild, 
complete  form.  Recovery,  however,  occurs,  as  a  rule,  very  rapidly. 
The  reaction  of  degeneration  may  be  used  for  determining'  the  prog- 
nosis of  the  case.  When  after  the  sixth  week  the  muscle  does  not 
respond  as  readily  as  before  to  direct  galvanic  stimulation,  and  the 
cathodal  closing  contraction  becomes  equal  to  or  greater  than  the  anodal 
opening  contraction,  the  prognosis  is  exceedingly  favorable.  Particu- 
larly the  increased  rapidity  of  the  contraction  is  of  great  significance. 
If,  on  the  other  hand,  after  from  six  to  twelve  weeks  no  change  has 
occurred  and  the  anodal  still  precedes  cathodal  contraction,  and  both 
are  worm-like  in  character,  the  prognosis  is  doubtful.  Months,  how- 
ever, may  elapse  before  the  muscle  gradually  begins  to  regain  its  normal 


DISEASES  OF  THE  NERVOUS  SYSTEM.  999 

character.  The  voluntary  contractions  of  the  muscle,  as  a  rule,  persist 
after  the  reaction  of  degeneration  has  become  manifest,  unless,  of  course, 
there  has  been  total  destruction  of  the  peripheral  motor  neurons.  Often 
in  cases  of  peripheral  neuritis  it  will  be  observed  that  the  reaction  of 
degeneration  is  present  in  muscles  that  are  apparently  healthy,  but 
which,  when  the  process  is  progressive,  subsequently  atrophy.  When 
regeneration  occurs  voluntary  motion  will  have  been  almost  completely 
restored  long  before  the  muscle  has  become  entirely  normal,  and  it 
may  often  reappear  before  any  improvement  can  be  detected  in  the 
electrical  reactions.  In  testing  these  reactions  the  following  points  are 
to  be  noted  :  First,  the  reaction  of  the  nerve  to  faradic  and  galvanic 
electricity  ;  second,  the  reaction  of  the  muscle  itself.  It  is  particularly 
important  to  be  certain  that  only  the  muscle  under  investigation  is 
affected  by  the  electrical  current.  Sometimes  it  will  be  impossible  to 
accomplish  this,  but  ordinarily  it  can  be  done  sufficiently  well  to  enable 
us  to  secure  positive  results.  It  must  be  remembered,  however,  that 
the  reactions  of  degeneration  often  occur  in  the  muscles  of  limbs  that 
have  been  injured,  or  are  found  in  limbs  in  which  some  of  the  groups 
of  muscles  have  already  undergone  atrophy,  and  thus  altered  the  ana- 
tomical relations.  Under  these  circumstances  mistakes  are  very  likely 
to  arise.  Sometimes  valuable  information  can  be  obtained  by  stimu- 
lating a  nerve-trunk  and  observing  whether  all  the  muscles  innervated 
show  normal  or  impaired  contractility.  Quantitative  and  qualitative 
reactions  of  degeneration  occur  primarily  as  a  result  of  disease  of  the 
peripheral  motor  neuron.  They  are,  therefore,  found  in  all  diseases  of 
the  spinal  cord  that  affect  the  anterior  cornua  or  the  motor  roots,  and 
in  all  diseases  of  the  medulla  that  affect  the  motor  nuclei  or  their  roots  ; 
therefore,  in  acute  and  chronic  antero-poliomyelitis,  progressive  spinal 
muscular  atrophy,  in  bulbar  palsy,  in  transverse  myelitis,  syringo- 
myelia, tumor  of  the  cord,  and  as  a  result  of  chronic  forms  of  menin- 
gitis, or  disease  of  the  vertebral  columns  pressing  upon  the  roots. 
They  are  also  found  in  all  forms  of  peripheral  neuritis,  either  the 
toxic,  the  infectious,  or  the  traumatic,  and  in  all  cases  of  solution  of 
continuity  of  the  nerves.  They  occasionally  occur  in  the  so-called 
idiopathic  muscular  dystrophies,  but  in  these  they  are  exceptional. 
They  are  also  found  in  a  few  cases  after  cerebral  lesions. 

Atypical  Types  of  the  Reaction  of  Degeneration.  Only  two  of  these 
are  important.  First,  the  myotonic  reaction,  consists  of  the  persistence 
of  the  muscular  contraction  after  the  electric  stimulus  has  been  removed. 
This  occurs  either  with  the  faradic  or  the  galvanic  current,  but  the  order 
of  contraction  to  the  various  forms  of  stimulation  of  the  latter  is  not 
altered.  This  reaction  is  pathognomonic  of  Thomsen's  disease — myo- 
tonia congenita.  It  is  more  likelv  to  occur  as  a  result  of  stimulation 
of  the  muscle  itself  than  of  stimulation  of  the  nerve.  Second,  the 
myesthenic  reaction  is  characterized  by  the  rapid  exhaustion  of  the 
muscle  or  the  nerve,  so  that  relaxation  may  take  place  while  the  faradic 
current  is  still  being  employed,  and  if  the  muscle  is  stimulated  succes- 
sively several  times,  it  loses  its  power  to  contract  or  requires  a  stronger 
current.  It  occurs  in  periodic  family  paralysis.  Remak  and  Marino 
have  described  a  peculiar  form  of  reaction  which  they  name  the  neuro- 


1000  SPECIAL  DIAGNOSIS. 

tonic  reaction.  It  consists  of  the  persistence  of  the  contraction  only 
after  stimulation  of  the  nerve. 

Disturbances  of  Speech.  These  may  be  divided  into  two  groups  : 
aphasia,  the  disturbance  of  the  central  nervous  mechanism  controlling 
speech,  writing,  and  mimicry ;  and  anarthria,  the  disturbance  of  the 
peripheral  motor  mechanism  of  speech. 

By  aphasia  is  meant  the  loss  or  impairment  of  the  ability  to  under- 
stand spoken,  written,  or  mimic  language,  and  to  express  thoughts 
by  the  same  means.  It  is  ordinarily  divided  into  two  forms  :  motor 
aphasia,  or  the  inability  to  innervate  the  motor  apparatus  for  speech, 
while  the  sensory  or  perceptive  functions  are  intact ;  and  sensory 
aphasia,  or  the  inability  to  recall  or  understand  words,  although  the 
ability  to  produce  sound  is  preserved.  A  variety  of  other  forms,  how- 
ever, have  in  the  course  of  time  come  to  be  recognized.  Oppenheim 
recognizes  the  following  five  varieties  :  (1)  Jlotor  aphasia.  This  consists 
of  the  loss  of  power  to  speak,  with  persistence  of  the  understanding  of 
spoken,  written,  and  mimic  speech.  This  is  the  first  form  of  aphasia  in 
which  it  was  possible  to  locate  with  accuracy  the  portion  of  the  brain 
involved.  The  lesion  is  cortical  or  subcortical,  and  involves  the  foot  of 
the  third  frontal  convolution  on  the  left  side.  The  symptoms  are 
variable  according  to  the  extent  and  destructiveness  of  the  lesion.  (2) 
Sensory  aphasia.  The  perception  of  sound  as  such  is  preserved,  but  there 
is  inability  to  recognize  the  significance  of  words,  although  spontaneous 
and  occasionally  voluntary  speech  is  preserved.  The  lesion  is  usually 
found  in  the  auditory  centre — that  is,  the  first  temporal  convolution 
on  the  left  side.  The  symptoms  may  be  variable,  alexia  being  often 
present.  (3)  Pure  alexia,  or  word  blindness.  In  this,  although  sight 
is  preserved  and  objects  may  be  recognized,  the  ability  to  understand 
written  or  printed  language  is  lost.  Spoken  speech  is  still  understood, 
voluntary  speech  and  writing  possible,  and  occasionally  written  words 
may  be  read  if  the  patient  is  permitted  to  trace  the  letters  with  a  pencil 
or  the  finger,  recognizing  each  one  as  it  is  formed.  The  lesion  is 
usually  found  in  the  left  occipital  lobe  on  the  external  surface,  but 
sometimes  involves  the  gyrus  angularis.  (4)  Pure  agraphia,  or  the 
loss  of  power  to  write,  all  the  other  cmalities  remaining  normal.  Lesions 
have  been  found  in  the  left  upper  parietal  lobe.  (5)  Optie  aphasia. 
In  this  objects  may  be  seen  and  recognized,  but  it  is  impossible  for  the 
patient  to  find  the  proper  name  for  them.  If  the  objects  are  recog- 
nized by  some  other  sense,  as,  for  example,  hearing  or  touch,  the  name 
may  be  recollected  instantly.  The  lesion  is  usually  found  at  the  junc- 
tion of  the  first  temporo-sphenoidal  and  the  occipital  lobes.  This  form 
is  frequently  a  symptom  in  otitic  abscess.  Loss  of  the  stereognostic 
sense  may  also  be  regarded  in  some  respects  as  an  aphatic  manifestation. 

In  order  to  explain  aphasia,  it  has  been  customary,  since  the  time 
of  Wernicke,  to  employ  the  diagram  given  in  Fig.  236.  In  this  the 
triangle,  A  C  31,  represents  the  intra-cerebral  paths  and  centres  for 
the  mechanism  of  speech,  and  the  lines  Aa  and  Mm  the  peripheral 
apparatus.  In  this  diagram  A  represents  the  centre  for  auditory  per- 
ception ;  31  the  centre  for  the  emission  of  motor  impulses  ;  and  C  the 
concept  centre,  in  which  the  intellect  analyzes  the  impressions  received 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


1001 


and  from  which  the  directing  influence  for  the  choice  of  language  is 
transmitted  to  the  motor  centre.  Aa  represents  the  auditory  nerve  ; 
Mm,  the  motor  nerves  to  the  pharynx,  tongue,  and  lips.  Auditory 
impressions   may,  therefore,   be  transmitted  along  Aa  to  A,  thence 


directly  to  M,  and  thence  to  the  larynx.  This  is  the  mechanism  sup- 
posed to  be  involved  in  ordinary  mechanical  speech — that  is  to  say, 
the  mechanical  repetition  of  spoken  words.  The  auditory  impressions 
may,  however,  pass  from  A  to  C,  there  be  analyzed  or  understood,  and 
then  transmitted  to  M,  either  in  the  same  or  altered  form.  This  con- 
stitutes the  intelligent  repetition  of  spoken  speech.  If  the  alteration 
of  form  is  considerable,  or  if,  without  immediate  auditory  impressions, 
impulses  are  transmitted  from  C  to  M,  voluntary  or  intelligent  speech 
is  said  to  occur.  Although  this  diagram  probably  does  not  accurately 
represent  the  conditions  existing  in  the  brain,  it  has  been  found  that 
the  varieties  of  aphasia  that  can  be  theoretically  deduced  from  it  cor- 
respond more  or  less  closely  to  those  that  may  be  recognized  in  actual 
practice.  These  varieties  are  as  follows  :  Destruction  of  the  motor 
centre,  M,  gives  rise  to  the  so-called  cortical  motor  aphasia  with  the 
following  symptoms  :  Loss  of  (1)  voluntary  speech ;  (2)  repetition  ; 
(3)  reading  aloud ;  (4)  voluntary  writing ;  (5)  writing  from  dictation. 
There  are  preserved  (1)  the  understanding  of  speech;  (2)  the  under- 
standing of  writing ;  (3)  the  ability  to  copy  writing.  Destruction  of 
the  auditory  centre,  A,  gives  rise  to  cortical  sensory  aphasia.  There 
are  lost  (1)  the  understanding  of  speech ;  (2)  the  understanding  of 
writing;  (3)  the  ability  to  repeat  speech;  (4)  the  ability  to  write  from 
dictation ;  (5)  the  ability  to  read  aloud.  There  are  preserved  (1)  vol- 
untary speech  ;  (2)  voluntary  writing  ;  (3)  the  ability  to  copy  writing. 
A  lesion  in  C  would  give  rise  to  cortical  apperceptive  aphasia.  The 
symptoms  of  this  form  would  differ  very  slightly  from  those  due  to 
interruption  of  the  tracts  supplying  it.  The  centre  is  probably  com- 
plex and  its  parts  are  widely  distributed.  The  speech  disturbances  of 
general  paresis  are  possibly  due  to  its  partial  destruction.  Lesions  of 
the  various  tracts  of  fibres  connecting  the  different  centres  with  each 
other  or  with  the  periphery  also  produce  symptoms.  Lesions  between 
A  and  M  produce  the  symptom  known  as  paraphasia.     (1)  Voluntary 


1002  SPECIAL  DIAGNOSIS. 

speech  ;  (2)  repetition  of  speech  ;  (3)  the  understanding  of  spoken  and 
written  language  ;  and  (4)  the  ability  to  copy  writing  are  all  preserved. 
The  only  symptom,  therefore,  of  this  condition  is  the  misuse  or  false 
pronunciation  of  words.  Thus,  objects  may  be  misnamed,  one  word 
used  in  place  of  another,  different  syllables  of  the  words  misplaced 
(literal  paraphasia),  or  the  words  jumbled  in  a  sentence  (verbal  par- 
aphasia). There  is  usually  also  paragraphia — that  is,  a  similar  dis- 
turbance of  written  language ;  paralexia,  manifest  when  the  patient 
attempts  to  read  aloud,  and  sometimes  the  symptom  known  as  agram- 
matism— that  is,  the  misuse  of  cases,  moods,  or  tenses.  Paraphasia, 
however,  occurs  also  in  certain  general  diseases  of  the  brain,  and  is 
practically  always  present  if  the  intrinsic  tracts  concerned  in  speech 
are  disturbed.  Interruption  of  the  tract  uniting  C  and  M  causes  trans- 
cortical motor  aphasia.  There  are  lost  (1)  voluntary  speech  and  (2) 
voluntary  writing.  There  are  preserved  (1)  the  understanding  of  speech ; 
(2)  the  understanding  of  writing  ;  (3)  the  ability  to  copy  ;  (4)  the  ability 
to  repeat  words  ;  (5)  the  ability  to  write  from  dictation  ;  (6)  the  ability 
to  read  aloud.  The  most  characteristic  symptom  is  the  inability  of  the 
patient  to  remember  words,  although  he  is  able  to  repeat  them  fluently. 
The  interruption  between  A  and  C  gives  rise  to  transcortical  sensory 
aphasia.  There  are  lost  (1)  the  understanding  of  speech  ;  (2)  the  under- 
standing of  writing.  There  are  preserved  (1)  voluntary  speech ;  (2) 
voluntary  writing  ;  (3)  the  repetition  of  speech  ;  (4)  reading  aloud  ; 
(5)  writing  from  dictation.  Both  voluntary  speech  and  writing  are 
usually  affected  by  the  paraphasia  common  to  the  interruption  of  the 
intrinsic  tracts.  It  differs  from  the  preceding  form  particularly  in  the 
fact  that  words  spoken  upon  repetition  or  written  from  dictation  are 
not  in  the  least  understood  by  the  patient.  In  this  form  communica- 
tion with  the  patient,  even  by  gestures,  is  often  impossible.  Finally, 
lesions  may  occur  in  the  tracts  uniting  the  centres  concerned  in  speech 
with  the  periphery.  Lesions  in  the  tract  Mm  give  rise  to  subcortical 
motor  aphasia.  There  are  lost  (1)  voluntary  speech ;  (2)  repetition  of 
speech  ;  (3)  the  ability  to  read  aloud.  There  are  preserved  (1)  the  under- 
standing of  speech ;  (2)  the  understanding  of  writing ;  (3)  the  ability 
to  copy  ;  (4)  voluntary  writing ;  and  (6)  writing  from  dictation.  This 
is,  of  course,  the  purest  form  of  motor  aphasia.  Interruption  of  the 
tract  Aa  gives  rise  to  subcortical  sensory  aphasia.  There  are  lost  (1) 
understanding  of  speech ;  (2)  the  repetition  of  speech ;  (3)  the  ability 
to  write  from  dictation.  There  are  preserved  (1)  voluntary  speech ; 
(2)  voluntary  writing ;  (3)  understanding  of  writing ;  (4)  reading  aloud ; 
and  (5)  copying. 

This  theoretical  classification  with  groupings  of  symptoms  is  sus- 
ceptible to  modification  in  actual  pathology  by  a  variety  of  conditions. 
The  most  important  modification  is  that  produced  by  the  existence  of 
possible  lesions  of  other  centres  concerned  in  speech.  Thus,  the  share 
taken  by  the  visual  receptive  and  apperceptive  centres  is  of  great 
importance  in  all  persons  who  have  been  taught  to  read.  They  are 
necessarily  concerned  also  in  the  production  of  writing.  It  is  not, 
however,  possible  to  represent  them  by  a  diagram  as  we  have  repre- 
sented auditory  and  motor  speech,  for  it  appears  that  impulses  from 


DISEASES  OF  THE  NEB  VO  US  SYSTEM. 


1003 


the  visual  centres  must  pass  through  the  receptive  centre  for  speech, 
or  A,  before  being  transferred  to  the  arm  centre  or  the  speech  centres. 
The  same  is  true  for  tactile  impressions.  These  are  of  importance 
chiefly  in  blind  persons  who  have  been  taught  to  read  with  their 
fingers,  in  whom,  indeed,  they  may  equal  in  importance  the  role  of 
the  visual  centres  in  normal  persons.  Various  complicated  diagrams 
have  been  devised  for  the  purpose  of  exhibiting  the  influence  of  all 
these  centres  upon  speech,  and  Mills  has  introduced  an  additional 
naming  centre,  situated  in  the  third  temporal  convolution,  in  which 


Fig.  237. 


R.P.A.C. 

L.P.A.C. 

A,  auditory  centre  (centre  for  word-hearing) ;  V,  visual  centre  (centre  for  word-seeing)  ;  N, 
naming  centre  (centre  where  percepts  are  given  in  name)  ;  B,  motor  speech  centre  in  Broca's 
convolution  (regarded  by  Broadbent  as  a  propositionizing  centre) ;  an  utterance  centre— motor 
centre — is  also  required  to  complete  the  motor  side  of  the  speech  process,  if  the  view  is  accepted  ; 
G,  graphic  centre;  R.  Oc,  primary  cortical  visual  centre  in  the  right  occipital  lobe;  L.  Oc, 
primary  cortical  visual  centre  in  the  left  occipital  lobe ;  R.  P.  O.  C,  optic  centres  at  the  base 
of  the  brain,  right  side;  L.  P.  O.  C,  optic  centres  at  tbe  base  of  the  brain,  left  side;  R  T., 
primary  cortical  auditory  centres  in  the  right  temporal  lobe;  L.  T  ,  primary  cortical  auditory 
centres  in  the  left  temporal  lobe ;  R.  P.  A.  C,  auditory  centres  at  the  base  of  the  brain,  right  side  ; 
L  P.  A.  C,  auditory  centres  at  the  base  of  the  brain,  left  side. 

perceptions  are  given  the  names  that  properly  belong  to  them.  His 
diagram  is  one  of  the  most  satisfactory  of  all  the  more  complicated 
diagrams  representing  the  speech  function  (see  Fig.  2-37),  but,  unfortu- 
nately, it  is  not  yet  possible  to  deduce  from  it  theoretically  the  symptoms 
that  actually  occur.  Another  source  of  error  is  the  fact  that  lesions 
may  be  only  partially  destructive,  or  may  be  so  large  as  to  involve  two 
or  more  tracts  or  centres  at  the  same  time.  Under  these  circumstances 
the  symptoms  become  very  complex,  and  it  is  often  impossible  to  deter- 
mine the  extent  of  the  physiological  disturbance  that  has  been  pro- 
duced.    Usually,  however,  the  localization  of  these  lesions  is  not  dim- 


1004  SPECIAL  DIAGNOSIS. 

cult,  on  account  of  the  predominance  of  certain  characteristic  localizing 
symptoms. 

It  will  be  obvious  from  this  description  that  it  is  necessary  in  each 
case  of  aphasia  to  test  a  variety  of  functions.  These  can  best  be 
examined  as  follows :  1.  Voluntary  speech.  If  the  patient  is  able 
to  answer  questions  intelligently  or  makes  spontaneous  intelligent 
remarks  to  the  physician,  voluntary  speech  is  preserved.  Voluntary 
speech  may,  however,  exist  and  the  remarks  of  the  patient  be  never- 
theless unintelligible  when  there  is  an  extreme  degree  of  paraphasia. 

2.  The  ability  to  repeat  words.  This  may  be  tested  by  merely  saying 
a  word  or  several  words  and  getting  the  patient  to  repeat  them. 
Mechanical  speech,  whose  centre  is  supposed  to  be  located  in  the 
speech  area  of  the  right  hemisphere,  may  also  be  tested  by  request- 
ing the  patient  to  repeat  some  well-known  series — such,  for  example,  as 
the  names  of  the  days  of  the  week,  the  alphabet,  the  numbers,  or  the 
months.  Sometimes  familiar  songs  may  be  remembered  and  spoken 
when  it  is  absolutely  impossible  for  the  patient  to  make  an  intelligent 
answer.  Under  striking  emotional  conditions  epithets  or  oaths  may 
also  be  employed.  The  ability  to  repeat  words  may  sometimes  be 
present  when  it  is  impossible  to  determine  it  on  account  of  the  exist- 
ence of  transcortical  sensory  aphasia.  Under  these  circumstances  it  is 
impossible  to  make  the  patient  understand  what  he  is  expected  to  do. 

3.  Reading  aloud.  It  must  not  be  forgotten  that  in  some  cases  this 
symptom  is  masked  by  defects  of  vision.  If  possible,  the  eyes  should 
always  be  examined  and  the  patient  be  given  his  glasses  if  he  has  been 
in  the  habit  of  using  them.  It  is  advantageous  to  use  large  type,  such 
as  the  headlines  of  newspapers.  4.  Voluntary  writing.  This  symptom 
may  be  masked  by  the  existence  of  right  hemiplegia  and  inability  to 
write  with  the  left  hand.  5.  Writing  from  dictation.  As  in  the  repe- 
tition of  speech,  this  symptom  may  be  masked  by  the  inability  of  the 
patient  to  understand  what  he  is  expected  to  do.  6.  Copying.  Errors 
of  vision  should  again  be  excluded  as  well  as  paralysis  and  other  motor 
disturbances  of  the  arm.  7.  The  understanding  of  speech.  This  is 
perhaps  one  of  the  most  difficult  of  all  aphatic  symptoms  to  determine. 
The  patient  is  usually  requested  to  perform  some  simple  action,  such 
as  putting  out  the  tongue,  touching  the  ear  with  the  hand,  etc.  This 
may  be  perfectly  performed,  but  more  complex  commands  or  long 
statements  may  not  be  understood.  It  is  supposed  that  this  is  per- 
haps due  to  incompleteness  of  the  lesion,  or  to  a  general  disturbance  of 
intellect,  such  as  must  occur  in  any  case  of  aphasia,  in  a  more  or  less 
pronounced  degree.  It  is,  therefore,  important  to  attempt  if  possible 
to  converse  with  the  patient,  getting  him  to  reply  by  gestures,  or  writ- 
ing, according  to  his  ability,  and  gradually  to  employ  more  and  more 
complex  statements.  In  cases  of  marked  paraphasia  the  improper  use 
of  words  in  the  replies  may  lead  to  the  belief  that  the  patient  does  not 
understand  what  is  said  to  him,  when,  as  a  matter  of  fact,  word  per- 
ception is  perfect.  8.  Understanding  of  writing.  This  is  subject  to 
the  same  errors  as  the  understanding  of  speech,  and,  in  addition,  the 
possibility  of  visual  defect.  9.  The  existence  of  paraphasia.  This,  of 
course,  can  only  be  detected  when  either  voluntary  speech  or  the  ability 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


1005 


to  repeat  words  is  present.  Under  these  circumstances  it  may  be  recog- 
nized when  it  is  only  slight  in  degree  by  getting  the  patient  to  repeat 
words  of  many  syllables,  such  as  "  incomprehensibility/'  or  sentences 
of  several  words.  Disturbances  of  writing,  apart  from  disturbances  of 
speech,  may  also  occur.  These  may  be  better  understood  by  a  considera- 
tion of  Fig.  238,  in  which  the  writing  centres  are  added  to  the  speech 
centres.  It  will  be  seen  from  this  that  there  may  be  destruction  of  W, 
or  agraphia.  There  are  lost  (1)  voluntary  writing;  (2)  copying;  and 
there  is  preserved  the  ability  to  read.  Destruction  of  F,  or  cortical 
alexia.  This  is  characterized  by  the  loss  of  (1)  the  recognition  of  writ- 
ten words  ;  (2)  voluntary  writing.  Speech  may  be  mtact.  Destruction 
of  W  V,  or  conduction  agraphia.  There  is  lost  (1)  voluntary  writing ; 
(2)  voluntary  copying.  There  is  preserved  ability  to  read — that  is  to 
say,  it  corresponds  exactly  to  the  preceding  form.  Under  such  circum- 
stances paragraphia  may  exist  in  this  type.     Transcortical  agraphia. 


There  is  lost  voluntary  writing.  There  is  preserved  (1)  mechanical 
copying;  and  (2)  reading.  Transcortical  alexia.  There  is  lost  the 
ability  to  read.  There  is  preserved  (1)  voluntary  writing;  (2)  copy- 
ing. "  Finally,  there  may  be  interruption  of  the  tracts  to  the  periphery, 
giving  rise  to  subcortical  agraphia.  There  are  lost  (1)  voluntary 
writing ;  (2)  copying.  There  is  preserved  reading.  Paragraphia 
never  occurs  in  this  form.  Subcortical  alexia.  There  are  lost  reading 
and  copying.  There  is  preserved  voluntary  writing.  All  of  these 
forms  may  coexist  with  the  various  types  of  aphasia.  In  testing  the 
patient  for  alexia  the  following  symptoms  should  be  examined  :  (1) 
Voluntary  writing  (see  above) ;  (2)  writing  from  dictation  (see  above)  ; 
(3)  copying  ;  and  (4)  the  recognition  of  letters  either  spoken  or  written. 
In  testing  patients  for  voluntary  writing  with  the  left  hand,  it  must  be 
remembered  that  many  aphasics  give  mirror  writing.  The  following 
terms  are  also  used  in  connection  with  aphasia  :  aphrasia,  the  inability 


1006  SPECIAL  DIAGNOSIS. 

to  form  sentences  with  words ;  dysphasia,  the  imperfect  formation  of 
sentences  ;  a/praxia,  the  total  loss  of  speech. 

By  axarthria  is  meant  a  disturbance  in  the  peripheral  motor 
mechanibm  of  speech,  as  a  result  of  disease  of  the  nuclei  in  the  medulla 
or  of  the  peripheral  nerves  arising  from  them.  This  may  vary  in 
degree  from  complete  aphonia,  or  loss  of  power  to  make  sounds  and 
words,  which  occurs  in  bulbar  paralysis,  or  the  aphonia  of  laryngeal 
paralysis,  in  which  whispering  speech  is  still  preserved,  to  merely  the 
imperfect  pronunciation  of  certain  consonants,  as  a  result  of  local  paral- 
ysis or  paresis  of  the  lips  or  tongue.  Anarthria  may  be  permanent  or 
temporary,  or,  in  cases  of  slight  paresis,  recurrent,  giving  rise  to  inter- 
mittent claudication  of  speech.  It  is  best  tested  by  directing  the  patient 
to  repeat  letters  of  the  alphabet,  to  count,  or  to  repeat  words  with  long 
syllables  and  difficult  consonants,  as  "  artillery,"  "  extraordinarily," 
etc.  Allied  to  anarthria,  but  perhaps  the  result  of  certain  functional 
disturbance,  are  stuttering  and  stammering.  In  the  former,  if  the  patient 
attempts  to  speak,  there  is  inhibition  of  motion  for  a  longer  or  shorter 
interval,  and  then  the  word  may  be  pronounced  with  explosive  violence, 
and  the  following  words  of  the  sentence  spoken  normally.  In  stam- 
mering there  is  frequently  repetition  of  the  first  two  or  three  consonants 
of  the  word,  particularly  if  these  happen  to  be  labials.  Stuttering 
and  stammering  are  sometimes  associated  with  defective  intelligence. 
Finally,  there  are  a  series  of  disturbances  of  speech  in  which  intellec- 
tual derangement  is  apparently  the  chief  factor.  These  may  perhaps 
be  forms  of  aphasia  due  to  partial  destruction  of  the  concept  centre  or 
centres.  Among  them  may  be  mentioned  the  inability  or  unwillingness 
to  speak,  that  occurs  in  the  mutism  of  the  insane  ;  a  tendency  to  exces- 
sive speech,  logorrhoea  ;  the  omission  of  syllables,  particularly  character- 
istic of  general  paresis  ;  difficult  words,  such  as  those  mentioned  above, 
being  pronounced  imperfectly,  as  "  arlry  "  for  "  artillery,"  or  even  less 
accurately.  Scanning  speech,  in  which  the  words  are  separated  by 
considerable  intervals,  and  are  spoken  with  a  peculiar  drawl  and  a 
descending  cadence.  It  is  particularly  characteristic  of  multiple  scle- 
rosis, but  may  occasionally  occur  in  general  paresis.  Other  forms  are  : 
explosive,  or  staccato  speech,  and  a  peculiar,  slow,  drawling  utterance, 
occasionally  termed  bradylalia,  that  occurs  in  certain  states  of  mental 
depression.  Echolalia  occurs  almost  exclusively  in  imbeciles,  and  is 
characterized  by  the  repetition  of  all  sounds  heard. 

Disorders  of  xtjtrittox,  or  trophic  changes,  are  lesions  pro- 
duced in  tissues  as  a  result  of  defective  or  altered  innervation.  They 
may  be  classified  clinically  into  superficial  trophic  changes  affecting 
the  skin  and  its  appendages,  etc.,  and  deep  trophic  changes  affecting 
the  muscles  and  joints.  Among  the  superficial  trophic  changes  of  the 
mild  form  may  be  included  vasomotor  disturbances.  In  a  strict  sense 
flushing  and  the  dead  finger  of  Raynaud's  disease  are  trophic  altera- 
tions, but  it  is  not  certain  what  parts  of  the  central  nervous  system  are 
involved  in  order  to  bring  them  about.  More  severe  are  the  various 
eruptive  disorders  that  occur,  particularly  a  herpetic  eruption  along 
the  course  of  the  nerve  (herpes  zoster).  This  occurs  chiefly  along  the 
intercostal  nerves,  but  may  also  occur  along  the  other  nerves  of  the 


DISEASES  OF  THE  NERVOUS  SYSTEM.  1007 

body,  such  as  those  of  the  face.  It  is  characterized  by  the  appearance 
of  numerous  vesicles  surrounded  bv  a  congested  zone  and  limited 
strictly  to  the  distribution  of  the  nerve  or  nerves  involved.  It  occurs 
in  neuralgias,  in  chronic  neuritis,  and  in  some  cases  as  a  result  of  an 
injury  to  the  ganglion  of  the  posterior  spinal  root.  Among  the  milder 
trophic  disturbances  are  the  graying  or  falling  out  of  the  hair  in  the 
distribution  of  some  particular  nerve  and  the  alterations  in  the  nails. 
The  latter  are  characterized  by  an  increased  brittleness,  the  formation 
of  longitudinal  ridges,  and  an  excessive  slowness  of  growth,  which  may 
be  best  detected  by  staining  the  nail  at  its  root  with  nitric  acid  and 
comparing  the  amount  of  growth  with  that  observed  in  a  normal  nail. 
These  trophic  disturbances  in  the  nail  occur  in  general  cachectic  states, 
but  they  are  usually  slight.  They  are  more  pronounced  in  lesions  of 
the  peripheral  nerves  supplying  the  fingers  and  toes,  and  also  occur  in 
destructive  lesions  of  the  spinal  cord  hi  the  lumbar  or  cervical  enlarge- 
ment, such  as  syringomyelia  and  pachymeningitis  cervicalis  hyper- 
trophica.  More  severe  lesions  are  those  due  to  the  combination  of 
defective  resistance  and  secondary  infection.  These  are  chiefly  the 
forms  of  panaritis  observed  in  syringomyelia  and  characterized  by  the 
formation  of  an  abscess  at  the  root  of  the  nail,  which  breaks  down, 
leaving  a  chronic  ulcer  that  heals  very  slowly,  usually  with  the  loss  of 
the  nail.  In  leprosy,  in  either  the  nodular  or  neural  forms,  and  in 
Morvan's  disease,  somewhat  similar  changes  also  occur.  Atrophy  of 
the  subcutaneous  tissue  with  loss  of  elasticity  of  the  skin  is  also  a 
characteristic  form  of  trophic  disturbance.  The  part  is  shrunken,  the 
finger-tips  become  pointed,  the  skin  is  dry  and  glossy  or  glazed,  and 
the  cutaneous  bloodvessels,  especially  the  veins,  are  distended.  This 
occurs  in  destructive  lesions  of  the  peripheral  nerves,  and  particularly 
in  myelitis  or  destructive  lesions  of  the  spinal  cord.  An  analogous  change 
sometimes  occurs  in  the  teeth.  These  either  become  carious  very  rapidly 
and  are  destroyed,  or  become  loosened  in  their  sockets  and  fall  out  pain- 
lessly. The  latter  symptom  is  characteristic  of  the  early  stage  of  tabes 
dorsalis.  There  is  also  a  tendency  to  the  formation  of  chronic  ulcers  in 
the  affected  parts  as  a  result  of  trifling  injuries.  Finally,  severe  lesions 
of  the  central  nervous  system  may  give  rise  to  gangrene.  This  is 
characterized  by  the  rapid  destruction  of  the  skin  and  underlying 
parts  in  regions  subjected  to  the  most  trifling  injuries,  such  as  pressure. 
The  part  first  becomes  red,  then  a  slight  abrasion  is  formed  upon  the 
surface,  followed  by  ulceration  and  the  conversion  of  the  surrounding 
tissue  into  a  gangrenous  mass,  black  and  offensive.  The  usual  situa- 
tion is  upon  the  back,  just  over  the  sacrum  or  to  either  side  of  it.  It 
is  called  bed-sore,  or  decubitus.  Bed-sores  may  also  appear  upon  the 
hips,  the  knees,  the  heels,  the  shoulders,  or,  in  fact,  almost  any  part  of 
the  body.  They  are  ordinarily  the  result  of  myelitis,  in  which  they 
progress  rapidly,  and  are  more  extensive  than  in  any  other  condition. 
They  may  also  occur,  however,  in  cases  of  profound  cachexia  or  ex- 
haustion, and  as  a  result  of  prolonged  unconsciousness  and  of  lack  of 
attention  in  mental  disease.  Gangrene  of  the  skin  may  also  occur  in 
hysteria.  The  mechanism  of  this  is  not  clearly  understood,  but  it  is 
supposed  to  be  due  to  vasomotor  disturbances.    Other  severe  cutaneous 


1008  SPECIAL  DIAGNOSIS. 

lesions  are  the  deep  ulcerations  that  occur  in  various  parts  of  the  body, 
particularly  the  feet  [mal  perforante).  These  have  been  noted  in  tabes 
dorsalis,  in  syringomyelia,  and  also  in  hysteria.  Finally,  destructive 
lesions  of  the  extremities  with  loss  of  the  fingers  may  occur  in  Raynaud's 
disease,  in  syringomyelia,  and  in  leprosy.  Trophic  lesions  of  the  deeper 
parts  iuvolve  the  joints  and  the  muscles.  Trophic  lesions  of  the  joints,  or 
arthropathies,  are  characterized  by  the  enlargement  of  the  joint  involved, 
usually  the  knee,  proliferation  of  the  bone,  relaxation  of  the  ligament, 
so  that  the  mobility  of  the  joint  is  much  greater  than  normal,  and,  for 
example,  in  the  knee,  there  may  be  considerable  lateral  motion  as  well 
as  flexion  and  extension.  The  joint  surfaces  become  rough  and  give 
rise  to  a  grating  upon  palpation.  Curiously  enough,  aside  from  the 
undue  mobility,  the  function  of  the  joint  remains  relatively  good,  and 
the  patient  is  often  able  to  walk  upon  a  knee  that  bends  laterally  almost 
to  a  right  angle.  There  is  usually  little  pain.  These  arthropathies 
may  also  assume  the  atrophic  instead  of  the  hypertrophic  form — the 
arthrite  seche  of  the  French.  In  this  case  the  ends  of  the  long  bones 
atrophy  and  luxation  commonly  occurs.  The  frequency  with  which 
the  different  joints  are  affected  is,  according  to  Growers,  as  follows : 
Knee,  45 ;  hip,  20 ;  shoulder,  1 1  ;  tarsus,  8  ;  elbow,  5  ;  ankle,  4.  In 
addition,  the  fingers  and  the  ends  of  the  ribs  may  show  these  altera- 
tions. 

Alteration  of  the  contour  of  the  body  occurs,  as  a  whole,  in  various 
nervous  diseases.  In  acromegaly  the  bones  of  the  feet,  hands,  and  face 
are  greatly  enlarged  ;  there  is  usually  slight  kyphosis,  and  the  soft  parts 
become  thickened,  the  whole  appearance  being  extremely  characteristic. 
In  myxoadema  the  subcutaneous  tissues  are  thickened,  giving  the  subject 
the  appearance  of  enormous  obesity.  In  the  various  forms  of  amyotro- 
phy, particularly  the  spinal  type,  the  patient  becomes  extremely  ema- 
ciated ;  alteration  of  the  shape  of  the  head  occurs  in  hydrocephalus,  the 
enlargement  being  globular,  and  the  face,  by  contrast,  very  small ;  in 
microcephaly  the  cranium  is  greatly  reduced  in  size,  and  the  face  appears 
more  prominent  and  rather  of  an  animal  type.  Occasionally,  in  the 
various  chronic  lesions  associated  with  idiocy  and  epilepsy,  there  may 
be  marked  asymmetry  of  the  skull.  Sometimes  an  intracranial  tumor 
will  also  produce  a  local  distortion.  Alterations  in  the  expression  or 
appearance  of  the  face  are  produced  by  exophthalmic  goitre,  which  is 
readily  recognized,  on  account  of  the  marked  prominence  of  the  eyes 
and  the  swelling  of  the  neck.  In  facial  tic  the  lightning-like  contrac- 
tions of  the  muscles  on  one  side  of  the  face,  occurring  at  more  or  less 
frequent  intervals,  are  extremely  characteristic.  In  facial  paralysis  in 
the  early  stage  the  absence  of  folds  on  one  side  of  the  face,  the  droop- 
ing corner  of  the  mouth,  and  partially  opened  eyelid  are  typical  of 
the  condition.  In  the  later  stage  contractures  may  occur,  causing  the 
mouth  to  be  drawn  up  and  the  eye  to  be  kept  partially  closed  with 
accentuation  of  the  normal  folds  of  the  skin.  Mimic  paralysis — that 
is,  failure  of  one  side  of  the  face  or  of  both  sides  to  assume  an  expres- 
sion in  accordance  with  the  language  or  the  feelings  of  the  patient — 
occurs  in  lesions  of  the  optic  thalamus,  and  perhaps  as  a  result  of  par- 
tial injury  to  the  facial  nerve.     Stolidity  of  expression — that  is,  immo- 


D IS 'EASES  OF  THE  NERVOUS  SYSTEM.  1009 

bility  of  the  facial  muscles — occurs  in  paralysis  agitans.  Finally,  in 
various  mental  diseases  the  expression  of  the  features  may  more  or  less 
closely  indicate  the  type.  Thus  the  mournful  countenance  of  the  mel- 
ancholic, the  excited,  eager  aspect  of  the  maniac,  or  the  furtive,  anxious 
expression  of  the  paranoiac,  have  all  been  described.  It  must  not  be 
forgotten,  however,  that  temporary  emotional  states  may  give  rise  to 
the  same  manifestations.  The  Mongolian  type  of  the  features — that 
is,  slightly  oblique  eyes  and  high  cheek  bones — seems  to  be  character- 
istic of  a  certain  form  of  idiocy.  The  reason  for  its  occurrence  is 
not  known.  Alterations  in  the  posture  of  the  body  occur  in  a  great 
variety  of  diseases.  The  spinal  column  may  be  permanently  bent  and 
ankylosecl  in  rhyzomyelic  spondylosis.  This  may  also  be  associated 
with  ankylosis  of  the  large  joints.  The  position  and  gait  in  every 
case  are  quite  characteristic.  Angular  deformity  of  the  spine  occurs 
in  Pott's  disease.  Lateral  curvature  frequently  occurs  in  the  various 
forms  of  muscular  dystrophy  and  in  Friedreich's  ataxia.  The  pres- 
ence of  a  large,  fluctuating  tumor  at  the  base  of  the  spinal  column  over 
the  lumbar  or  sacral  region  is  indicative  of  spina  bifida,  the  lesion 
being,  of  course,  congenital,  and  in  this  case  there  is  often  an  extensive 
growth  of  hair  upon  the  skin  covering  the  tumor. 

Changes  in  the  Extremities.  Various  alterations  in  the  contour  of  the 
arms  are  produced  by  muscular  atrophy.  The  most  characteristic  is 
the  flattening  of  the  shoulder-joint  that  occurs,  as  a  result  of  the  wast- 
ing of  the  deltoid  and  the  peculiar  appearance  of  the  hand  produced 
by  the  wasting  of  the  thenar  and  hypothenar  muscles.  In  the  latter 
the  thumb  assumes  a  position  parallel  to  the  fingers,  which  is  only 
characteristic,  however,  when  it  involves  the  metacarpal  bone  as  well 
as  the  phalanges  (ape-hand).  The  position  of  the  hand  is  affected  in 
paralysis  of  the  extensors,  giving  rise  to  wrist-drop  in  injury  to  the 
radial  and  to  the  ulnar  nerves.  If  the  latter  is  involved  the  interossei 
muscles  are  paralyzed,  so  that  the  proximal  phalanges  can  no  longer 
be  flexed,  and  the  extensors  gradually  pull  them  backward  until  they 
are  perpendicular  to  the  dorsum  of  the  hand  (main  en  griffe).  Enlarge- 
ment of  the  hands,  as  a  whole,  occurs  in  acromegaly  and  in  pulmonary 
osteoarthropathy.  Mutilation  of  the  fingers  is  frequently  characteristic 
of  syringomyelia,  Morvan's  disease,  Raynaud's  disease,  and  leprosy. 
(See  Trophic  Changes.)  The  alterations  produced  by  muscular  disease 
in  the  lower  extremities  are  analogous  to  those  that  occur  in  the  upper 
extremities.  In  addition,  however,  there  is  a  peculiar  alteration  pro- 
duced by  pseudo-hypertrophic  muscular  atrophy,  in  which  the  limbs 
appear  to  be  of  Herculean  development.  Enlargement  of  the  feet,  as 
a  whole,  occurs  in  the  same  conditions  as  does  enlargement  of  the 
hands.  Deformities  of  the  feet  are  much  more  common  as  a  result  of 
contractures  following  anterior  poliomyelitis,  which  gives  rise  to  the 
various  types  of  club-foot.  Certain  nervous  diseases  frequently  cause 
deformity  of  the  knee  and  hip-joints,  particularly  syringomyelia, 
which  gives  rise  to  a  form  of  dry  arthritis  of  the  hip  ;  and  tabes  dor- 
salis,  producing  the  tabetic  arthropathies.     (See  Trophic  Lesions.) 

Mental  Disturbances.  These  are  of  most  varied  kinds.  They 
may  be  divided  into  disturbance  of  consciousness  and  disturbance  of 

64 


1010  SPECIAL  DIAGNOSIS. 

intellection.  Disturbances  of  consciousness  may  be  of  various  degrees. 
The  mildest  form  is  called  apathy.  The  patient  lies  quietly,  makes  no 
voluntary  attempt  to  commence  a  conversation,  shows  no  interest  in  his 
surroundings,  and  only  answers  if  spoken  to.  A  more  severe  state  may 
be  spoken  of  as  lethargy  or  stupor.  The  term  coma  implies  that  it  is 
impossible  to  arouse  the  patient  by  any  means,  and  at  the  same  time  the 
condition  resembles  more  or  less  closely  actual  sleep.  The  reflexes  are 
usually  preserved,  and  there  is  a  certain  degree  of  perception  to  painful 
impulses,  manifested  by  the  withdrawal  of  the  part  irritated.  Uncon- 
sciousness is,  of  course,  a  condition  that  cannot  be  sharply  differentiated 
from  this.  The  term  is  ordinarily  applied  to  conditions  that  do  not 
resemble  natural  sleep.  The  patient  may  lie  quietly,  but  the  breathing 
is  stertorous ;  the  eyes  may  be  open  ;  all  the  muscles  may  be  relaxed 
or  various  types  of  spasm  may  be  present.  These  conditions  occur  in 
the  intoxications,  infections,  poisonings,  and  as  a  result  of  severe  injury 
to  the  head.  A  peculiar  type  of  coma,  known  as  coma  vigil,  is  charac- 
terized by  complete  relaxation  of  the  patient,  whose  eyes,  nevertheless, 
remain  open  and  appear  to  observe  that  which  transpires  around  the 
bed.  The  mildest  form  of  disturbance  of  intellect  consists  in  impair- 
ment of  memory,  or  amnesia.  This  may  be  restricted  to  the  memory 
of  certain  things  only,  as  the  names  of  certain  classes  of  objects  or  cer- 
tain groups  of  words.  It  may  also  be  restricted  to  loss  of  memory  for 
certain  definite  periods  of  time,  which  may  occur  as  a  result  of  severe 
injury  or  disease  during  or  about  this  period.  If  the  memory  is  lost 
for  the  period  preceding  the  traumatism,  the  condition  is  spoken  of 
as  antero-active  amnesia ;  if  for  the  period  following,  retro-active  am- 
nesia. Memory  is  commonly  impaired  in  old  age,  and  often  as  a  result 
of  chronic  cerebral  disease,  particularly  in  paralytic  dementia.  General 
impairment  of  the  intellect  is  spoken  of  as  imbecility  or  idiocy.  In  its 
milder  forms  imbecility  consists  in  diminution  of  the  reasoning  powers, 
so  that  the  patient  is  unable  to  form  accurate  judgments.  In  its  severer 
grades,  and  particularly  in  the  more  pronounced  forms  of  idiocy,  intel- 
lectual activity  may  appear  to  be  absolutely  abolished,  life  being  merely 
a  mechanical  process  not  under  control  of  the  reason.  Both  conditions 
are  usually  associated  with  alterations  in  the  substance  of  the  brain, 
either  in  the  form  of  hydrocephalus  or  of  the  various  scleroses  associ- 
ated with  epilepsy.  Exaltation  of  the  intellectual  functions  associated 
with  excitement,  and  more  or  less  violence  is  usually  spoken  of  as  delir- 
ium. This  may  be  severe  or  mild.  It  is  characterized  by  a  tendency  to 
talk  or  to  be  noisy,  and  by  great  restlessness.  Delirium  occurs  in  many 
of  the  acute  infectious  diseases,  particularly  in  meningitis.  Among  the 
commoner  symptoms  of  intellectual  disorder  usually  grouped  under 
the  term  insanity  are  exaltation,  or  mania,  depression,  or  melancholia, 
and  delusional  states,  or  paranoia.  By  mania  is  meant  excessive  intel- 
lectual activity,  characterized  by  a  tendency  to  be  noisy,  to  be  active, 
fondness  for  singing,  shouting,  swearing,  or  punning.  There  is  usually, 
also,  in  the  acute  forms  a  rapid  loss  of  weight  and  decrease  in  the  physical 
powers,  while  the  patient  believes  himself  to  be  in  the  most  admirable 
and  exceptional  condition.  Mania  occurs  as  a  nervous  disease  and  as 
the  result  of  inflammations  of  the  brain-substance  in  acute  delirium. 


DISEASES  OF  THE  NER  VO  US  S YSTEM.  1011 

It  occurs  in  the  exacerbations  of  general  paresis  and  in  diseased  states 
of  unknown  etiology  that  are  denominated  by  the  term  itself.  In 
melancholia  the  expression  of  the  patient  is  mournful,  he  is  commonly 
quiet,  sits  with  his  head  cast  down,  refuses  to  speak,  to  eat,  or  to  take 
any  interest  in  what  goes  on  about  him.  Often  he  weeps  or  groans 
constantly,  and  when  persuaded  to  talk,  expresses  an  acute  sense  of  his 
manifold  sins  and  the  hopelessness  of  salvation,  or  will  complain  of 
misfortune-  that  have  not  befallen  him.  Melancholia  occasionally 
occurs  in  general  paresis,  particularly  in  patients  whose  vitality  has 
been  exhausted  by  excesses.  It  also  occurs  as  one  of  the  varieties  of 
insanity.  The  term  paranoia  is  used  by  different  authors  in  very  dif- 
ferent senses.  In  general,  it  may  be  said  that  the  majority  imply  by 
it  the  existence  of  delusions  or  false  ideas  that  have,  among  themselves, 
a  certain  logical  sequence,  or,  as  the  term  is,  are  organized.  Thus  a 
paranoiac  may  believe  that  he  is  being  persecuted  by  a  certain  person, 
and  be  able  to  give  reasons  why  his  persecutor  should  torment  him. 
It  must  not  be  forgotten  that  occasionally  these  delusions  may  be  true 
in  fact,  although  none  the  less  symptoms  of  the  mental  condition. 
AVhen  there  is  merely  a  false  idea  it  is  spoken  of  as  a  delusion.  If 
the  person  complains  of  certain  physical  impressions,  such  as  non-exist- 
ent sounds,  visions,  odors,  or  tastes,  the  term  haUueinatixm  is  generally 
employed. 

Localization  of  Lesions  of  the  Nervous  System.  In  a  diag- 
nosis of  diseases  of  the  nervous  system,  particularly  those  that  are  the 
result  of  focal  lesions,  it  is  usually  far  more  important  to  determine  the 
situation  of  the  lesions  than  the  nature  of  the  pathological  process. 
The  nervous  system  may  be  regarded  physiologically  as  a  collection  of 
neurons.  By  neuron  is  meant  a  nerve-cell  and  all  its  processes  to  their 
ultimate  ramifications.  The  processes  are  of  two  kinds  :  the  so-called 
protoplasmic  processes,  Avhich  are  relatively  short,  thick,  and  branched, 
and  appear  to  resemble  in  many  respects  the  protoplasm  of  the  nerve- 
cell  itself  ;  and  the  axis-cylinder,  a  long,  slender  process  that  in  its 
course  gives  off  at  regular  intervals  still  more  slender  branches,  the 
collaterals,  and  at  its  termination  usually  breaks  up  into  a  small  tuft  of 
fibres  that  surround  some  other  ganglion  cell.  An  exception  to  the 
latter  rule  is  formed  by  the  axis-cylinders  of  the  motor  cells  that  run 
to  the  muscles,  and  end  in  tufts  of  fibres  distributed  to  peculiar 
terminations  in  the  muscle-fibres.  The  axis-cylinders,  at  a  certain 
distance  from  the  nerve-cell,  usually  become  surrounded  by  myelin 
sheaths,  and  constitute  the  nerve-fibres  which  make  up  the  greater  bulk 
of  the  central  nervous  system  (the  white  substance),  and  practically  all  of 
the  peripheral  nervous  system.  Xeurons  with  similar  functions  are  usu- 
ally grouped  together,  the  aggregation  of  the  cells  forming  a  nucleus,  and 
of  the  fibres  a  bundle  or  system.  The  gray  matter  is  largely  composed 
of  these  group-  of  ganglion  cell-  or  nuclei.  Physiology  lias  shown,  al- 
though not  absolutely  conclusively,  that  the  axis-cylinders  convey  im- 
pulses from  the  cell,  and  the  protoplasmic  processes  convey  impulses  or 
nutriment  to  the  cell.  In  the  cell  itself  these  impulses  are  modified  or 
altered  in  some  as  yet  unknown  manner.  At  present  the  course  and 
functions  of  comparatively  few  of  the  groups  of  neurons  are  known. 


1012  SPECIAL  DIAGNOSIS. 

Those  that  have  been  most  accurately  studied  may  be  divided  into  the 
sensory  neurons,  conveying  impulses  from  the  peripheral  nervous  sys- 
tem, and  the  motor  neurons,  conveying  impulses  from  the  central 
nervous  system  to  the  muscles.  The  sensory  neurons  commence  in  the 
various  sensory  corpuscles,  in  the  skin,  and  organs.  They  pass  through 
the  peripheral  nervous  system  to  the  posterior  roots  of  the  spinal  cord, 
and  here  they  enter  the  cells  in  the  ganglia  of  the  posterior  roots. 
From  these  cells  a  fibre  emerges  that  for  a  short  distance  is  continuous 
with  the  eutering  fibre,  and  then  leaves  it  and  continues  along  the  pos- 
terior root  of  the  spinal  cord.  Here  it  divides  into  two  branches,  an 
ascending  and  a  descending  branch.  Of  the  function  of  the  latter 
nothing  certain  is  known.  Some  of  the  ascending  branches  pass  into 
the  lateral  posterior  column  (Burdach),  and  at  a  higher  level  into  the 
median  posterior  column  (Goll).  Those  entering  the  cord  in  the  upper 
dorsal  and  cervical  regions,  however,  do  not  pass  into  the  median  poste- 
rior column,  but  continue  in  the  lateral  posterior  column  to  a  nucleus  in 
the  medulla.  Both  columns  end  respectively  in  the  nucleus  cuneatus 
and  the  nucleus  gracilis.  These  two  nuclei  may  be  looked  upon  as  indi- 
cating the  termination  of  the  peripheral  sensory  neurons.  These  two 
groups  of  fibres  probably  convey  only  touch  and  muscular  sensations. 
The  fibres  conveying  pain  and  temperature  sensations  apparently  pass 
up  the  cord  through  the  central  gray  matter,  but  their  central  termi- 
nation is  not  vet  definitely  known.  From  the  ganglion  cells  in  the 
two  nuclei  in  the  medulla,  axis-cylinders  arise  that  pass  toward  the 
brain  and  form  a  mass  of  fibres  known  as  the  filet.  In  the  medulla 
these  are  situated  on  either  side  of  the  median  line,  lying  between 
the  olivary  bodies.  They  continue  to  occupy  the  central  regions  of 
the  pons  in  its  posterior  part,  but  anteriorly  they  gradually  spread  out 
until  they  form  a  narrow  band,  placed  horizontally,  just  below  the 
gray  matter  surrounding  the  aqueduct  of  Sylvius.  They  then  enter 
the  tegmentum  of  the  crus,  and  the  majority  lose  themselves  in  the 
ventral  nucleus  of  the  optic  thalamus.  They  constitute  the  second 
chain  of  sensory  neurons.  It  is  probable  that  from  the  optic  thal- 
amus, and  from  the  other  nuclei  in  which  perhaps  fibres  of  the  filet 
terminate,  other  axis-cylinders  arise  which  pass  through  the  corona 
radiata  to  the  sensory  areas  in  the  cortex.  These  sensory  areas  will 
be  discussed  in  connection  with  the  cortical  localization. 

Destructive  lesions  in  the  peripheral  sensory  nerves  produce  total 
anaesthesia  of  the  part  supplied.  Partial  lesions  may  produce  partial 
anaesthesia  or  even  dissociation  of  sensation.  Irritative  lesions  of  the 
peripheral  nerves  produce  severe  pain,  usually  referred  to  the  part  sup- 
plied by  the  nerye,  and  there  are  also  sensitive  points  or  general  tender- 
ness over  the  nerve  trunk.  Certain  forms  of  irritative  lesion  produce 
partial  alteration  of  sensation,  which  is  usually  spoken  of  as  pares- 
thesia (q.  v.).  Trophic  changes  in  the  skin  often  occur.  Lesions  of 
the  posterior  roots  also  produce  total  anaesthesia.  If  the  lesion  is  on 
the  peripheral  side  of  the  ganglion  there  are  in  addition  trophic  changes 
in  the  part  supplied.  If  the  lesion  lies  between  the  ganglion  and  the 
spinal  cord,  the  anaesthesia  is  total,  but  trophic  changes  do  not  occur. 
Lesion  of  the  ganglion  itself  usually  produces  anaesthesia  and  atrophic 


DISEASES  OF  THE  XEBVOUS  SYSTEM. 


1013 


changes,  if  complete ;  if  partial,  the  symptoms  are  variable.  In  some 
cases  herpes  zoster  along  the  course  of  the  nerve  has  been  observed. 
Irritative  lesions  of  the  posterior  roots  produce  fulgurant  pains  in  the 
limbs,  or  a  feeling  of  constriction  in  the  trunk.  They  may  also  be  the 
cause  of  visceral  crises.  Destructive  lesions  of  the  posterior  columns 
of  the  spinal  cord  produce  more  or  less  tactile  anaesthesia  and  loss  of 
the  muscle  sense.  As  a  result  of  the  latter  there  is  ataxia.  Lesions  of 
either  of  the  two  central  sensory  neurons  produce  various  forms  of  anaes- 
thesia, depending  upon  their  extent.     According  to  our  knowledge  of 


Diagram  to  show  the  relative  positions  of  the  several  motor  tracts  in  their  course  from  the  cortex 

to  the  crus. 
The  section  through  the  convolutions  is  vertical ;  that  through  the  internal  capsules,  I  C,  hori- 
zontal;   that  through  the  crus  is  again  vertical.     CN,  caudate  nucleus;  OTH,  optic  thalamus; 
L2  and  L3,  the  middle  and  outer  parts  of  the  lenticular  nucleus  ;  fa  I,  face,  arm,  and  leg  fibres. 
The  words  in  italics  indicate  the  corresponding  cortical  centres.    (Gowers.) 

this  subject,  destructive  lesions,  such  as  hemorrhage  or  aneurism  in  the 
posterior  portion  of  the  posterior  limb  or  the  internal  capsule,  or  destruc- 
tive lesions  of  the  optic  thalamus,  are  usually  associated  with  hemian- 
esthesia on  the  apposite  side  of  the  body.  At  times,  tactile  sense  is 
preserved  and  only  the  pain  sense  lost.  As  a  rule,  however,  all  forms 
of  sensation  are  more  or  less  affected. 

The  motor  neurons  consist  of  two  groups,  the  central  and  peripheral 
neurons.  The  central  motor  neurons  commence  in  the  motor  portion 
of  the  cortex.  They  then  pass  through  the  corona  radiate  to  the  inter- 
nal capsule,  where  they  form  a  large  band  of  fibres  occupying  the  knee 


1014 


SPECIAL  DIAGNOSIS. 


and  the  anterior  two-thirds  of  the  posterior  limb.  (See  Fig.  239.) 
The  fibres  for  the  face  occupy  the  knee  and  anterior  third  of  this  por- 
tion. Next  come  the  fibres  for  the  arm,  then  those  for  the  leg,  and, 
finally,  the  fibres  for  the  trunk.  From  the  internal  capsule  the  fibres 
pass  into  the  crura  cerebri,  where  they  lie  beneath  the  substantia  nigra, 
occupying  about  the  middle  of  each  cms.  The  fibres  for  the  face  and 
cranial  nerves  lie  internal  to  those  for  the  extremities  and  trunk. 
From  here  they  pass  to  the  ventral  portion  of  the  pons,  where  they  are 
broken  up  into  small  bundles  by  the  association  of  fibres  of  the  two 
cerebellar  hemispheres.  These  reunite  and  form  the  pyramids  in  the 
anterior  portion  of  the  medulla,  which  decussate  in  the  first  cervical 
segment  and  pass  down  the  cord  as  the  lateral  pyramidal  columns. 
(See  Fig.  240.)     A  few  of  the  other  fibres,  however,  do  not  decussate 


Fig.  240. 


pos 

ROOT 


Diagram  showing  the  different  tracts  of  the  cord.    (Gowers.) 


at  this  time,  but  pass  downward  in  the  direct  pyramidal  columns,  which 
decussate  through  the  anterior  commissure  of  the  cord  at  lower  levels. 
The  fibres  for  the  cranial  nerves  decussate,  as  a  rule,  in  the  neighbor- 
hood of  the  nuclei  for  these  nerves,  and  by  this  means  we  are  able  to 
locate  with  considerable  accuracy  the  situation  of  lesions  in  the  pons 
and  medulla.  The  fibres  for  the  oculomotor  nerves  decussate  in  the 
tegmentum  and  the  nuclei  around  the  aqueduct  of  Sylvius.  The  fibres 
for  the  facial  decussate  in  the  anterior  portion  of  the  pons.  From  this 
point  downward  fibres  are  continually  crossing  the  median  raphe  to 
the  nuclei  of  the  various  motor  cranial  nerves  until  the  main  decussa- 
tion— that  is,  in  the  first  cervical  segment.  It  follows,  therefore,  that 
if  a  lesion  occurs  in  such  a  position  that  it  affects  the  fibres  of  one  of 
the  cranial  nerves  after  they  have  crossed  the  median  line,  at  the  same 
time  involving  the  undecussated  fibres  of  the  pyramids,  we  will  have 
the  syndrome  known  as  a  crossed  paralysis — that  is,  the  muscles  sup- 
plied by  the  affected  cranial  nerves  will  be  paralyzed  on  the  same  side 


DISEASES  OF  THE  NERVOUS  SYSTEM.  1015 

as  the  lesion,  and  the  rest  of  the  body  on  the  opposite  side.  (See 
Lesions  of  the  Cranial  Nerves.)  The  peripheral  motor  neurons  com- 
mence in  the  cells  of  the  anterior  cornna  of  the  spinal  cord,  passing  out 
through  the  anterior  roots,  and  reach  the  muscles  through  the  periph- 
eral nerves. 

The  functions  of  these  two  neurons  are  apparently  not  identical. 
The  central  motor  neurons  convey  impulses  from  the  cortex  to  the 
cells  of  the  anterior  cornua,  by  which  the  latter  are  stimulated  to  pro- 
duce muscular  movement.  At  the  same  time  they  seem  to  possess  an 
inhibitory  influence  by  means  of  some  form  of  constant  activity,  so 
that  while  they  are  intact  the  reflexes  are  restrained,  and  the  muscles 
do  not  become  spastic.  Upon  the  nutrition  of  the  muscles  they  appar- 
ently have  no  influence  whatever,  or  at  least  act  only  indirectly  by 
causing  paralysis.  The  peripheral  motor  neurons  control  directly  mus- 
cular activity.  By  their  continuous  action  they  maintain  muscle  tonus, 
and  when  unrestrained  by  the  influence  of  the  upper  neurons  produce  a 
condition  of  spasticity.  While  they  and  the  sensory  neurons  forming 
the  arc  are  intact,  reflex  action  persists.  They  also  control  in  some 
mysterious  way  the  nutritional  changes  in  the  muscles.  Destructive 
lesions  of  the  lower  neurons — that  isrof  the  peripheral  nerves  involving 
the  motor  fibres  of  the  anterior  root  and  of  the  ganglion  cells  in  the 
cornua — cause  paralysis  and  degenerative  changes  in  the  muscles.  Irri- 
tative lesions  cause  spasms ;  these  are  usually  tonic  in  character,  and 
either  momentary  (as  in  facial  tic)  or  more  rarely  persistent  (tetanic). 
The  muscle  tonus  is  lost,  and,  therefore,  the  paralysis  is  flaccid  in  char- 
acter and  the  reflexes  are  abolished.  Destructive  lesions  in  the  central 
motor  neurons,  on  the  other  hand,  produce  paralysis  of  the  muscles, 
but  their  nutrition  is  not  impaired,  their  muscle  tonus  is  increased 
until  they  become  spastic,  and  the  reflexes  are  exaggerated.  Irritative 
lesions  of  the  central  nervous  neurons  produce,  as  a  rule,  clonic  spasms. 
These  may  be  limited  to  the  part  irritated,  as  occurs  in  some  form  of 
central  softening  in  the  motor  region,  or  become  generalized.  (See 
Convulsions). 

Cortical,  Localization.  The  origins  of  the  motor  neurons  and  the 
terminations  of  the  sensory  neurons  are,  as  will  be  seen  from  this  descrip- 
tion, in  the  cortex  of  the  brain.  It  is,  therefore,  of  considerable  im- 
portance to  be  able  to  locate  the  portions  of  the  cortex  that  have  to 
do  with  these  functions.  As  a  result  of  experimental  work  and  of  the 
repeated  examination  of  pathological  specimens,  a  considerable  amount 
of  knowledge  has  been  acquired  upon  this  subject.  The  motor  regions, 
indeed,  are  marked  out  with  accuracy,  and  some  of  the  regions  for  the 
reception  of  impulses  from  the  organs  of  special  sense  are  also  certainly 
known.  The  cortex  of  the  brain  has  been  divided  into  various  regions 
that  are  referred  to  certain  fissures  that  are  quite  constant  in  position. 
The  most  important  of  these  is  the  fissure  of  Sylvius.  It  separates 
the  temporo  sphenoidal  lobe  below  from  the  frontal  and  parietal  lobes 
above.  Around  its  posterior  extremity  there  winds  the  convolution 
known  as  the  gyrus  angularis.  Next  is  the  Rolandic  fissure,  passing 
from  the  superior  longitudinal  fissure  to  the  fissure  of  Sylvius,  with 
which  it  forms  an  acute  angle.     It  separates  the  frontal  from  the  pari- 


1016 


SPECIAL  DIAGNOSIS. 


etal  lobe,  and  lies  in  the  midst  of  the  motor  region  of  the  cortex.  In 
front  of  it  is  the  ascending  frontal  convolution,  and  behind  the  ascend- 
ing parietal  convolution.  These  two  contain  nearly  all  the  motor 
centres.     The  third  prominent  fissure  is  the  occipito-parietal.     It  is 


Fig.  241. 


Cortical  centres  and  areas  of  representation  on  the  lateral  aspect  of  the  hemi cerebrum.    (Mills.) 

Fig.  242." 


*A      °      J      0 


Cortical  centres  and  areas  of  representation  on  the  mesial  aspect  of  the  hemicerebrum.    (Mills.) 


DISEASES  OF  THE  XERVOUS  SYSTEM.  1017 

best  defined  on  the  median  surface  of  the  brain,  but  can  be  traced  for  a 
short  distance  on  the  convex  surface.  It  separates  the  parietal  from 
the  occipital  lobe.  On  the  median  surface  it  unites  at  an  acute  angle 
with  the  calcarine  fissure,  the  two  enclosing  between  them  the  trian- 
gular convolution  that  is  known  as  the  cuneus.  (See  Fig.  241  and  Fig. 
242.)  The  motor  centres  are  so  arranged  that  those  for  the  face  are 
in  the  lowest  portion  of  the  motor  region,  those  for  the  arms  just  above 
them,  those  for  the  legs  around  these,  and  those  for  the  trunk  in  the 
posterior  termination  of  the  ascending  parietal  convolution,  along  the 
margin  of  the  superior  longitudinal  fissure.  These  centres  do  not  repre- 
sent particular  muscles,  but  particular  forms  of  movement,  involving 
frequently  the  simultaneous  contraction  of  several  muscular  groups. 
It  is  not  known  how  sharp  their  limitations  are,  but  it  is  supposed  that 
the  central  portion  of  the  focus  is  most  exclusively  devoted  to  its  func- 
tion, while  at  the  periphery  this  fades  gradually  into  the  surrounding 
centres.  The  motor  region  for  speech  was  first  discovered  by  Broca,  in 
1861.  It  occupies  the  posterior  portion  of  the  third  frontal  convolu- 
tion and  the  lower  part  of  the  ascending  frontal  convolution.  The 
termination  of  the  sensory  neurons  is  not  yet  conclusively  determined. 
It  seems  likely  that  some  of  them  terminate  in  the  motor  region,  and 
others  in  the  upper  portion  of  the  parietal  lobe.  It  is  probable  that 
different  forms  of  sensation  are  represented  by  different  areas  upon 
the  cortex,  but  at  present  our  knowledge  of  this  subject  is  uncertain. 
The  stereognostic  sense  appears  to  be  situated  in  the  parietal  lobe — 
that  is,  lesions  in  this  locality  will  cause  its  loss  without  disturbance 
of  tactile  sensation.  As  it  has  been  shown  that  this  sense  is  largely 
dependent  upon  muscular  and  localization  senses,  it  is  likely  that  the 
fibres  concerning  these  terminate  in  the  parietal  lobe.  It  is  to  be  noted 
that  although  it  is  the  general  rule  that  fibres  from  one  hemisphere 
ultimately  pass  to  the  opposite  side  of  the  body,  this  is  by  no  means 
in  variably  the  case.  Certain  muscles,  such  as  those  of  the  trunk,  appar- 
ently are"  innervated  from  both  sides  of  the  brain — that  is,  bilaterally 
— so  that  if  one  centre  is  destroyed  the  other  assumes  its  functions, 
and  no  paralysis  ensues.  It  also  appears  possible,  in  certain  instances, 
for  the  centre  of  one  hemisphere  gradually  to  learn  to  perform  the 
functions  of  the  centre  of  the  other  hemisphere  when  the  latter  has 
been  destroyed.  This  is  seen  most  clearly  in  cases  of  the  destruction 
of  the  speech  centre  on  the  left  side,  when,  if  the  patient  is  still  young, 
the  speech  centre  on  the  right  side  may  assume  all  its  duties. 

The  Centres  for  Reception  of  SpeM  Senses.  The  cuneus  of  the 
median  surface  of  the  occipital  lobe  appears  to  receive  directly  the 
fibres  from  the  optic  tract.  When  it  is  destroyed  there  is  bilateral 
contralateral  hemianopsia.  The  pupillary  reflexes  are,  however,  pre- 
served, so  that  light  impulses  must  exert  some  activity  at  a  point  in 
the  chain  of  neurons  between  this  and  the  eye,  probably  in  the  anterior 
quadrigeminal  bodies.  The  centre  for  audition  is  situated  in  the  tem- 
poro-sphenoidal  convolution.  Destructive  lesions  produce  deafness  in 
the  ear  of  the  opposite  side,  or  at  least  impairment  of  hearing,  which, 
as  a  rule,  rapidly  disappears.  The  centres  for  smell  and  taste  have 
been  placed  respectively  in   the   uncinate  and  fornicate  convolutions. 


1018  SPECIAL  DIAGNOSIS. 

The  evidence  for  these  localizations  is  very  strong,  but  is  not  yet  abso- 
lutely conclusive.  It  is  doubtful  whether  irritative  lesions  in  any  of 
the  centres  for  special  sense  are  responsible  for  hallucinations. 

The  functions  of  the  frontal  lobes  are  not  well  known.  It  has  been 
supposed  that  they  are  the  seat  of  intelligence,  but  there  has  never 
been  adequate  proof  of  this  belief.  Lesions  of  the  frontal  lobes  may, 
therefore,  exist  without  giving  rise  to  any  symptoms  that  lead  to  a  sus- 
picion of  their  presence.  On  the  other  hand,  the  patients  may  exhibit 
various  intellectual  disturbances,  but,  on  the  whole,  none  that  are  char- 
acteristic, and  perhaps  these  symptoms  do  not  occur  more  frequently  as 
a  result  of  disease  of  this  part  than  when  some  other  part  of  the  brain 
has  been  affected.  It  has  been  claimed  that  there  is  a  certain  degree 
of  intellectual  impairment ;  that  the  patient,  while  not  insane  or  even 
eccentric,  becomes  incapable  of  exercising  the  same  degree  of  judgment 
and  comprehension  that  he  formerly  possessed.  It  has  been  claimed,  also, 
that  a  peculiar  form  of  insanity,  characterized  by  progressive  dementia 
associated  with  a  manifestation  of  self-contentedness,  occurs  only  in 
lesions  of  this  part,  and  it  has  been  given  the  term  moria.  The  pro- 
duction of  a  tendency  to  make  puns  has  also  been  described  to  lesions 
in  this  region.  It  does  not  always  occur,  but,  on  the  other  hand,  it 
may  occur  as  an  early  manifestation  of  insanity  without  gross  lesion 
or  in  connection  with  the  lesions  of  other  parts  of  the  brain.  The 
most  important  symptoms,  of  course,  are  those  due  to  the  involvement 
of  the  adjacent  motor  centres.  The  one  most  frequently  affected  is  the 
speech  centre  in  the  third  frontal  gyri,  and  as  a  result  aphasia  is  a  com- 
mon associated  symptom,  particularly  if  the  lesion  is  situated  in  the  left 
hemisphere.  The  other  motor  centres  may,  however,  be  involved  and 
produce  characteristic  symptoms. 

The  functions  of  the  basal  ganglia  of  the  brain  are  as  yet  insufficiently 
known  to  enable  us  to  diagnose  lesions  situated  in  them  with  certainty. 
Lesions  in  the  lenticular  nucleus  may  be  entirely  latent.  In  some  cases 
they  appear  to  have  produced  sensory  disturbances,  but  even  this  is 
doubtful.  Ordinarily,  the  only  symptoms  they  produce  are  those 
resulting  from  pressure  upon  the  surrounding  parts,  such  as  the  inter- 
nal capsule.  The  optic  thalamus  appears  to  receive  fibres  from  many 
parts  of  the  cortex.  Its  relation  to  the  fillet  has  already  been  men- 
tioned, and  lesions  in  this  region  frequently  produce  sensory  disturb- 
ances. The  pulvinar  appears  to  be  one  of  the  three  basal  ganglia  asso- 
ciated with  the  optic  tract,  and  when  it  is  destroyed  there  is  usually 
bilateral  contralateral  hemianopsia.  There  is  some  doubt,  however, 
whether  this  is  not  due  to  the  involvement  of  the  neighboring  struc- 
tures, either  the  fibres  of  the  optic  tract  passing  just  beneath  it  or  of 
the  geniculate  bodies.  Nothnagel  and  v.  Bechterew  have  called  atten- 
tion to  the  fact  that  certain  localized  movements  on  the  part  of  the 
muscles  of  the  face,  particularly  those  concerned  in  the  expression  of 
the  emotions,  are  more  or  less  completely  abolished  by  destruction  of 
the  optic  thalami.  The  existence  of  this  mimic  paralysis  has;  in  a  few 
cases,  led  to  the  correct  diagnosis  of  thalamic  lesion.  The  anterior 
corpora  quadrigemina  apparently  form  one  of  the  intermediate  stations 
for  the  optic  tract,  the  fibres  from  the  nerve  ending  in  them,  and  new 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


1019 


neurons  commencing  that  possibly  form  the  fibres  of  the  optic  radiation* 
They  are  apparently  the  situations  in  which  the  arch  of  the  pupillary 
reflex  is  completed.  The  internal  geniculate  ganglia  and  the  posterior 
corpora  quadrigemina  appear  to  be  associated  with  hearing. 

Lesions  in  the  pons  and  medulla  produce,  as  a  rule,  characteristic 
symptoms  that  make  it  possible  to  locate  them  with  considerable  accu- 
racy. This  is  due  to  the  fact  that  the  nuclei  of  the  cranial  nerves  are 
situated  in  these  two  portions  of  the  brain,  and  also  that  they  form  the 
great  source  of  communication  between  the  cerebrum  and  the  spinal 
cord,  containing  both  motor  and  sensory  fibres.  (See  Fig.  243.)  The 
nucleus  of  the  oculomotor  nerve  is  found  surrounding  the  anterior 
portion  of  the  aqueduct  of  Sylvius,  just  beneath  the  anterior  corpora 
quadrigemina.  Numerous  groups  of  cells  have  been  separated  which 
are  supposed  to  belong  each  to  a  different  muscle.  Destructive  lesions 
cause  partial  or  complete  ophthalmoplegia,  according  to  the  extent  of 
the  lesion.     There  is,  therefore,  abolition  of  the  pupillary  reflex.    Just 


Fig.  243. 


-31,  - 

>0£oJ§^ ■■••.•.•.:::■•••-■     MB&Ws  II 

r      V.  mot. 

I 

Relative  location  of  the  nuclei  of  the  different  cranial  nerves.    (Edinger.) 


behind  it,  and  beneath  the  posterior  corpora,  is  a  small  group  of  cells 
for  the  pathetic  nerve.  The  nucleus  of  the  trigeminus  is  situated  in 
the  anterior  portion  of  the  pons,  just  to  the  outer  side  of  the  fillet,  the 
motor  group  of  cells  lying  inside  the  sensory  group.  The  Gasserian 
ganglion  receives  the  peripheral  branches  of  this  nerve  and  corresponds 
to  the  spinal  ganglia.  In  addition  the  nerve  receives  a  bundle  of  fibres 
from  the  lower  portion  of  the  medulla.  Disturbances  of  the  nucleus 
produce  anaesthesia  on  the  same  side  of  the  face,  involving  the  conjunc- 
tiva and  the  mucous  membrane  of  the  mouth.  There  is  loss  of  taste  in 
the  anterior'  two-thirds  of  the  tongue,  and  there  is  some  disturbance  of 
smell  in  the  nostril  on  the  same  side.  At  the  same  time  the  pterygoid 
muscles  are  paralyzed  and  mastication  is  imperfect.  Irritative  lesions 
cause  tic  douloureux.  This  may  also  be  the  result  of  disease  of  the 
ganglion.  The  nucleus  of  the  abducens  lies  in  the  posterior  portion  of 
the  pons,  just  beneath  the  floor  of  the  fourth  ventricle.  Destructive 
lesions  cause  internal  strabismus.     The  nucleus  of  the  facial  nerve  is 


1020  SPECIAL  DIAGNOSIS. 

found  in  the  posterior  portion  of  the  pons,  lying  slightly  behind  and  to 
the  median  side  of  the  nuclei  for  the  trigeminus.  The  fibres  from  this 
nerve  pass  out  first  forward,  then  downward  and  backward,  and  arise 
from  the  lateral  surface  of  the  medulla  at  its  anterior  extremity,  pass- 
ing forward  over  the  pontine  cerebellar  tubercles.  Destructive  lesions 
cause  paralysis  of  the  same  side  of  the  face,  usually  involving  the  upper 
branch.  (See  Hemiplegia.)  Irritative  lesions  cause  facial  tic.  The 
nucleus  of  the  acusticus  is  found  in  the  anterior  portion  of  the  medulla 
oblongata,  just  beneath  the  floor  of  the  fourth  ventricle,  lying  just  above 
the  superior  olivary  body.  Lesions  produce  nerve  or  mental  deafness 
on  the  same  side.  The  nuclei  of  the  vagus  and  the  glosso-pharyngeal 
nerves  are  apparently  in  the  jugular  and  petrosal  ganglia — that  is  to 
say,  they  are  sensory  nerves,  and  correspond  to  the  sensory  fibres  enter- 
ing the  spinal  cord.  From  these  ganglia  fibres  pass  into  the  medulla 
oblongata  at  its  lateral  aspect,  and  end  in  a  nucleus  in  the  floor  of  the 
fourth  ventricle.  The  motor  nucleus  of  the  vagus  is  supposed  to  be 
the  nucleus  ambiguus,  situated  just  posteriorly  to  the  olive  in  the  poste- 
rior portion  of  the  floor  of  the  fourth  ventricle.  Close  to  the  median 
line  is  the  hypoglossal  nucleus.  Its  destruction  produces  paralysis  and 
degenerative  atrophy  of  the  corresponding  side  of  the  tongue. 

The  functions  of  the  pons  are  merely  those  of  the  centres  and  tracts 
it  contains,  and  therefore  the  symptoms  are  dependent  upon  the  situ- 
ation and  greater  or  less  amount  of  destruction  that  the  lesions  produce. 
On  account  of  the  decussation  of  the  central  fibres  for  the  facial  nerve 
in  this  region,  crossed  paralysis  is  usually  considered  pathognomonic  of 
pontine  disease.  The  functions  of  the  medulla  are  also  largely  dependent 
upon  the  nuclei  and  tracts  it  contains.  As  it  contains  the  centres  for 
the  pneumogastric  and  some  of  the  centres  or  tracts  of  fibres  for  respi- 
ration, lesions  in  it  are  ordinarily  followed  very  promptly  by  death. 
Lesions  of  the  restiform  bodies — that  is,  the  lower  portion  of  the  medul- 
lary peduncle  to  the  cerebellum — are  frequently  associated  with  nystag- 
mus, and  may  cause  the  symptoms  of  cerebellar  ataxia.  As  the  medulla 
contains  the  nuclei  of  the  motor  nerves  to  the  pharynx,  larynx  and 
mouth,  paralysis  of  the  muscles  in  this  region  is  spoken  of  as  bulbar 
palsy. 

The  cerebellum  is  supposed  to  be  concerned  in  co-ordination  and 
the  maintenance  of  the  equilibrium.  The  hemispheres  may,  however, 
be  extensively  diseased  without  giving  rise  to  any  symptoms.  If  the 
middle  lobe  is  affected  the  characteristic  manifestations  are  disturbance 
of  equilibrium  and  inco-ordination.  The  gait  resembles  that  of  a 
drunken  man,  nystagmus  is  frequent,  especially  in  cases  of  tumor. 
Giddiness  and  vomiting  sometimes  occur,  but  are,  however,  of  no 
localizing  value.  The  knee-jerk  is  often  absent,  but  sometimes  in- 
creased and  sometimes  variable.  If  the  pyramidal  tracts'  are  pressed 
upon  it  is  always  increased,  and  there  is  then  weakness  in  the  extremi- 
ties. As  a  result  of  pressure  there  may  be  paralysis  of  the  cranial 
nerves,  difficulty  in  articulation,  and  occasionally  epileptiform  convul- 
sions. If  the  medullary  peduncle  is  affected  by  an  irritative  lesion, 
quite  characteristic  symptoms  result.  These  are  forced  movements — 
that  is  to  say,  the  patient  may  have  an  irresistible  tendency  to  fall 


DISEASES  OF  THE  NERVOUS  SYSTEM.  1021 

toward  or  lie  upon  one  side.  There  are  no  symptoms  diagnostic  of 
disease  of  the  superior  or  middle  peduncles.  Disease  of  one  side  of 
the  pons  may  cause  symptoms  similar  to  those  of  cerebellar  trouble. 

Localization  of  Spinal  Lesions.  The  spinal  cord  may  be  re- 
garded in  two  ways  :  First,  as  the  pathway  between  the  peripheral 
nervous  system  and  the  brain,  containing  the  tracts  running  from  the 
brain  to  the  motor  nerves,  and  from  the  sensory  nerves  to  the  brain ; 
second,  as  a  number  of  groups  of  ganglion  cells  arranged  in  horizontal 
layers  or  segments.  These  segments  are  usually  classified  according 
to  the  nerve-roots  that  spring  from  them.  There  are,  therefore,  eight 
cervical,  twelve  dorsal,  five  lumbar,  and  five  sacral  segments  of  the 
cord.  The  white  matter  of  the  spinal  cord  is  divided  into  two  regions  : 
the  antero-lateral  part,  extending  from  the  median  fissure  to  the  poste- 
rior horns,  and  the  posterior  part,  lying  between  the  posterior  horns. 
The  antero-lateral  part  contains  the  motor  fibres  or  pyramidal  tracts, 
whose  functions  have  already  been  described.  In  addition,  there  are 
certain  fibres  that  pass  downward  whose  functions  are  not  certainly 
known.  The  gray  matter  of  the  cord  is  divided  into  the  anterior  and 
the  posterior  horns.  It  is  composed  of  nerve-cells  and  nerve-fibres. 
The  nerve-cells  in  the  anterior  horns  form  a  large  group,  which  send 
their  axis-cylinders  into  the  anterior  roots,  and  comprise  the  peripheral 
motor  neurons.  In  the  posterior  horns,  in  the  dorsal  region,  there  is  a 
group  of  cells  on  the  inner  side  known  as  the  column  of  Clarke,  which 
apparently  have  something  to  do  with  equilibration.  Other  cells,  whose 
functions  are  not  definitely  known,  are  also  found  in  the  posterior 
cornua.  The  gray  matter  also  contains  a  large  number  of  nerve-fibres, 
some  of  which  pass  transversely  and  apparently  are  concerned  in  reflex 
action ;  others  ascend,  and  convey  to  the  brain  the  sensations  of  pain, 
heat  and  cold.  Each  segment  of  the  cord  innervates  and  receives  sen- 
sory impressions  from  an  approximately  corresponding  segment  of  the 
body,  and  contains  the  lower  reflex  arcs.  The  motor  and  reflex  func- 
tions of  the  various  segments  are  shown  in  the  table  and  the  sensory 
functions  in  Fig.  244  and  Fig.  245. 


1022 


SPECIAL  DIAGNOSIS. 


Table  of  Motor  axd  Beflex  Functions  of  the  Segment  of  the 
Spjxal,  Coed.    Modified  feom  Gowees  and  Mullee. 

Segments.  Motor  innervation.  Reflex  centres. 

c. 


1  \  Small  rotators  of  head 

2  J   Depressors  of  hyoid 

3  )    Diaphragm 

4  J  Platysma  (?) 


Scaleni. 

Lev.  ang.  scapulse. 

Cucullaris. 


5  ]    Deltoid 

Biceps 
I   Coraco  brachialis 
}■  Supinator  lougus 

Spinati 
|    Serratus  major 

6  J   Pectoral  major  (clay.)  ]   Pronators 

|   Triceps 

7  1   Flexors  of  wrist  and    [   Extensors   of  wrist 


fingers 
I   Pectoralis  (costal} 

I    Subscapulars 
I    Latissimus  dorsi 
8  J   Teres  major 

D. 
1 

2 
3 

4 
5 

Intercostal  muscles 
1 


8 

9 

10  j  f 
I 
J 


J        and  fingers 

")    Muscles  of  hand 

j-  Extensors  of  thumb 

I 

J 

1 

Erectors  of  spine 


Abdominal  muscles 


11 
12 

L. 

1 


Quadratus  lumborum     J 

lleo  psoas 

Cremaster 

Sartorius 

Pectineus 

Adductors 

Quadriceps  ~) 

Gracilis 

Obturator 

Adductors 

Flexors  of  knee 


Gluteal 


~|   Dilatation  of  the  pupil, 
sensory  part. (?) 

Scapular. 


Tendon   reflexes   of   the 
muscles  of  the  arms. 


Dilatation  of  pupil, 
motor  part.  (?) 


J         J 


Epigastric. 


Abdominal. 


Cremasteric. 
Knee-jerk. 


1 
i 

j-  Gluteal  reflex. 
J 


External  rotators  of  thigh 
Extensors  of  foot 
Tibialis  anticus 
Peroneal  muscles 

Perineal  and  anal  muscles 


Achillis  tendon  reflex. 
Plantar  reflex. 


Centres  for  the  bladder 
and  rectum. 


DISEASES  OF  THE  NERVOUS  SYSTEM. 

Fig.  244.  Fig.  245. 


1023 


(From  Oppenheim.) 


(From  Oppenheim  ) 


General  Symptomatology  of  Le.sioxs  of  the  Brain.  Lesions 
of  the  brain  may  be  irritative  or  destructive.  The  former,  if  affecting 
the  motor  tract,  produce  clonic  spasms.  If  destructive,  they  produce 
paralysis  without  atrophy,  and  cause  increase  in  the  muscle-tone  by 
the  removal  of  the  influence  of  the  superior  arc  and  exaggeration  of 
the  reflexes.  All  these  changes  occur  in  the  muscles  of  the  opposite 
side  of  the  body.  Irritative  lesions  are  most  likely  to  be  extra-cerebral 
— that  is,  pressing  upon  the  cortex.  Lesions  in  the  brain-substance  are 
usually  destructive,  and,  therefore,  cause  paralysis.  As  motor  fibres 
are  distributed  over  a  considerable  area  of  the  cortex,  lesions  in  this 
region,  if  circumscribed,  are  likely  to  cause  monoplegia.  If  involving 
the  area  for  the  face,  the  upper  branch  of  the  facial  nerve,  which  is 
innervated  from  both  sides,  is  rarely  involved.  Aphasia  only  occurs 
if  the  left  side  is  destroyed.     Lesions  in  the  corona  radiata  near  the 


1024  SPECIAL  DIAGNOSIS. 

cortex  usually  cause  monoplegia  ;  if  near  the  internal  capsule,  hemi- 
plegia is  more  common.  Lesions  in  the  internal  capsule  almost  invari- 
ably cause  hemiplegia.  If  the  knee  and  anterior  portion  of  the  posterior 
limb  are  involved,  hemiplegia  without  sensory  changes  results.  If 
they  also  affect  the  posterior  third  of  the  posterior  limb,  sensory  dis- 
turbances are  present,  and  there  is  likely  to  be  hemianopsia.  Lesions 
in  the  anterior  portion  of  the  anterior  limb  produce  no  recognizable 
symptoms,  and  are  termed  latent.  General  disturbances  of  the  brain  may 
be  caused  by  increase  of  the  intracranial  pressure.  This  may  be  brought 
about  by  growths,  traumatism,  oedema,  or  inflammation.  There  is  usually 
headache,  delirium  or  coma,  and  vomiting.  If  the  process  is  of  slow 
development,  a  certain  amount  of  adaptation  may  occur,  and  only  the 
headache  and  vomiting  may  be  present.  The  former  is  occasionally 
sharply  localized.  In  addition,  if  the  pressure  be  long  continued,  there 
is  cedema  of  the  optic  nerve.     (See  Disorders  of  the  Special  Senses.) 

General  Symptoms  of  Disease  of  the  Spinal  Cord.  These 
depend  upon  the  segment  of  the  cord  and  upon  the  nerve-tracts  in- 
volved. Lesions  are  spoken  of  as  transverse  if  they  involve  the  whole 
cord,  unilateral  if  they  involve  but  one  side,  and  focal  if  they  involve 
only  a  circumscribed  portion.  Transverse  lesions  may  be  produced  by 
inflammation,  by  pressure  either  by  a  tumor  or  as  a  result  of  deformity 
of  the  vertebral  column  (Pott's  disease).  Transverse  lesions  above 
the  fifth  cervical  segment  usually  cause  death  by  paralysis  of  the 
diaphragm.  If  the  patient  survive  there  is  paralysis  of  all  four 
extremities  and  total  anaesthesia  of  the  body.  There  is  also  paralysis 
of  the  bladder  and  rectum  and  abolition  of  the  cutaneous  reflexes,  and, 
in  the  majority  of  cases,  of  the  tendon  reflexes.  Transverse  lesions 
between  the  fifth  cervical  and  the  first  dorsal  segments  produce  atrophy 
and  degeneration  of  certain  muscles  of  the  arm,  according  to  their 
situation.  There  is  spastic  paralysis  of  the  legs  and  total  anaesthesia 
of  the  body  as  far  up  as  the  part  that  transmits  sensation  to  the  lowest 
intact  segment.  There  is  paralysis  of  the  bladder  and  rectum,  aboli- 
tion of  the  reflexes  whose  arcs  are  found  in  the  segments  involved,  and 
sometimes  exaggeration  of  all  the  tendon  reflexes  that  are  completed  in 
the  lower  segments.  The  cutaneous  reflexes  are  abolished.  Lesions  of 
the  dorsal  region  produce  spastic  paraplegia  and  paralysis  of  the  bladder 
and  rectum.  The  arms  escape  entirely,  and  respiration  is  not  disturbed. 
The  anaesthesia  extends  up  to  the  segment  involved.  Lesions  in  the 
lumbar  region  produce  atrophy  and  degeneration  of  certain  groups  of 
muscles  in  the  legs,  with  paralysis  and  disturbances  of  sensation,  dis- 
tributed according  to  their  extent.  The  situation  of  a  lesion  may  be 
roughly  determined  by  a  study  of  the  reflexes.  If  the  lesion  involve 
the  segments  concerned  in  any  of  these,  they  are,  of  course,  abolished. 
If  the  lesion  is  above  them,  they  are  sometimes  exaggerated  ;  if  below 
them,  they  are  ordinarily  not  involved.  Lesions  of  the  conus  termin- 
alis  and  the  cauda,  as  they  involve  the  large  number  of  nerve-roots, 
produce  a  complexity  of  symptoms.  There  are  irregular  areas  of 
anaesthesia  corresponding  to  the  posterior  roots  involved,  and  atrophy 
and  degeneration  of  the  muscles  supplied  by  the  anterior  roots.  The 
bladder  and  rectum  usually  are  affected. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  1025 

Unilateral  Lesion  of  the  Spinal  Cord  (the  syndrome  of  Brown-Sequard). 
This  produces  paralysis  of  the  same  side  and  anesthesia  of  the  oppo- 
site side,  both  symptoms  extending  as  far  upward  as  the  region  sup- 
plied by  the  segment  that  has  been  affected.  Disturbance  of  sensation 
is  not  total.  There  is  tactile  anaesthesia,  analgesia,  and  loss  of  tem- 
perature-sense on  the  side  opposite  the  lesion,  but  persistence  of  the 
muscular  sense,  which,  however,  is  diminished  or  lost  on  the  same  side 
as  the  lesion.  Disturbance  of  motion  is  complete.  Atrophy  and  de- 
generation occur  in  the  muscles  supplied  by  the  involved  segment ; 
below  this  there  is  spastic  paralysis,  with  increase  in  the  reflexes. 
Above  the  paralytic  area  there  is  a  zone  of  hyperesthesia  that  has 
never  been  satisfactorily  explained.  The  commonest  cause  of  unilat- 
eral lesion  is  traumatism,  particularly  bullet  and  stab  wounds.  Occa- 
sionally the  symptoms  develop  in  the  early  stages  of  syringomyelia  or 
as  a  result  of  tumor  or  hemorrhage  of  the  spinal  cord.  Focal  lesions 
in  the  spinal  cord  produce  various  symptoms,  according  to  their  situa- 
tion. Inflammations  involving  the  gray  matter  are  commonly  spoken 
of  as  poliomyelitis.  They  usually  attack  the  anterior  cornua  and  in- 
volve only  the  peripheral  motor  neuron — that  is,  they  produce  paralysis, 
atrophy,  and  degeneration  of  the  muscles.  Inflammatory  lesions  in  the 
white  matter  are  spoken  of  as  leukomyelitis.  They  produce  symptoms 
according  to  the  tracts  they  involve. 

The  Cranial  Nerves.  The  olfactory,  optic,  oculomotor,  pathetic, 
abducens,  auditory,  and  glosso-pharyngeal  have  already  been  described 
in  connection  with  the  special  senses.  The  trigeminal  nerve  takes  its 
origin  from  the  centres  in  the  pons  and  medulla  already  described. 
Destructive  lesions  of  the  motor  portion  cause  paralysis  of  the  ptery- 
goid muscles.  If  they  are  unilateral  it  is  impossible  for  the  patient 
to  move  the  mouth  toward  the  opposite  side  when  the  lower  jaw  is  pro- 
truded. It  is  to  be  assumed  that  atrophy  and  degeneration  of  these 
muscles  occur,  but  their  electrical  examination  is  practically  impossible. 
Irritative  lesions  produce  cramp  known  as  trismus.  This  is,  of  course, 
usually  due  to  central  disease.  The  sensory  portion  of  the  trigeminus 
supplies  the  skin  of  the  face  and  the  mucous  membranes  of  the  cavities 
of  the  head.  The  distribution  of  the  three  branches  is  shown  in  Fig. 
246.  Irritative  lesions  produce  tic  douloureux  ;  destructive  lesions, 
anaesthesia  in  the  distribution  of  the  part  affected.  The  facial  nerve 
arises  from  the  nuclei  in  the  posterior  portion  of  the  pons.  These  are 
probably  double,  each  supplying  a  separate  branch  of  the  nerve,  and 
the  superior  nucleus  is  innervated  from  both  sides  of  the  cerebrum.  It 
is  the  motor  nerve  for  the  muscles  of  the  face,  and  supplies  the  tem- 
poral, masseter,  the  orbicularis  palpebrarum,  the  muscles  of  the  lower 
part  of  the  face,  the  muscles  of  the  palate,  and  the  platysma  myoides. 
Unilateral  destructive  lesions  produce  paralysis  of  the  muscles  of  the 
face  (Bell's  palsy).  This  can  be  recognized  by  the  disappearance  of 
the  folds,  drooping  of  the  corner  of  the  mouth,  and  the  inability  to 
close  the  eye.  In  addition  there  may  be  loss  of  taste  and  hyperacusis 
in  the  ear  on  the  same  side.  Occasionally  there  is  deviation  of  the 
tongue,  the  palate  is  oblique,  and  the  uvula  is  pulled  toward  the  sound 

65 


1026  SPECIAL  DIAGNOSIS. 

side.  If  the  peripheral  portion  of  the  nerve  is  involved,  usually  both 
the  upper  and  lower  branches  are  affected,  and  the  paralysis  is  general. 
If  the  lesion  is  central  the  upper  branch  commonly  escapes,  or,  at  least, 
instead  of  being  paralyzed,  is  only  paretic.  Moreover,  in  central  lesions 
lying  above  the  pons  the  opposite  side  of  the  bod}r  is  paralyzed.  Secre- 
tion of  saliva  on  the  same  side  is  diminished  or  abolished.  This  may 
be  tested  on  the  sublingual  glands  by  raising  the  tip  of  the  tongue, 
carefully  drying  the  sublingual  space  and  getting  the  patient  to  inhale 
some  pungent  substance,  such  as  acetic  acid  or  musk.  The  saliva  will 
immediately  appear  on  the  sound  side,  but  will  fail  to  appear  on  the 
other.  In  facial  paralysis  it  is  impossible  for  the  patient  to  masticate 
on  the  diseased  side,  because  the  food  collects  between  the  cheek  and 
the  gums.  It  is  also  impossible  for  him  to  whistle.  Saliva  freely 
dribbles  from  the  drooping  corner  of  the  mouth,  and  as  it  is  impossible 
to  contract  the  orbicularis  palpebrarum  the  eye  remains  open  even  in 
sleep  (lagophthalmus),  and  the  corneal  reflex  is  abolished  or  imperfect. 
When  the  patient  attempts  to  close  the  eye  the  ball  rolls  upward  and 
outward.  In  addition,  the  palatine  reflex  also  disappears.  In  facial 
paralysis  of  long  standing  contractures  may  occur.  In  all  cases  the 
muscles  show  either  partial  or  complete  reactions  of  degeneration.  Irri- 
tative lesions  of  the  facial  nerve  cause  spasm  of  the  facial  muscles, 
usually  spoken  of  as  facial  tic.  The  vagus  nerve  supplies  motor  fibres 
to  the  larynx,  sensory  fibres  to  the  lungs,  and  inhibitory  fibres,  prob- 
ably sensory  in  nature,  to  the  heart.  It  also  probably  sends  sensory 
fibres  to  the  gastro-intestinal  tract.  Destructive  lesions  of  the  vagus 
produce,  if  unilateral,  unilateral  paralysis  of  the  vocal  cords,  interference 
with  deglutition,  and  transient  tachycardia.  The  laryngeal  changes 
are  most  characteristic.  (See  Chapter  I.,  Part  II.)  Irritative  lesions 
produce  spasm  of  the  glottis,  with  dyspnoea  or  aphonia.  The  spinal 
accessory  nerve  is  the  motor  nerve  for  the  trapezius  and  part  of  the 
sternocleidomastoid.  Destructive  lesions  of  this  nerve  are  the  chief 
cause  of  torticollis.  The  hypoglossal  nerve  is  the  motor  nerve  for  the 
tongue,  and  is,  therefore,  concerned  in  chewing,  swallowing,  and  speak- 
ing. Unilateral  destructive  lesions  produce  paralysis  of  one-half  of  the 
tongue,  which  is  protruded  toward  the  paralyzed  side,  with  atrophy  and 
degeneration  of  the  muscle.  Fibrillary  twitchings  are  usually  present. 
The  functional  disturbance,  however,  is  slight,  and  the  patient  may 
complain  of  no  discomfort.  Bilateral  paralysis  produces,  however,  very 
severe  symptoms.  The  tongue  lies  flaccid  in  the  mouth,  it  is  impossible 
to  protrude  it,  or  even  to  move  it  from  side  to  side.  Mastication  is 
impossible  and  swallowing  exceedingly  difficult.  Speech  is  at  first  seri- 
ously affected,  but,  as  a  rule,  the  patient  in  time  learns  to  compensate 
the  lingual  palsy.  Paralysis  of  the  tongue  as  a  result  of  central  lesion 
almost  never  occurs. 

General  Diagnosis  of  Nervous  Diseases.  It  is  necessary  to 
study  the  patient  according  to  some  fixed  plan,  otherwise  its  com- 
plexity and  the  numerous  investigations  that  it  is  necessary  to  make 
render  a  thorough  examination  almost  impossible.  It  is  true,  of  course, 
that  in  actual  clinical  practice  diseases  will  be  met  whose  clinical  symp- 
toms are  so  characteristic  that  the  diagnosis  can  be  made  almost  by 


DISEASES  OF  THE  NERVOUS  SYSTEM.  1027 

inspection  alone,  and  a  prolonged  examination  will  only  be  useful  for 
the  purpose  of  excluding  or  detecting  possible  complications.  On  the 
other  hand,  certain  cases  will  occur  that  almost  defy  diagnosis,  on  account 
of  the  multiplicity  and  contradictory  character  of  the  symptoms.  In  gen- 
eral it  may  be  said  that,  aside  from  the  history  and  the  subjective  symp- 
toms, the  physician  will  meet  with  four  groups  of  signs  :  disturbance 
of  sensation,  disturbances  of  motility,  atrophic  and  degenerative  lesions, 
and  disturbances  of  intelligence.  These  should  be  taken,  up  in  the  fol- 
lowing order  :  1.  Disturbance  of  intellect.  It  is  often  possible  to  detect 
this,  when  it  exists,  by  simple  conversation  with  the  patient.  It  may 
be  indicated  by  the  history,  or,  on  the  other  hand,  the  history  and  the 
behavior  of  the  patient  may  exclude  it  altogether.  2.  Disturbances  of 
motion.  It  is  well  to  study  first  the  more  patent  alterations.  Thus  the 
patient  should  be  told  to  move  the  arms  and  legs,  in  order  to  detect 
paralysis ;  he  should  be  requested  to  walk,  in  order  to  study  the  gait ; 
he  should  be  directed  to  perform  some  fine,  co-ordinated  movement,  in 
order  to  detect  possible  ataxia ;  and  to  put  the  muscles  in  a  state  of 
tension,  in  order  to  exaggerate  a  possible  tremor.  Following  this  the 
individual  movements  should  be  carefully  examined.  It  must  be 
remembered  that,  whether  the  lesion  is  in  the  central  or  peripheral 
nervous  system,  disturbance  of  motility  is  manifested  only  in  the 
muscles  themselves,  and  the  investigations,  therefore,  should  commence 
with  these — that  is  to  say,  it  is  not  desirable  to  test  the  motor  functions 
of  each  particular  nerve,  but  rather  of  each  particular  group  of  muscles, 
and  to  deduce  from  the  changes  found  in  them  the  nerve  or  segment 
involved.  The  following  table  from  Sahli  gives  a  classification  of  the 
muscles  of  the  extremities,  according  to  their  functions,  with  their 
nerve-supply  : 

Table  of  the  Voluntary  Muscles  Grouped  According  to  their 
Functions,  with  their  Nervous  Supply.    (From  Sahli.) 

Upper  Extremity. 
A.  Movements  of  the  shoulder-blade. 

1 .  Elevators  of  the  shoulder. 

Middle  part  of  the  cucullaris  (N.  accessorius). 
Rhomboidei  (N.  dors,  scapul.,  5th  cervical  nerve). 
Levator  scapulse  (2d  and  3d  cerv.  nerv.  and  N.  dors.  scap. ). 
Upper  portion  of  the  pectoral  major  (Nn.  thorac.  ant.,  5th  and  6th  cerv. 
nerves). 

2.  Depressors  of  the  shoulder. 

Pectoralis  minor  (Nn.  thorac.  anterior). 

Lower  portion  of  the  latissimus  dorsi  (N.  subscapulars). 

Lower  portion  of  the  pectoralis  major  (N.  thorac.  ant.). 

3.  Adduction  of  the  shoulder. 

Lower  portion  of  the  cucullaris  (N.  accessor. ). 

Upper  portion  of  the  latissimus  dorsi  (N.  subscapulars). 

4.  Abduction  of  the  shoulder. 

Upper  third  of  the  pectoral,  major  (N.  thor.  ant.). 

Serratus  anticus  major  (N.  thorac.  longus,  6th,  7th,  8th  cerv.  nerv. ). 


1028 


SPECIAL  DIAGNOSIS 


B.  Movements  of  the  shoulder-joint. 

1 .  Elevators  of  the  arm. 

(a)  Laterally,  deltoid  (K  axillaris). 

Vertically,  serratus  anticus  major  (N.  thorac  longus )._ 

(b)  Anteriorly,  anterior  portion  of  the  deltoid  (K  axillaris). 
Coracohrachialis  (N.  musculocutaneous). 

Biceps  (N.  musculocutaneous). 

(c)  Posterior  portion  of  the  deltoid  (N.  axillaris). 

2.  Adduction  of  the  arm. 

Pectoralis  major  (N.  thorac.  anticus,  5th  and  6th  cerv.  n.). 
Latissimus  dorsi  and  teres  major  (N.  subscapularis). 
Infraspinatus  (N.  suprascapular,  5th  and  6th  cerv.  n. ). 
Teres  minor  (N.  axillaris). 

These  muscles  also  depress  the  arm. 

3.  Internal  rotation. 

Subscapulars  (Nn.  subscapulares). 

4.  External  rotation. 

Infraspinatus  (N.  suprascapularis). 
Teres  minor  (N.  axillaris). 

C.  Movements  of  the  elbow. 

1.  Flexion. 

Biceps  (N.  musculocutan.). 
Brachialis  (N.  musculocutan.). 
Supinator  longus  (N.  radialis). 

2.  Extension. 

Triceps  (N.  radialis). 

3.  Supination. 

Supinator  brevis  1  (N_  radialis). 
Supinator  longus  j  v 

4.  Pronation. 

Pronator  quadratus  j  (N>  medianus). 
Pronator  teres  I  v 

Supinator  longus  (N.  radialis). 

D.  Movements  of  the  wrist-joint. 

1.  Flexion. 

Flex,  carpi  radialis  (N.  medianis). 
Flex,  carpi  ulnaris  1  (N_  ulnaris)- 
Palmaris  longus       J  v 

2.  Extension. 

Extensor  radialis  longus  and  brevis  \  ,-^_  radialis). 
Extensor  ulnaris  J 

3.  Abduction. 

Flexor  carpi  radialis        _   1  (K  Qiedianis  ana  N.  radialis). 
Badiahs  longus  and  brevis  j 

4.  Adduction. 

Extensor  ulnaris  and  flexor  carpi  ulnaris  (Nn.  radial,  and  ulnar). 

E.  Movements  of  the  fingers. 

1.  Flexion. 

Flexor  digitor.  sublim.;  flexion  of  the  2d  phalanx  (IS.  median). 

Flexor  digitor.  prof.;  flexion  of  the  terminal  phalanx  (Nn.  median,  ulnar) 

Interossei  and  lumbrical  muscles,  flexion  of  the  proximal  phalanx  (Nm 

ulnaris,  median. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  1029 

2.  Extension. 

Extensor  dig.  comni.  (N.  radialis). 

Interossei  and  lumbrical  muscles  (N.  ulnar,  jS".  median). 

F.  Movements  op  the  thumb. 

1.  Flexion. 

Flexor  pollicis  longus  and  brevis  (N.  median). 

2.  Extension. 

Extensor  pollicis  longus  and  brevis  (N.  radialis). 

3.  Abduction. 

Abductor  pollicis  long.  (N.  radialis). 
Abductor  pollicis  brev.  (N.  median). 

4.  Adduction. 

Adductor  pollicis  (X.  ulnaris). 

5.  Opposition. 

Opponens  pollicis  )  ,w         ■,.      ■, 

*  jj     .  ii-  •    u  >N.  median). 

Adductor  pollicis  brev.  J  v 

G.  Movements  of  the  little  fingeb. 

1.  Flexion. 

Flexor  communis  digitorum  profundus  and  sublimis  (N.  median  and  N. 
Flexor  brevis  minimi  digiti  (N.  ulnaris).  ulnaris). 

2.  Extension. 

Extensor  minimi  digiti  proprius  (N.  radial. ). 

3.  Abduction. 

Abductor  minimi  digiti  (N.  ulnaris). 

4.  Opposition. 

Opponens  minimi  digiti  (N.  ulnaris). 

Loweb  Extbemity. 
A.  Movements  of  the  hip- joint. 

1.  Elevation  of  thigh. 

Iliopsoas  (N.  plexus  lumbalis). 
Kectusfemoris|(Kci,urali 
oartorius  I  v 

2.  Depression  of  thigh. 

Glutseus  maximus  (Nn.  glut.  inf.  and  ischiadicus). 
Flexors  of  the  knee  (N.  ischiadicus). 

3.  Internal  flexion. 

Glutseus  med.  and  minim.  (N.  glut,  super.). 

4.  External  rotation. 

Quadratus  femoris  j  (  N   ischiadicus). 

Obturator  int.  and  Gemelli  J  v 

Obturator  ext.  CN.  obturat. ). 

Piriformis  (Plex.  ischiad. ). 

Iliopsoas  (Plex.  lumbal.). 

Glutseus  max.  (N.  glutseus  inf. ). 

5.  Adduction. 

Adductores  (N.  obturator). 
Pectineus  (N.  crural   and  obturat.  ). 
Gracilis  (N.  obturator). 

6.  Abduction. 

Glutseus  med.  and  min.  (N.  glut.  sup. ). 


1030  SPECIAL  DIAGNOSIS. 

B.  Movements  of  the  knee-joint. 

1.  Flexion, 

Sartorius  (N.  cruralis). 
Gracilis  (jST.  obturat. ). 
Semitendinosus       ) 
Semimembranosus  >  (N.  ischiad. ). 
Biceps.  J 

Popliteus  (N.  tibial,  N.  ischiad.). 

2.  Extension. 

Quadriceps  (N.  cruralis). 

C.  Movements  of  the  askle- joint. 

1.   Dorsal  flexion. 
Tibial  antic 


libial  antic.  I  (N.  peron.  prof.). 

Extensor  commun.  dig.  long.  J  r 

2.  Plantar  flexion. 

Gastrocnemius)  (Ntibial)  _ 

Soleus  I  v 

Perineus  long.  (N.  peron.  superficial). 

3.  Adduction. 

Tibial  postic  (N.  tibial). 
Tibial  ant.  (N.  peron.  prof. ). 

4.  Abduction. 

Peroneus  long.       "j 

Peroneus  brevis      V  (N.  peron.  prof.). 

Comm.  dig.  long  J 

5.  Elevation  of  the  inner  side  of  the  foot. 

Tibial  ant.  (]>    peron  prof. ). 
Tibial  post.  (N.  tibial). 

6.  Elevation  of  the  outer  side  of  foot. 

Peroneus  long,  and  brev.  \    K  n  rf>  y 

Peroneus  tertius  I 

D.  Movements  of  the  toes. 

1.  Flexion. 

Flexor  comm.  digit,  long,  and  brev.  \  ,^  tibial). 
Interrossei  and  lumbricales  J 

2.  Extension. 

Extensor  comm.  digit,  long,  and  brev.  (N.  peron.  prof. 

3.  Adduction. 

Interossei  plantares  (N.  tibial). 

4.  Abduction. 

Interossei  dorsales  (N.  tibial). 

E.  Movements  of  the  great  toe. 

1.  Flexion. 

Flexor  ballucis  long,  and  brev.  (N.  tibial). 

2.  Extension. 

Extensor  ballucis  long,  and  brev.  (N.  peron.  prof.). 

3.  Adduction. 

Adductor  hallucis  (N.  tibial). 

4.  Abduction. 

Abductor  hallucis  (N.  tibial). 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


1031 


F.  Movements  of  the  small  toe. 

1.  Flexion. 

Flexor  minimi  digit.  (N.  tibial). 

2.  Abduction. 

Abductor  minimi  digit.  (N.  tibial). 

3.  Opposition.  . 

Opponens  minimi  digit.  (X.  tibial). 

Each  movement  should  be  tested  by  requesting  the  patient  to  per- 
form it  first  unimpeded,  and  then  against  resistance.  (For  functions 
of  motor  cranial  nerves,  see  page  1025.)  3.  Sensory  disturbances.  As 
in  testing  the  motor  disturbances,  there  is  first  obtained  a  rapid  orien- 
tation of  the  sensory  condition  of  the  patient.  For  this  purpose  it  is 
customary  to  touch  with  the  finger  or  a  blunt  object  both  sides  of  the 


Fig.  246. 


Cutaneous  nerves  of  the  head  and  face. 
Vu  V*  V3,  first,  second,  and  third  branches  of  the  trigeminus ;  S  0,  supra-orbital  :  I,  lachrymal 
tl,  supratrochlear ;  it,  infratrochlear ;  e,  ethmoidal ;   am,  malar  ;  at,  auriculotemporal ;  6,  buc 
cinator ;  m,  mental ;  am,  auricularis  magnus  ;  oma  and  omi,  occipitalis  major  and  minor. 

face,  the  arms,  the  legs,  and  both  sides  of  the  body.  If  the  patient 
declares  that  there  is  no  difference  in  the  sensory  perceptions,  tactile 
anaesthesia  may  be  temporarily  excluded.  The  same  regions  are  tested 
for  pain  and  temperature-sense,  and  it  is  often  desirable  to  test  the 
muscle-sense  at  the  same  time,  although  this  properly  belongs  to  dis- 
turbances of  motility.  It  is  often  possible,  in  testing  sensation,  to  decide 
whether  the  lesion  is  peripheral  or  central  by  its  distribution.  If  it 
affects  the  spinal  cord  it  will  be  segmental  in  type.  (See  Fig.  244  and 
Fig.  245.)  If  it  affects  the  peripheral  nerves,  the  area  or  areas  will 
correspond  to  the  cutaneous  distribution  of  the  nerve  or  nerves  involved. 
(See    Fig.    246    et   seq.)      4.    The   cutaneous    trophic   changes   occur 


1032 


SPECIAL  DIAGNOSIS. 


particularly  in  the  form  of  panaritis  of  glossy  skin  or  of  bed-sores. 
Trophic  changes  in  the  joints  occur  especially  in  the  knee,  shoulder,  and 
hip.  Trophic  changes  in  the  muscles  may  occur  in  any  part  of  the  body. 
They  are,  of  course,  nearly  always  associated  with  distinct  paralysis. 
Having  obtained  a  rough  idea  of  the  condition  of  the  patient,  it  is  then 


Pig.  247. 


Cutaneous  nerves  of  the  anterior  surface  of  the  trunk.    (Sahli.) 


necessary  to  make  a  more  minute  examination.  1.  The  various  func- 
tions should  be  carefully  studied,  particularly  those  of  the  cerebral 
nerves.  These  should  be  taken  up  in  order  and  all  their  functions 
tested.  2.  It  is  important  to  note  the  reflexes,  especially  those 
of  the  eye>  and  the  tendon  and  cutaneous  reflexes  of  the  body  and 


DISEASES  OF  THE  NER  VO  US  SYSTEM. 


1033 


extremities.     3.  The  position,  station,  and  gait.     4.  The  disturbances 
of  speech.     5.  The  condition  of  the  individual  muscles  and  nerves  of 


Fig.  248. 


N.radia/. 


Cutaneous  nerves  of  the  anterior  surface  of  the  arm.   (Sahli. 


the  body.  The  diagnosis  must  then  be  made  by  the  study  of  the  symp- 
toms elicited.  It  should  be,  if  possible,  both  topical  and  pathological, 
although  it  is  not  always  possible  to  make  the  latter. 


SPECIAL  DIAGNOSIS  OF  DISEASES  OF  THE  NERVOUS 

SYSTEM. 

The   semeiological  classification  of  nervous  diseases  presents   many 
difficulties.     Many  of  the  diseases  that  are  closely  analogous  in  their 


1034 


SPECIAL  DIAGNOSIS. 


symptoms  are  widely  different  in  their  pathology  or  etiology,  and 
many  diseases  present  such  variations  in  their  symptom-complex  that 
at  one  period  they  could  properly  be  placed  in  one  group  and  at 
another  period  elsewhere.  In  general,  it  may  be  said,  however,  that 
the  diseases  of  the  peripheral  motor  neurons  differ  so  widely  from 
those  of  the  central  motor  neurons  that  they  can  be  classified  as  two 
separate  groups,  and  in  a  third  group  would  come  the  diseases  of  the 
sensory  neurons.  Combinations  of  these  three  groups,  producing  on 
their  part  rather  clearly  marked  complexes  of  symptoms,  may  then  be 
described,  and  finally  the  general  and  local  diseases  of  the  brain  and 


Fig.  249. 


'Medianus 


Distribution  of  the  cutaneous  nerves  in  the  hand. 

cord.  An  entirely  separate  group,  characterized  by  peculiar  symptoms, 
are  the  so-called  functional  nervous  diseases,  or  the  neuroses.  It  must 
be  admitted,  however,  that  this  group,  as  a  result  of  more  accurate 
methods  of  investigation,  is  growing  rapidly  smaller. 


Diseases  of  the  Peripheral  Motor  Neurons  and  the  Muscles. 
Diseases  Characterized  by  Pure  Motor  Disturbance. 

Progressive  Muscular  Atrophy.  Two  forms  are  recognized  —  the 
scapulo-humoral  type  of  Erb  and  the  facio-scapulo-humoral  type 
of  Dejerine-Landouzy.  In  the  former  the  disease  commences  in  the 
muscles  of  the  shoulder,  especially  the  pectorals  and  the  latissimus 
dorsi.  Next  the  adjacent  muscles  are  involved,  followed  by  the 
muscles  of  the  arms,  thighs,  and  finally  the  muscles  of  the  calf. 
There  is  gradual  loss  of  power  corresponding  to  the  atrophy  of  the 
muscles,  but  reactions  of  degeneration  do  not  occur.    As  a  result  of  the 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


1035 


wasting,  peculiar  alterations  occur  in  the  configuration  of  the  body — 
that  is,  the  shoulder-blades  become  prominent,  lordosis  occurs,  and,  as 
a  result  of  the  weakness  of  the  glutei,  it  may  be  necessary  for  the 


Fig.  250. 


N.  cut.  brach.  est.  (From 
the  N.  musculocuta- 
neus). 


N    median. 
Cutaneous  nerves  of  the  posterior  surface  of  the  arm.    (Sahli.  ) 


patient  to  arise,  as  in  the  following  form,  by  climbing  up  his  legs. 
The  gait,  as  a  result  of  the  atrophy  of  the  quadriceps,  is  waddling  in 
character.     The  disease  usually  presents  itself  about  puberty. 

In  the  latter  type  the  symptoms  are  essentially  the  same,  excepting 
that  the  first  muscles  to  undergo  atrophy  are  those  of  the  eyelids  and 


1036  SPECIAL  DIAGNOSIS. 

mouth.     This  form  usually  commences  about  the  third  or  fourth  year 
of  life. 

Pseudo-hypertropliic  Muscular  Paralysis.  The  disease  usually  com- 
mences in  the  muscles  of  the  calves.  These  become  greatly  enlarged, 
hard,  and  there  is  great  loss  of  power.     Other  muscles  of  the  legs  are 

Fig.  251. 

WfQf 

fymiitlM-liiimm  4 N-  Pud-  conrm.  (pl.sacr.) 

\fu.ui'b)\  /Hi- N-  cut-  fem-  P°st-  (P1-  (sacr.) 

d i 

V| N.  obturator,  (pi.  lumb. 


X.  peroneus 


N.  peroneus  superf. 


X.  cut.  dorsi  pedis  ext. 

N.  plant,  ext. 


^**  N.  peroneus  prof. 


N.  plant,  int. 


Cutaneous  nerves  ol  the  anterior  surface  of  the  leg.    (Sahli.) 


next  involved  ;  then  those  of  the  back,  and  perhaps  the  arms.  Not  all 
the  muscles  that  undergo  atrophy  show  a  preliminary  hypertrophy. 
The  electrical  reactions  remain  normal,  and  the  loss  of  power  is  due 
merely  to  the  atrophy  of  the  true  muscle  substance.  The  gait  is 
waddling,  and  the  patient  is  unable  to  arise  from  the  ground,  except 
by  getting  upon  the  hands  and  knees  and  then  gradually  climbing  up 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


1037 


his  legs.  There  is  usually  lordosis  or  scoliosis,  and  occasionally  con- 
tractures occur,  leading  to  formation  of  club-foot.  In  all  these  three 
forms  of  disease  the  course  is  slowly  progressive. 


Fig.  252. 


I'#r 


/     r     l  *       \ileoflifpoq. 

*<■<■■:■:■.     \\Mc(inixMplex. 
I  lwmb.eiCsacr.) 


N.  obturatorius 


N.  saphenus  maj. 


N.  calcan. 
N.  plant,  int. 


—  X.  cut.  fem.  lat.  (pi.  lunib.) 


N.  communicans  tibial  et 
peroneus. 


N.  peroneus  superfic. 
N.  cut.  dorsi  pedis  ext. 
N.  plant,  ext. 


Cutaneous  nerves  of  the  posterior  surface  of  the  leg.    (Sahlt.) 

Diseases  Characterized  by  Motor  Disturbance,  with  Degen- 
erative Changes  in  the  Muscles. 

Progressive  Muscular  Atrophy  Consecutive  to  Disease  of  the  Nerves. 
(The  Charcot-Marie-Hoffmann  type;  the  peroneal  type  of  Gowers.j 
The  first  muscles  affected  are  those  of  the  feet  and  hands,  usually  in 
the  former,  the  peronei,  the  extensors  of  the  toes,  and  the  small  muscles 


1038  SPECIAL  DIAGNOSIS. 

of  the  foot ;  in  the  latter,  the  interossei  and  the  muscles  of  the  thenar 
and  the  hypothenar  eminences.  The  affected  muscles  show  distinct 
fibrillary  twitchings  and  usually  the  characteristic  reactions  of  degenera- 
tion to  the  electrical  current.  These  reactions  of  degeneration  are  also 
present  in  the  nerves.  There  is  usually  a  coarse,  irregular  tremor,  and 
the  atrophy  of  some  of  the  muscles  with  contractures  of  others  give  rise 
to  various  deformities,  such  as  the  ape-hand,  the  main  en  griffe,  or,  if 
the  foot  is  first  affected,  to  foot-drop.  Later  the  foot  assumes  a  posi- 
tion of  equino  valgus  or  varus.  In  this  disease  there  is  sometimes 
involvement  of  the  sensory  fibres,  and  the  patients  may  complain  of 
slight  paresthesia  or  even  of  pain.  Hypsesthesia  is  also  occasionally 
present.  In  a  form  of  this  disease  described  by  Dejerine  under  the 
title  of  Infantile  Hypertrophic  and  Progressive  Interstitial  Neuritis-, 
there  are,  in  addition  to  the  above  changes,  the  symptoms  of  locomotor 
ataxia — that  is,  Romberg's  symptom — lancinating  pains,  atactic  gait, 
and  even  disturbance  of  the  pupillary  reflexes.  The  nerve-trunks 
become  enlarged  and  can  be  felt  beneath  the  skin. 

Progressive  Spinal  Muscular  Atrophy.  (Type  of  Duchenne-Aran.) 
The  disease  commences  usually  in  the  muscles  of  the  hand,  particularly 
in  those  of  the  thenar  eminences,  giving  rise  to  the  formation  of  the 
ape-hand.  The  interosseous  spaces  become  deeper,  the  fingers  become 
gradually  weakened,  and  ultimately  become  fixed  in  a  semi-flexed  con- 
dition— incomplete  main  en  griffe.  The  muscles  show  fibrillary  twitch- 
ing and  give  the  reactions  of  degeneration  to  the  electrical  current. 
Usually  the  process  is  bilateral.  As  the  disease  progresses  it  next 
involves  the  muscles  of  the  shoulder,  especially  the  deltoids,  and  later 
the  muscles  of  the  upper  arm,  and  then  of  the  forearm.  Finally,  the 
muscles  of  the  back  become  involved,  and  even  the  lower  extremities. 
Sensory  disturbances  are  never  present.  The  emaciation  is  extreme, 
but  total  paralysis  occurs  only  very  late  in  the  disease. 

Acute  Anterior  Poliomyelitis.  This  is  really  an  infectious  disease, 
commencing  with  chills  and  fever  and  characterized  by  the  rapid  ap- 
pearance of  flaccid  paralysis  in  one  or  more  limbs.  The  onset  is  usually 
sudden,  and  the  paralysis  may  occur  before  the  development  of  the 
general  symptoms.  The  legs  are  more  frequently  involved  than  the 
arms ;  the  muscles  are  usually  affected  in  functionally  similar  groups, 
such,  for  example,  as  the  flexors  of  the  upper  arm,  and  then  very  rapidly 
begin  to  undergo  contractures.  These  produce  deformities,  particularly 
various  forms  of  club-foot,  scoliosis  or  lordosis,  and  contractures  of 
the  hand.  The  disease  usually  occurs  in  children,  and  the  affected 
extremity  does  not  grow  as  rapidly  as  the  other.  Occasionally  adults 
are  attacked.  Sensory  disturbances  are  absent,  the  reflexes  are  abol- 
ished, and  the  electrical  reactions  are  those  of  degeneration.  In  the 
very  early  stage  pains,  usually  radiating  from  some  point  in  the  back, 
have  been  noted  in  a  few  instances.  Ordinarily,  the  paralysis  is  more 
extensive  at  first  than  later  —  that  is  to  say,  many  of  the  muscles 
involved  recover  completely. 

Chronic  Anterior  Poliomyelitis.  This  is  characterized  by  the  slow 
development  of  paralysis  in  one  or  more  groups  of  muscles  or  extremi- 
ties of  the  body.     The  flexors  are  more  likely  to  be  attacked  than  the 


DISEASES  OF  THE  NERVOUS  SYSTEM.  1039 

extensors.  The  muscles  show  fibrillary  twitchings  and  the  reactions 
of  degeneration,  and  the  paralysis  is  usually  flaccid.  The  process  is 
usually  self -limited,  but  bulbar  symptoms  may  appear  and  cause  death. 
The  disease  resembles  closely  progressive  spinal  muscular  atrophy. 

Periodic  Paralysis.  This  is  a  disease  characterized  by  the  occur- 
rence from  time  to  time  of  paralysis  of  all  four  extremities.  The 
paralysis  is  usually  flaccid  in  type,  occurs  without  pain,  and  is  associ- 
ated with  extraordinary  increase  in  the  electrical  resistance  of  the  skin. 
The  disease  usually  occurs  in  several  members  of  the  same  family,  the 
paroxysms  lasting  three  or  four  days. 

Diseases  Characterized  by  Disturbance  of  Motion  Occurring 
without  keference  to  any  definite  portion  of  the  cere- 
BRAL Nervous  System. 

Chorea  (Sydenham's  chorea)  is  characterized  by  irregular  twitching 
movements  affecting  various  groups  of  muscles  in  the  body  that  are 
usually  functionally  associated,  so  that  the  movements  appear  to  be  the 
result  of  voluntary  innervation.  These  movements  may  be  generally 
distributed,  or  more  pronounced  on  one  side  than  the  other,  or  may 
even  occur  only  in  one  part  of  the  body.  They  may  involve  the  muscles 
of  the  face,  the  arm,  the  leg,  or  the  muscles  of  the  trunk,  particularly 
the  diaphragm,  giving  rise  to  an  irregular,  jerking  inspiration.  They 
may  vary  in  severity  from  slight,  almost  imperceptible  contractions  to 
severe,  general  convulsive  movements  in  which  the  violence  is  so  great 
that  bruises  or  even  fractures  may  occur.  As  a  rule,  the  affected  limbs 
are  slightly  weaker,  and  in  some  cases  this  paralysis  is  very  pronounced 
(paralytic  chorea).  The  mind  is  usually  clear,  but  there  may  be  some 
irritability  of  temper.  In  a  few  cases  with  violent  movements  there  is 
pronounced  insomnia  and  violent  delirium  (chorea  insaniens).  Speech 
may  be  affected  either  as  a  result  of  choreic  movements  of  the  lips  or  on 
account  of  psychic  disturbance.  Associated  symptoms  are  the  presence 
of  a  heart  murmur,  irregularity  of  cardiac  action,  rheumatic  pains  in 
the  limbs,  which  usually  disappear  as  the  movements  become  more 
pronounced ;  and,  occasionally  in  the  violent  form,  fever. 

Huntington's  chorea  is  characterized  by  the  development,  between  the 
ages  of  twenty  and  forty,  of  choreiform  movements  of  moderate  degree, 
associated  with  gradually  progressive  dementia.  The  disease  is  strictly 
hereditary,  occurring  only  in  the  offspring  of  those  who  have  suffered 
from  it.  The  twitchings  resemble  those  of  chorea,  but  are  rarely  vio- 
lent, and  often  associated  with  a  slight  rigidity.  The  first  mental 
symptom  is  usually  loss  of  memory.  Later,  the  patient  may  have 
delusions  of  grandeur  or  severe  melancholia.  Usually  life  is  prolonged 
to  an  advanced  age,  the  mental  symptoms  gradually  passing  into  the 
type  of  severe  senile  dementia.  A  curious  condition  is  the  tendency 
of  the  patient  to  avoid  society. 

Chorea  Electrica.  There  arc  various  varieties  of  this  condition — one 
occurring  in  children,  characterized  by  lightning-like  contractions  of 
groups  of  muscles,  sometimes  those  of  the  trunk  or  those  of  the  ex- 
tremities ;  another,  Dubini's  disease,  which  appears  to  be  an  infectious 


1040  SPECIAL  DIAGNOSIS. 

process,  commences  with  violent  pains  in  the  head,  neck,  and  back,  slight 
fever,  and  general  convulsions.  Muscular  contractions  occur,  usually 
involving  all  the  muscles  of  the  body  that  are  characterized  by  their  fre- 
quent recurrence  and  brief  duration.     Death  is  the  usual  termination. 

Paramyoclonus  Multiplex.  This  is  a  disease,  probably  hysterical  in 
nature,  characterized  by  lightning-like  contractions  in  groups  of  muscles, 
which  do  not,  however,  produce  movement  that  would  in  any  way 
resemble  co-ordinated  action.  Often  the  patient  from  time  to  time 
emits  a  peculiar  sound  resembling  a  grunt,  probably  the  result  of 
diaphragmatic  involvement.  The  electrical  reactions  are  normal,  and 
the  reflexes  are  sometimes  slightly  increased. 

Habit  spasm  is  characterized  by  the  repetition  of  some  peculiar, 
unnecessary  movement,  such  as  shrugging  the  shoulders,  winking  the 
eye,  rubbing  the  elbow  against  the  side,  etc.  Emotional  disturbances 
or  the  presence  of  bystanders  always  increase  the  symptoms. 

Saltatoric  spasm  (jumper's  disease,  latah)  is  a  hysterical  manifesta- 
tion in  which  the  patient,  whenever  he  or  she  attempts  to  stand,  is 
compelled  to  rise  on  the  toes  or  even  to  spring  from  the  ground. 
Often  after  such  movements  the  patient  falls.  The  spasm  disappears 
if  the  patient  lies  down,  but  may  be  produced  by  pressure  upon  the 
soles  of  the  feet. 

General  Tie  (Maladie  de  Gilles  de  la  Tourette;  maladie  der  tics  con- 
vulsifs).  This  is  a  psychical  condition  characterized  by  curious  move- 
ments of  the  limbs  and  grimaces  and  the  utterance  of  words,  that  have 
no  relation  to  the  evironment,  that  may  be  profane  or  obscene  (copyro- 
lalia),  or  the  imitations  of  sounds  heard  (echolalia).  The  patient  becomes 
more  or  less  melancholy,  and  may  even  be  violently  insane. 

Paralysis  Agitans.  This  is  characterized  by  a  peculiar,  fine  tremor 
of  the  extremities,  rigidity  of  the  muscles,  disturbance  of  gait,  and 
gradually  progressive  paresis.  The  first  symptom  noted  is  usually  a 
slight  impairment  of  agility.  As  the  disease  commences  in  advanced 
life,  this  is  not  regarded  with  suspicion ;  but  later  the  immobility  of 
the  muscles  of  the  face  and  the  complete  loss  of  facial  expression  sug- 
gests the  nature  of  the  case.  It  will  now  be  found  that  the  patient 
will  have  difficulty  in  rolling  over,  if  lying  down,  and  that  there  is  dif- 
ficulty in  commencing  to  walk  and  afterward  a  tendency  to  take  quick 
steps  (festinatioii).  The  patient,  if  studied,  will  be  seen  to  have  from 
time  to  time  a  slight  movement  forward  or  backward,  which,  if  stand- 
ing or  walking,  may  cause  him  to  fall  in  one  direction  or  the  other 
(propulsion,  retropulsion).  Speech  is  also  involved,  difficulty  in  articu- 
lation being  characterized  at  first  by  slight  halting  and  then  the  rapid 
utterance  of  the  words.  The  tremor  of  the  hands  is  spoken  of  as  pill- 
roller's  tremor  (q.  v.).  Tremor  of  the  head  is  a  nodding  movement  to 
and  fro.  There  may  also  be  irregular  movements  of  the  toes  or  legs. 
The  tremor  is  diminished  or  abolished  temporarily  by  voluntary  move- 
ment and  disappears  during  sleep. 

Tetany  is  probably  an  infectious  disease  characterized  by  cramp  of 
the  muscles  of  the  arms  and  the  persistence  of  peculiar  nervous  and 
mental  alterations.  The  attack  usually  commences  with  paresthesia  or 
pain  in  the  limbs  ;  then  the  muscles  controlling  the  fingers  become  stiff. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  1041 

The  flexors  gradually  contract  and  draw  the  fingers  and  thumb  together, 
the  so-called  obstetrical  hand.  This  cramp  is  tonic  in  character,  and 
may  last  for  several  minutes  or  even  for  many  hours.  It  is  often  asso- 
ciated with  intense  pain  During  the  interval  it  may  be  reproduced 
by  prolonged,  severe  pressure  upon  the  nerve-trunks,  particularly  the 
median  nerve  (Trousseau's  sign).  The  muscles  show  marked  irrita- 
bility to  mechanical  stimuli,  particularly  those  of  the  face,  and  twitch- 
ing may  be  caused  by  tapping  upon  the  trunk  of  the  facial  nerve,  upon 
the  malar  bone,  or  over  the  infraorbital  foramen  (Chvostek's  sign). 
The  muscles  show  extreme  electrical  irritability,  contract  to  very  weak 
currents,  and  in  some  cases  AOTe  and  COTe  have  been  obtained 
(Erb's  sign).  Finally,  the  patient  is  extremely  sensitive  to  the  induced 
current  (Hoffmann's  sign).  During  the  attack,  and  even  during  the 
interval,  there  is  sometimes  slight  oedema  of  the  face,  hands,  and  feet, 
and  the  latter  have  a  tendency  to  assume  a  partial  equino-varus  posi- 
tion.    Often  there  is  slight  fever. 

Occupation  Neuroses.  These  are  characterized  by  the  development 
of  pain  in  the  limb  employed  when  the  attempt  is  made  to  perform 
some  habitual  movement.  It  is  most  common  as  a  result  of  writing. 
The  patient  notices  at  first  that  he  becomes  more  readily  fatigued  than 
usual,  and  there  may  be  dull  pains  in  the  joints  or  in  the  palm  of  the 
hand.  The  painful  sensations  may  then  extend  up  the  arm,  often  as 
far  as  the  shoulder.  They  are  rarely  severe,  but  by  their  persistent, 
dull  character  are  extremely  annoying.  The  motor  symptoms  are 
characterized  by  a  tonic  spasm  of  the  muscles  employed  in  grasping 
the  pen,  so  that  it  is  held  too  tightly,  and  often  there  is  difficulty  in 
holding  it  properly.  From  time  to  time  the  spasmodic  condition  may 
increase  and  cause  inaccurate  strokes.  The  writing  is  usually  heavy  and 
often  quite  illegible.  The  muscles  apparently  never  degenerate.  The 
electrical  reactions  are  normal  or  only  slightly  altered.  If  the  patient 
learns  to  write  with  the  left  hand,  the  symptoms  of  the  disease  usually 
develop  in  it  after  a  short  time.  Similar  symptoms  occur  in  piano- 
players,  violin-players,  dairy-maids,  telegraphists,  and  various  other 
persons  who  are  obliged  to  perform  the  same  movement  for  long  periods. 

Thomsen's  Disease.  This  is  characterized  by  the  occurrence  of  tonic 
spasm  as  the  result  of  voluntary  innervation  of  the  muscles.  The 
patient,  upon  attempting  to  make  a  movement,  finds  the  part  rigidly 
fixed  for  a  longer  or  shorter  interval  of  time.  The  spasm  then  relaxes, 
the  movement  can  be  performed,  and  does  not  recur  while  the  muscles 
are  kept  active.  There  are  occasionally  cramp-like  pains  in  the  mus- 
cles and  a  peculiar  alteration  in  the  electrical  reactions.  (See  Myotonic 
Reaction.)  The  disease  is  chronic,  but  subject  to  exacerbations,  partic- 
ularly as  a  result  of  exposure  to  cold,  previous  excessive  exercise,  or 
emotional  disturbance. 

Diseases  of  the  Sensory  Neuron,  with  Disturbances  of 

Sensation. 

These  are  generally  included  under  the  term  neuralgia.  Neuralgia 
is  a  condition  characterized  by  pain  of  a  dull,  burning,  or  shooting 

66 


1042  SPECIAL  DIAGNOSIS. 

character  that  occurs  in  the  distribution  of  some  particular  sensory 
nerve  or  nerves.  The  pain  may  be  remittent  or  intermittent.  It  is 
exaggerated,  as  a  rule,  by  external  irritation  or  emotional  disturbance. 
The  nerve-trunk  is  often  tender,  not  only  during  the  attack,  but  also 
during  the  interval.  Associated  symptoms  are  often  present.  The 
most  common  are  the  vasomotor  disturbances,  the  area  of  distribution 
of  the  affected  side  showing  persistent  or  paroxysmal  flushing  or  occa- 
sionally pallor.  Secretion  of  sweat  is  sometimes  increased,  and  there 
may  be  exaggeration  of  the  activity  of  glands  supplied  by  the  nerve. 
Occasionally  there  is  marked  oedema  of  the  skin,  and  sometimes  a 
herpetic  eruption.  Very  rarely  in  neuralgia  there  is  local  graying  of 
the  hair.  Motor  symptoms  may  also  occur.  These  consist  of  spas- 
modic twitching  that  may  be  associated  with  exacerbations  of  the  pain. 
Neuralgias  due  to  various  general  conditions  sometimes  have  a  charac- 
teristic localization.  Thus  in  diabetes,  sciatica  occurs ;  in  malaria, 
supra-orbital  neuralgia  ;  in  neurasthenia,  occipital  neuralgia. 

Special  Forms.  Neuralgia  of  the  Trigeminal  Nerve  (tic  douloureux). 
This  usually  occurs  in  only  one  branch  of  the  nerve,  and  is  commonly 
unilateral.  The  pain  is  paroxysmal  and  very  severe,  and  is  often 
referred  by  the  patient  to  some  supposed  source  of  peripheral  irritation, 
as  disease  of  the  nose,  carious  teeth,  etc.  It  is  usually  associated  with 
increase  in  the  secretion  of  various  glands,  such  as  the  tear  glands,  the 
salivary  glands,  the  nasal  mucous  membrane,  etc.  Trophic  changes 
are  not  uncommon.  These  may  vary'  from  herpetic  eruptions  and 
graying  of  the  hair  to  atrophy  of  the  soft  parts  and  even  of  the  bones 
of  the  face.     Occasionally  trophic  alterations  of  the  cornea  also  appear. 

Occipital  Neuralgia^  This  involves  the  occipitalis  major  nerve,  but 
occasionally  the  auricularis  magnus  and  the  nerves  of  the  neck  are  also 
affected.  The  pain  is  distributed  over  the  occipital  region  of  the  head, 
and  is  usually  bilateral.  The  point  of  greatest  tenderness  is  over  the 
cervical  vertebrae,  usually  slightly  to  one  side  of  the  spinous  processes. 

Brachial  neuralgia  is  characterized  by  pain  distributed  in  the  arm  of 
the  affected  side.  This  may  be  either  persistent  or  paroxysmal.  If 
the  latter,  paresthesia?  in  the  hand  or  arm  are  frequent  during  the 
intervals.  The  points  of  tenderness  are  found  where  the  nerves  pass 
over  the  bones  or  just  behind  the  clavicle.  Occasionally  trophic  changes 
are  observed. 

Intercostal  neuralgia  is  characterized  by  pain  distributed  along  the 
course  of  the  intercostal  nerves.  There  are  three  characteristic  tender 
points — one  next  to  the  spinal  column,  one  in  the  axillary  line,  and 
one  over  the  sternum  or  rectus  abdominus.  There  are  usually  trophic 
disturbances  in  the  skin  over  the  affected  nerve,  characterized  by  red- 
dening or  especially  by  a  herpetic  eruption  (herpes  zoster). 

Lumbar  neuralgia  is  characterized  by  pain  radiating  from  the  lumbar 
to  the  gluteal  region.  Occasionally  the  anterior  surfaces  of  the  thighs 
are  also  involved.  The  sensitive  points  are  found  over  the  lumbar 
vertebra?  along  the  edge  of  the  crest  of  the  ilium  and  over  the  linea  alba. 

Crural  neuralgia  is  characterized  by  pains  radiating  from  the  front 
of  the  thigh  into  the  feet.  Paresthesia?  are  frequently  present  during 
the  intervals  of  the  attacks. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  1043 

/Sciatica  is  characterized  by  pain  in  the  posterior  surface  of  the  thigh, 
often  radiating  to  the  feet.  It  is  an  exceedingly  common  form,  usually 
paroxysmal  in  character,  the  attacks  being  preceded  by  paresthesia?. 
The  pain  is  increased  by  any  movement  tending  to  stretch  the  nerve, 
and  as  a  result  the  patient  walks  with  a  peculiar  gait,  the  thigh  of  the 
affected  side  being  held  fixed  and  parallel  to  the  body.  This  some- 
times results  in  a  slight  curvature  of  the  spine.  The  nerve  is  often 
sensitive  through  its  entire  length.  The  special  points  of  tenderness 
are  found  near  the  posterior  superior  spine  of  the  ilium,  at  the  lower 
edge  of  the  gluteus  maximus,  just  outside  the  tuber  ischii,  and  in  the 
cavity  of  the  knee-joint.  The  reflexes  are  usually  slightly  exaggerated. 
There  is  sometimes  slight  weakness  of  the  muscles  and  occasionally 
fibrillary  twitchings. 

Other  forms  of  neuralgia  are  mastodynia,  or  irritable  breast ;  neuralgia 
of  the  phrenic  nerve,  characterized  by  deep  pain  in  the  thorax  and  slight 
dyspnoea  ;  coccygodynia  ;  and  various  neuralgia-like  pains  in  the  viscera. 

Diseases  somewhat  similar  to  neuralgia  are  meralgia  paresthetica, 
characterized  by  tingling,  burning,  or  tearing  in  the  area  of  the  distri- 
bution of  the  external  cutaneous  nerve  of  the  thigh,  usually  unequally 
bilateral,  and  made  worse  by  prolonged  exercise,  either  walking  or 
standing.  Frequently  there  is  a  tender  point  just  below  the  anterior 
superior  spine  of  the  ilium.  Sensory  disturbances  in  the  form  of 
hypesthesia,  hypalgesia,  and  diminished  electro-cutaneous  sensibility 
are  very  common. 

Achropaixesthesice  are  characterized  by  tingling  or  pain  in  the  extremi- 
ties. The  affected  members  are  usually  tender,  and  there  is  hyperes- 
thesia. Occasionally  vasomotor  disturbances  are  present.  An  allied 
condition  is  the  symptom  known  as  tender  toes  that  occurs  in  the  course 
of  typhoid  fever. 

Diseases  of  the  Sensory  Neuron  Characterized  by  Disturb- 
ance op  Motion,  Sensation,  and  Trophic  Disorders. 

Tabes  Dorsalis.  This  is  characterized  by  ataxia,  particularly  of  the 
lower  extremities,  lancinating  pains  in  the  legs,  loss  of  the  knee-jerk, 
and  the  Argyll-Robertson  pupil.  It  is  divided  into  three  stages  :  the 
preatactic,  the  atactic,  and  paralytic.  The  symptoms  of  the  preatactic 
stage  frequently  commence  with  disturbance  in  the  nerves  affecting 
the  eyeball.  There  may  be  paresis  of  the  abducens,  giving  rise  to 
diplopia ;  of  the  levator  palpebral,  giving  rise  to  ptosis ;  or  sluggish  or 
absent  reaction  to  light  on  the  part  of  the  pupil,  while  the  reaction  of 
accommodation  still  persists  (Argyll-Robertson  pupil).  The  symptoms  in 
the  nerves  of  the  lower  extremities  are  particularly  the  lancinating  pains 
that  are  felt  in  the  posterior  portion  of  the  thigh.  These  come  on  from 
time  to  time,  and  the  patient  feels  as  if  he  has  been  stabbed.  They  are 
more  frequent  in  damp  weather,  and  are  frequently  confused  with  rheu- 
matism. The  knee-jerk  is  absent,  and  the  patient  may  note  that  it  is  a 
little  bit  more  difficult  to  walk  in  the  dark.  The  station  in  the  early  stage 
is  usually  only  slightly  affected.  There  is  a  sense  of  constriction  about 
the  body  (girdle  pain),  and  sometimes  hypesthesia  of  the  lower  extremi- 


J044  SPECIAL  DIAGNOSIS. 

ties  that  may  be  associated  with  a  slight  hyperalgesia  in  the  zone  just 
above  it.  The  patients  may  also  remark  that  they  have  slight  difficulty 
in  urination  and  some  diminution  of  sexual  potency.  The  second 
stage,  or  the  stage  of  ataxia,  is  characterized  by  the  symptoms  of  the 
preceding  stage,  all  of  which  are  now  pronounced.  In  addition  the 
patient  exhibits  inco-ordination  of  movement,  especially  in  the  lower 
limbs.  Station  is  so  impaired  that  it  is  usually  impossible  for  him 
to  stand  alone  with  the  eyes  closed  and  the  feet  together.  Walk- 
ing in  the  dark  is  difficult  and  usually  associated  with  frequent  falls. 
In  the  daylight,  with  the  aid  of  the  eyes,  the  patient  can  usually 
walk  quite  well,  but  lifts  the  feet  higher  than  usual  from  the  ground, 
and  separates  them  widely.  (See  Ataxic  Gait.)  The  inco-ordination  is 
manifested  by  the  difficulty  with  which  the  patients  perform  certain 
movements,  such  as  touching  some  object  with  the  tip  of  the  finger — as, 
for  example,  the  nose,  ear— or  in  bringing  the  heel  of  one  foot  against 
the  knee  of  the  other.  There  is  diminished  muscle-tone,  and,  of  course, 
absolute  loss  of  tendon  reflexes,  even  when  reinforced.  There  are 
paresthesia?,  especially  in  the  lower  extremities  ;  analgesia  in  the  same 
situation,  or  sometimes  delay  in  the  conduction  of  pain.  Micturition  is 
sometimes  difficult ;  at  others  there  is  incontinence,  but  insufficiency 
of  the  sphincter  ani  rarely  occurs.  Impotence  is  complete.  The 
Argyll-Robertson  pupil  is  present ;  there  is  usually  myosis,  nyctalopia, 
and  occasionally  atrophy  of  the  optic  nerve.  In  the  latter  condition 
it  has  been  noted  that  when  blindness  has  fully  developed  the  ataxia 
becomes  less  pronounced  or  may  disappear  completely.  The  visceral 
crises  are  characterized  by  attacks  of  intense  pain  involving  usually 
the  stomach  or  sometimes  affecting  the  larynx  or  heart  or  other  viscera. 
The  laryngeal  crises  are  often  accompanied  by  distressing  cough  and 
dyspnoea.  Trophic  changes  occur,  of  which  the  most  common  are  the 
arthropathies.  These  involve  particularly  the  knee,  hip,  and  shoulder- 
joints.  In  addition,  the  patient  may  have  painless  falling  out  of  the 
teeth  or  rapid  softening  of  them.  In  certain  cases  a  chronic  ulcer 
develops  on  the  sole  of  the  foot,  which  usually  progresses  until  it  has 
produced  perforation  (jnal  perforante).  In  the  paralytic  stage  of  ataxia 
the  loss  of  muscle-tone  has  reached  such  an  exreme  degree  that  loco- 
motion is  impossible.  The  patients  by  this  time  have  usually  developed 
cystitis,  and  death  occurs  either  as  a  result  of  exhaustion  or  of  general 
septicemia. 

The  Cervical  Type  of  Tabes  Dorsalis.  This  is  characterized  by 
the  development  of  the  symptoms  chiefly  in  the  arms.  The  lightning 
pains  are  found  in  the  upper  extremities,  there  is  loss  of  the  bicipital 
and  tricipital  reflexes,  and  the  girdle  sensation  is  usually  felt  in  the 
upper  part  of  the  thorax.  The  ocular  symptoms  are  the  same.  The 
visceral  crises  are  likely  to  affect  the  larynx.  In  this  form  ataxia  in 
the  legs,  Romberg's  symptom,  and  the  absence  of  the  knee-jerk  may 
not  be  present  until  late  in  the  disease. 

Friedreich's  Ataxia.  This  is  characterized  by  inco-ordination,  loss 
of  knee-jerk,  weakness,  irregular  speech,  and  slight  deformities.  The 
disease  commences  in  youth,  and  is  usually  hereditary  in  character. 
The  first  symptom  is  inco-ordination  of  the  lower  limbs.     This  gradu- 


DISEASES  OF  THE  NERVOUS  SYSTEM.  1045 

ally  becomes  more  severe,  the  muscles  grow  weaker,  the  flexors  more 
so  than  the  extensors,  often  giving  rise  in  time  to  pes  equino-varus. 
The  muscles  of  the  back  also  grow  weaker,  giving  rise  to  scoliosis ;  the 
knee-jerks  are  absent,  the  pupillary  reflexes  remain  normal,  and  intelli- 
gence is  unaffected.  The  speech  is  peculiar,  some  of  the  syllables  being 
pronounced  readily  and  others  slowly,  with  a  drawl.  The  gait  becomes 
markedly  ataxic,  the  patients  keeping  the  legs  widely  separated.  In 
time  the  paresis  and  inco-ordination  become  so  severe  that  walking 
is  impossible.  The  disease  is  progressive  and  usually  affects  several 
members  of  the  same  family. 

The  cerebellar  type  of  hereditary  ataxia  differs  from  the  foregoing  by 
the  fact  that  the  knee-jerks  are  exaggerated,  and  there  is  occasionally 
absence  of  the  pupillary  reflex  to  light. 

Diseases  of  the  Peripheral  Motor  and  the  Sensory  Neuron. 

These  are  all  characterized  by  disturbances  of  motion  and  sensation, 
usually  associated  with  more  or  less  severe  trophic  changes. 

Neuritis.  Inflammation  of  the  nerves  is  characterized  by  pain  local- 
ized in  the  nerve  affected,  tenderness,  and  perhaps  paresis  or  paralysis 
of  certain  groups  of  muscles.  The  pain  is  made  more  severe  if  the 
limb  is  held  in  such  a  position  that  the  nerve  is  stretched.  As  it  is  a 
true  inflammatory  condition,  there  are  usually  constitutional  disturb- 
ances, such  as  fever,  malaise,  etc.  Often  the  disease  is  progressive, 
extending  from  the  peripheral  to  the  more  central  nerve-trunks.  This 
is  spoken  of  as  ascending  neuritis.  Along  the  course  of  the  nerve  there 
are  often  vasomotor  and  secretory  disturbances,  or  the  lesions  may  be 
more  severe,  such  as  atrophy  of  the  skin,  with  glossiness,  or  trophic 

Fig.  253. 


c 


Alcoholic  neuritis.    Foot-drop  and  wrist-drop. 

changes  in  the  nails.  Multiple  neuritis  is  characterized  by  the  appear- 
ance of  the  symptoms  of  the  disease  in  a  number  of  nerves  at  the  same 
time.  The  nerves  of  the  limbs  are  far  more  frequently  affected  than 
those  of  the  trunk.  The  symptoms  are  modified  by  the  cause.  In 
alcoholic  polyneuritis  there  arc  usually  slight  paresthesia  of  the  limbs, 
with  marked  paresis  of  the  muscles,  particularly  the  extensors,  giving 
rise  to  foot-drop  and  wrist-drop.  (See  Fig.  2-"):;.)  The  disease  usually 
affects  all  four  extremities.  In  lead-poisoning  the  disease  is  sometimes 
unilateral,  is  usually  restricted  to  the  arms,  and  the  sensory  disturb- 


1046  SPECIAL  DIAGNOSIS. 

ances  are  very  slight  or  absent.  There  is  paralysis  of  the  extensor 
muscles  of  the  arm,  which  in  severe  cases  goes  on  to  muscular  degen- 
eration. Neuritis  may  also  be  produced  by  arsenic.  Diphtheritic  poly- 
neuritis is  usually  characterized  by  paralysis  of  the  muscles  of  the 
palate,  but  occasionally  the  muscles  of  the  limbs  are  also  involved. 
In  certain  of  the  chronic  forms  of  polyneuritis,  instead  of  loss  of  power, 
there  is  marked  loss  of  co-ordination.  This  is  spoken  of  as  the  ataxic 
variety. 

Beri-beri,  or  kakhe,  is  an  infectious  disease  characterized  by  the  symp- 
toms of  a  peripheral  multiple  and  symmetrical  neuritis.  The  patients 
usually  present  general  symptoms,  as  fever  and  chills,  and  then  com- 
plain of  a  sense  of  weakness  or  heaviness  in  the  legs,  paresthesia?,  and 
diminution  of  tactile  sensation.  The  electrical  examination  of  the 
muscles  of  the  legs  usually  shows  the  reactions  of  degeneration.  Later, 
the  muscles  undergo  further  degeneration  and  become  paralyzed.  There 
is  oedema  of  the  skin,  and  the  anaesthesia  becomes  more  pronounced. 
Occasionally  pain-sense  is  preserved,  giving  rise  to  anaesthesia  dolorosa. 
The  paralysis  becomes  more  extensive,  and  the  patient  may  die  as  a 
result  of  the  involvement  of  the  respiratory  muscles. 

Multiple  neuromata  sometimes  occur  very  extensively  upon  the  nerves 
of  the  skin,  at  times  producing  symptoms  of  multiple  pressure  upon  the 
nerves — that  is,  paresthesia,  paralyses,  or  loss  of  sensation.  At  other 
times  they  produce  no  symptoms  whatever,  and  can  only  be  recognized 
by  inspection. 

Diseases  of  the  Spinal  Cord  Involving  the  Central  Motor 

Neurons. 

Primary  spastic  paraplegia  is  characterized  by  weakness  of  the  legs 
without  muscular  degeneration  and  with  increased  reflexes.  The  dis- 
ease was  formerly  supposed  to  be  the  result  of  the  involvement  of  the 
lateral  columns  of  the  cord.  The  first  symptoms  are  weakness  or  a 
feeling  of  heaviness  in  the  legs ;  then  spontaneous  cramps  app  ar. 
The  reflexes  are  greatly  exaggerated,  and  the  muscle  tone  is  so  in- 
creased, particularly  in  the  extensors  of  the  thigh  or  knee  and  foot,  that 
the  patient  walks  with  the  leg  partially  extended,  dragging  the  toe 
along  the  ground ;  the  arms  are  rarely  involved.  The  electrical  reac- 
tions of  the  muscles  are  normal.  The  sphincters  are  very  rarely  in- 
volved, and  sensation  is  usually  unimpaired.  If  cramps  are  frequent, 
however,  the  muscles  may  be  sore.  In  children  the  adductors  become 
stronger  than  the  abductors,  and  a  peculiar,  crossed-legged  gait  is  there- 
by produced. 

Amyotrophic  Lateral  Sclerosis.  This  is  characterized  by  a  spastic 
paraplegia,  with  exaggeration  of  the  reflexes  and  degeneration  of  the 
muscles.  The  symptoms  consist  of  weakness  in  the  legs,  which  at  the 
same  time  become  stiff.  The  muscles  rapidly  atrophy  ;  there  are  fibril- 
lary twitchings  and  reactions  of  degeneration.  The  arms  are  usually 
involved  first,  the  degeneration  commencing  in  the  muscles  of  the  hands 
and  giving  rise  ultimately  to  the  production  of  various  deformities,  such 


DISEASES  OF  THE  NERVOUS  SYSTEM.  1047 

as  the  claw-hand.  The  tendon  reflexes  are  greatly  exaggerated  j  there 
are  patellar  clonus  and  ankle  clonus.  The  muscles  are  greatly  weakened, 
but  remain  rigid  until  late  in  the  course  of  the  disease.  The  sphincters 
are  rarely  involved,  the  pupillary  reflexes  are  normal,  and  there  are 
no  sensory  disturbances.  Bulbar  symptoms — that  is,  paralysis  of  the 
larynx,  pharynx,  and  palate — occur,  giving  rise  to  dysphagia,  alteration 
in  speech,  and  frequently  causing  an  inspiration  pneumonia. 

Multiple  Sclerosis.  This  is  a  condition  that  involves  the  sensory  and 
motor  tracts  in  the  spinal  cord  and  occasionally  in  the  brain.  The 
characteristic  symptoms  are  intention  tremor,  nystagmus,  and  scan- 
ning speech.  The  patient  usually  has  weakness  of  the  legs,  with  some 
tremor  and  exaggeration  of  the  reflexes.  In  the  arms  the  same  con- 
ditions are  present,  and  in  the  attempt  to  grasp  any  object  a  violent 
tremor  is  developed,  which  continues  until  the  movement  has  been 
accomplished.  Various  areas  of  anaesthesia  are  also  present,  depending 
largely  upon  the  localization  of  the  lesions.  There  is  usually  persistent 
nystagmus,  lateral  in  character ;  the  speech  is  slow  and  drawling,  and 
the  patient  has  a  tendency  to  laugh  or  weep  without  provocation.  In 
a  large  proportion  of  the  cases  there  is  more  or  less  complete  atrophy 
of  the  optic  nerve.  Less  frequent  symptoms  are  vertigo,  occurring  in 
paroxysmal  attacks,  diminution  of  intelligence,  and  occasionally  dis- 
turbances of  the  function  of  the  bladder,  and  in  a  few  cases  atrophy 
and  degeneration  of  the  muscles.  The  disease  is  usually  chronic,  but 
from  time  to  time  there  are  exacerbations.  It  appears  to  be  frequently 
associated  with  hysterical  manifestations.  In  some  cases  bulbar  symp- 
toms appear  early  and  rapidly  lead  to  death. 

Hypertrophic  Cervical  Pachymeningitis.  This  is  characterized  by  pain 
in  both  arms,  followed  by  muscular  degeneration  commencing  in  the 
hands.  Later,  there  may  be  spastic  paraplegia  of  the  legs,  with  anaes- 
thesia of  the  body  below  the  affected  segment.  Occasionally  this 
disease,  which  is  usually  due  to  tuberculous  meningitis,  may  occur  in 
other  portions  of  the  spinal  cord,  giving  rise,  therefore,  to  various 
symptoms. 

Acute  spinal  meningitis  is  characterized  by  intense  pain  in  the  back, 
radiating  into  the  legs ;  rigidity  of  the  spinal  column,  with  opisthot- 
onos ;  intense  hyperesthesia  of  the  skin  of  the  body,  and,  if  the  dis- 
ease lasts  long  enough,  paralyses.  Kernig's  symptom — that  is,  the 
inability  to  extend  the  flexed  leg  as  a  result  of  flexor  cramp — is  said 
to  occur  only  in  this  condition  and  in  cerebral  spinal  meningitis.  The 
tdche  spinale  occurs  also  in  other  conditions. 

Syphilitic  spinal  meningitis  produces  a  great  variety  of  symptoms. 
There  are,  however,  pains  due  to  pressure  upon  the  posterior  roots, 
girdle  pains  of  the  body,  and  occasionally  paralysis  of  the  muscles  of 
the  extremities,  with  atrophy  and  degeneration.  Often,  also,  the  spinal 
cord  is  involved,  giving  rise  to  the  symptoms  of  pressure  or  transverse 
myelitis  (q.  v.)  or  Brown-Sequard's  syndrome  (q.  v.).  The  sensory  symp- 
toms, aside  from  the  pains,  consist  of  hyperesthesia,  hypsesthesia,  or 
anesthesia.  The  tendon  reflexes  of  the  lower  extremities  may  be  lost 
and  reappear,  and  this  by  some  is  supposed  to  be  pathognomonic  of  the 
disease. 


1048  SPECIAL  DIAGNOSIS. 

Diseases   Characterized   by   the   Syndrome   of   Transverse 
Interruption  of  the  Spinal  Cord. 

Pott's  Disease  (caries  of  the  vertebras).  This  is  characterized  by  an 
angular  deformity  of  the  spine,  spastic  paraplegia,  and  various  disturb- 
ances of  sensation  in  the  body  below  the  level  of  the  lesion.  In  the 
earlier  stage  the  only  symptoms  may  be  pain  in  the  back,  usually  radi- 
ating around  toward  the  ventral  surface.  There  may  be  no  deformity, 
but  sudden  pressure  upon  the  head,  jarring  of  the  spine  by  coming 
down  heavily  upon  the  heels,  and  pressure  over  the  tender  point  in  the 
back  may  elicit  sharp  pains.  In  this  stage  there  are  usually  slight 
exaggeration  of  the  reflexes  and  perhaps  a  slight  weakness  of  the  legs. 
Later,  the  angular  deformity  becomes  apparent,  usually  in  the  form  of 
a  sharp  projection  in  the  dorsal  portion  of  the  spinal  column,  but  it 
may  appear  also  in  the  cervical  and  lumbar  region.  The  weakness  of 
the  lower  extremities  becomes  more  pronounced,  and  may  give  rise  to  an 
actual  paraplegia.  The  pains  are  usually  severe,  radiate  around  the 
trunk,  and  sometimes  affect  other  portions  of  the  body.  Sensation 
may  be  slightly  impaired.  There  may  be  distinct  dissociation  below 
the  lesion — that  is,  loss  of  temperature  and  pain  senses,  with  preserva- 
tion of  tactile  sense — or  there  may  be  total  anaesthesia.  As  in  myelitis, 
bed-sores  or  other  trophic  changes  of  the  skin  are  very  likely  to  develop, 
and  the  patients  suffer  severely  in  general  nutrition.  In  the  earlier 
stages,  and  more  particularly  in  the  stage  of  recovery,  after  the  de- 
formity has  become  stationary,  ataxia  may  exist.  The  reflexes  are 
sometimes  greatly  exaggerated,  and  there  is  often  ankle  clonus.  When 
the  paraplegia  has  become  complete  all  the  reflexes  are  usually  abolished. 
Girdle  sensation  is  also  very  common.  The  course  is  very  variable.  At 
times  the  destruction  of  the  body  of  the  vertebra  is  rapid,  and  the  symp- 
toms develop  acutely.  At  others  it  occurs  very  slowly,  and  the  symp- 
toms, even  after  years'  duration,  may  be  exceedingly  slight.  Caries  of 
the  upper  cervical  vertebra?  produce  pains  that  involve  the  neck  and 
the  occipital  region  of  the  head.  The  position  of  the  head  is  peculiar ; 
it  is  drawn  slightly  forward  and  carried  very  rigidly,  and  the  chin  is 
elevated.  These  patients  may  sometimes  die  suddenly  as  a  result  of 
pressure  by  the  odontoid  process  on  the  medulla. 

Tumors  of  the  Membranes.  The  symptoms  of  this  condition  are  ex- 
tremely variable,  according  to  the  location,  nature,  and  extent  of  the 
growth.  Occasionally  deformities  occur  as  a  result  of  pressure  upon 
the  arches  of  the  vertebra?.  Paraplegia  usually  develops,  sometimes 
very  suddenly,  sometimes  gradually.  There  is  usually  exaggeration  of 
the  reflexes  and  ankle  clonus  ;  but  this  in  time  may  disappear,  or  may 
never  occur  if  the  tumor  is  situated  in  the  lumbar  region.  When  the 
posterior  roots  are  pressed  upon  there  are  root  pains  and  the  girdle  sen- 
sation. Sensory  disturbances  are  more  or  less  complete  according  to  the 
degree  of  destruction  that  has  occurred  in  the  spinal  cord.  Dissociation 
of  sensation  rarely  occurs,  but  anaesthesia  is  very  common.  After  com- 
plete destruction  of  the  spinal  cord  at  any  point  trophic  changes  occur. 

Chronie  Internal  Meningitis.  This  is  usually  characterized  by  pain 
that  radiates  into  various  portions  of  the  body,  particularly  the  limbs, 


DISEASES  OF  THE  NERVOUS  SYSTEM.  1049 

and  by  more  or  less  hyperesthesia.  The  motor  symptoms  con- 
sist of  tremors,  spasms,  and  occasionally,  when  the  anterior  roots  are 
involved,  paralyses,  with  muscular  degeneration.  In  the  milder  forms 
the  only  motor  symptoms  may  be  inco-ordination  of  movement.  Her- 
petic eruptions  along  the  course  of  the  nerves  arising  from  the 
involved  posterior  roots  are  quite  common. 

Acute  Myelitis.  There  are  a  number  of  varieties  of  this  condition, 
the  most  common  and  typical  being  transverse  myelitis.  It  is  an 
acute  inflammatory  disease  associated  with  constitutional  disturbance — 
that  is,  chills,  fever,  and  malaise,  and  is  occasionally  ushered  in  with  a 
convulsion.  The  symptoms  are  those  of  transverse  lesion  of  the  spinal 
cord.  Ordinarily  the  dorsal  part  is  affected ;  and  there  are,  therefore, 
in  the  earlier  stages  weakness  and  paresthesia  of  the  legs,  and  perhaps 
a  girdle  sensation  and  hyperesthesia  over  the  spine,  the  zone  sup- 
plied by  the  involved  segment.  In  the  course  of  a  few  days  or  hours  the 
weakness  of  the  legs  increases  until  there  is  complete  paraplegia.  The 
tone  of  the  muscles  is  enormously  exaggerated,  the  knee-jerks  are  in- 
creased, and  there  is  both  patellar  and  ankle  clonus  and  often  Sinkler's 
toe-jerk.  The  limbs  are  usually  spastic  and  kept  in  a  position  of  ex- 
tension. From  time  to  time  the  muscles  give  violent  twitches.  There 
is  complete  anaesthesia  up  to  the  horizontal  line  surrounding  the  trunk, 
at  which  point  there  is  girdle  sensation,  and  above  it  there  is  a  zone  of 
hyperesthesia.  The  muscles  supplied  by  the  affected  segment  atrophy 
and  give  reactions  of  degenerations.  Those  in  the  region  below  main- 
tain their  nutrition  for  a  considerable  time.  There  is  difficulty  in 
micturition,  usually  paralysis  of  the  bladder,  and  finally  overflow  from 
retention.  The  urine  becomes  alkaline,  cystitis  develops  very  rapidly, 
and  is  often  followed  by  extensive  sloughing  of  the  surrounding  parts. 
Bed-sores  occur  early  and  extend  deeply.  Trophic  lesions  also  occur 
in  the  legs,  the  skin  becomes  thin  and  glazed,  and  the  toe-nails  are 
brittle.  Even  arthropathies  have  occasionally  been  observed.  After 
the  acute  stage  has  passed  more  or  less  improvement  may  occur,  charac- 
terized by  gradual  return  of  power  in  the  legs  and  partial  recovery  of 
sensation. 

Acute  Focal  Myelitis.  This  gives  rise  to  only  part  of  the  symptoms 
described  above,  depending  upon  the  tracts  involved  by  the  process 
and  the  various  nuclei  that  have  been  destroyed.  There  is,  therefore, 
usually  a  monoplegia,  associated  with  exaggeration  of  the  reflexes  and 
irregular  areas  of  anesthesia,  or,  if  the  focus  be  in  the  arm  or  the  leg 
centre,  diminution  or  loss  of  the  reflexes  and  degeneration  of  the  muscles. 

Disseminated  myelitis  gives  rise  to  a  complicated  group  of  symptoms, 
according  to  the  number,  situation,  and  extent  of  the  lesions.  It 
resembles  perhaps  most  closely  transverse  myelitis  (g.  v.). 

Chronic  myelitis  is  distinguished  from  the  acute  form  by  the  more 
gradual  development  of  the  symptoms.  The  patient  first  notices  weak- 
ness of  the  legs,  perhaps  characterized  from  time  to  time  by  complete 
transient  loss  of  power  (giving  way  of  the  legs).  If  the  reflexes  are 
examined  at  this  time,  they  will  be  found  slightly  exaggerated  ;  later 
they  become  very  markedly  increased,  and  ankle  clonus  develops.  The 
patient  also  complains,  in  the  early  stages,  of  paresthesie  in  the  limbs 


1050  SPECIAL  DIAGNOSIS. 

that  may  involve  the  arms  as  well  as  the  legs,  and  sometimes  the  trunk. 
A  girdle  sensation  is  also  frequently  present.  Finally,  muscular  atro- 
phies occur,  and  even  severe  trophic  disturbances ;  the  picture  ulti- 
mately resembling  that  of  acute  myelitis. 

Pressure  upon  the  spinal  cord  may  be  produced  either  by  injury  to 
the  vertebral  column  or  by  growths  in  or  hemorrhages  into  the  mem- 
branes. The  symptoms  are  those  of  transverse  lesion.  If  due  to  tumor, 
they  develop  very  slowly  ;  if  due  to  traumatism,  as  a  rule,  very  rapidly. 
There  is  weakness  or  paralysis  of  the  legs,  with  increase  of  the  muscle- 
tone  and  exaggeration  of  the  reflexes.  Ankle  clonus  is  almost  invariably 
present.  The  pains  are  usually  due  to  pressure  upon  the  posterior  roots, 
and  are  paroxysmal  and  lightning-like  in  character.  Girdle  sensation 
is  also  present.  The  muscles  supplied  by  the  segments  of  the  cord 
involved  undergo  degenerative  atrophy. 

Landry's  Paralysis.  This  is  characterized  by  progressive  paralysis 
of  the  legs,  arms,  and  muscles  of  the  throat,  leading  ultimately  to 
death.  The  first  symptoms  noted  are  weakness  of  the  legs,  which  may 
involve  both,  or  at  first  only  one.  This  gradually  ascends,  and  at  the 
same  time  the  patient  notices  paresthetic  sensations.  There  are,  how- 
ever, few  or  no  objective  sensory  disturbances  excepting  occasionally 
a  slight  hyperesthesia.  The  reflexes  are  lost,  the  muscles  are  without 
tone,  and  the  paralysis  is,  therefore,  flaccid.  Electrical  changes  do  not 
occur,  or  only  in  very  chronic  cases.  The  paralysis  gradually  ascends, 
involving  the  muscles  of  the  abdomen,  the  thorax,  and  arms.  TThen 
the  thorax  is  involved  the  patient  usually  has  rapid  respiration,  and 
complains  of  dyspnoea.  Later  there  are  symptoms  of  bulbar  involve- 
ment, difficulty  in  deglutition,  and  interference  with  speech.  The 
diaphragm  becomes  paralyzed,  and  the  patients  die  as  a  result  of 
exhaustion.  The  intelligence  remains  normal  throughout  the  disease  ; 
there  is  never  loss  of  consciousness  and  there  is  no  disturbance  of  the 
function  of  the  bladder  or  rectum.     Fever  does  not  occur. 

Hemorrhage  into  the  Cord  (spinal  apoplexy).  This  is  characterized 
by  the  sudden  interruption  of  the  functions  of  the  cord  at  a  certain 
level.  There  is  usually,  at  the  time  the  hemorrhage  occurs,  severe 
pain,  then  rapidly  developing  paralysis  of  the  legs,  which  may  be 
flaccid  if  the  lumbar  region  is  involved,  or  spastic  if  the  lesion  is 
higher  up.  Hasmatomyelia  into  the  cervical  region  may  cause  paralysis 
of  the  arms,  but  death  usually  occurs  suddenly.  The  sensory  dis- 
turbances are  irregular  in  character.  At  times  there  is  dissociation  of 
sensation,  more  frequently  complete  anaesthesia  up  to  the  level  of  the 
hemorrhage.  The  patient  has  no  fever,  consciousness  is  not  disturbed, 
but  there  is  interference  with  the  functions  of  the  bladder  and  rectum. 
Occasionally  the  hemorrhage  involves  particularly  one  side  of  the  cord 
or  only  one-half  of  the  gray  matter,  producing  the  syndrome  of  Brown- 
Sequard  (q.  v.).  The  diagnosis  can  frequently  be  made  from  the  subse- 
quent course  of  the  case.  If  death  does  not  occur,  rapid  improvement 
is  usually  the  rule.  The  sphincters  regain  their  functions,  power 
returns  in  the  limbs,  and  ultimately  the  patient  may  recover  com- 
pletely. In  some  cases,  however,  the  recovery,  although  pronounced, 
is  only  partial. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  1051 

Syringomyelia  (cavity  in  the  spinal  cord).  This  is  characterized  by  a 
group  of  symptoms  whose  occurrence  together  is  almost  pathognomonic. 
First,  dissociation  of  sensation  ;  pain  and  temperature  senses  are  lost ; 
tactile  and  muscle  senses  are  retained.  Second,  degenerative  atrophy 
of  the  muscles,  associated  with  fibrillary  twitchings  and  alteration  of 
the  electrical  reactions.  Third,  trophic  lesions  which  may  involve  the 
skin,  particularly  that  of  the  fingers  or  the  joints.  The  disease  appears 
to  develop  with  extreme  slowness.  The  earliest  symptoms  may  be  the 
occurrence  of  painless  whitlows — that  is,  inflammation  around  the 
finger-nail,  with  perhaps  the  ultimate  destruction  of  the  nail  itself. 
These  may  recur  in  one  finger  after  another  for  several  years  and 
without  the  presence  of  any  other  symptoms,  excepting  perhaps  a 
slight  disturbance  of  sensation  in  the  fingers.  Later,  muscular  atro- 
phies appear.  These  involve  particularly  the  muscles  of  the  shoulder 
or  the  hand.  In  the  latter  situation  they  may  give  rise  to  the  appear- 
ance that  occurs  in  progressive  spinal  muscular  atrophy.  At  the  same 
time  the  sensory  disturbances  become  more  pronounced,  gradually 
ascending  the  arm  and  perhaps  involving  the  trunk.  The  upper 
border  forms  a  horizontal  line  about  the  body — that  is,  the  alterations 
are  segmental  in  type.  The  trophic  changes  may  then  assume  a  more 
severe  form,  giving  rise  to  deep,  painless  ulcerations  in  the  fingers,  and 
perhaps  loss  of  the  terminal  phalanges.  For  a  long  time  the  symp- 
toms may  remain  almost  exclusively  unilateral,  and  it  is  rare  for  the 
two  sides  to  be  equally  affected.  The  motor  symptoms,  aside  from  the 
weakness  resulting  from  the  muscular  atrophy,  consist  of  weakness  of 
the  legs  with  exaggeration  of  the  reflexes — that  is,  spastic  paraparesis. 
At  times  the  lower  portion  of  the  cord  is  particularly  affected,  and  then 
the  sensory  and  trophic  changes  are  found  in  the  legs.  Station  may 
be  slightly  altered  in  the  latter  stages  of  the  disease,  but  this  is  by  no 
means  a  characteristic  symptom.  Ultimately  the  patient  develops  scoli- 
osis, trophic  changes  affect  other  parts  than  the  hands,  giving  rise  to 
arthropathies,  or  to  a  form  of  dry  arthritis  with  absorption  of  the  bone. 
There  may  be  vasomotor  disturbances,  and  in  some  cases  inequality  of 
the  pupils.  The  intellect  is  undisturbed.  The  patients  ordinarily  die 
as  a  result  of  exhaustion  or  pulmonary  involvement,  but  occasionally 
in  the  latter  stages  of  the  disease  bulbar  symptoms  occur. 

Morvan's  Disease.  This  is  characterized  by  the  appearance  of  painless 
whitlows  in  the  fingers,  sometimes  associated  with  deep  ulcerations  of  the 
soft  parts.  There  are  usually  sensory  disturbances  similar  to  those 
found  in  syringomyelia,  with  the  addition  of  tactile  anaesthesia,  but 
muscular  atrophy  rarely  exists.  The  disease  is  exceedingly  chronic. 
It  is  possibly  only  a  variety  of  syringomyelia. 

Traumatism  of  the  Spinal  Cord.  This  may  either  produce  destruc- 
tion, partial  or  complete,  of  the  tissue  of  the  cord  itself,  giving  rise  to 
the  syndrome  of  transverse  interruption,  or  else  give  rise  to  a  group 
of  indefinite  motor,  sensory,  and  mental  disturbances  that  have  been 
grouped  under  the  term  traumatic  neuroses.  (See  Hysteria.)  The 
symptoms,  the  result  of  organic  lesion,  may  come  on  gradually  or 
immediately.  They  are  similar  to  those  produced  by  pressure  upon 
the  cord. 


1052  SPECIAL  DIAGNOSIS. 

Diseases  of  the  Brain  Characterized  by  General  Symptoms  and 
Sensory  and  Motor  Disturbances. 

Diseases   Characterized   by   Mental,   Motor,  Sexsory,   and 
Sometimes  Trophic  Disorders. 

External  pachymeningitis  is  a  rare  condition,  usually  secondary  to 
traumatism  or  abscess,  characterized  by  fever,  headache,  often  sharply 
localized,  and  convulsions.  Frequently  the  symptoms  are  masked. 
If  there  is  much  thickening  of  the  membrane,  evidence  of  focal  dis- 
ease in  the  form  of  paralyses  or  convulsions  may  be  present.  Hcema- 
toma  of  the  dura  mater  is  a  condition  usually  occurring  in  cases  of 
chronic  disease.  There  may  be  slight  fever  and  headache  without 
other  symptoms.  In  some  cases,  however,  the  onset  is  sudden  and 
apoplectiform  in  type.  The  patients  develop  hemiplegia,  unconscious- 
ness, and  occasionally  unilateral  convulsions. 

Internal  or  Leptomeningitis.  The  symptoms  vary  according  to  the 
nature  of  the  process,  its  localization,  and  extent.  The  patient  may 
for  a  few  days  preceding  an  attack  complain  of  malaise  and  headache, 
then  there  is  often  a  chill  followed  by  fever,  convulsions,  and  delirium. 
The  headache  becomes  more  intense,  and  frequently  there  is  vomiting, 
sometimes  without  associated  nausea.  The  headache  is  usually  severe, 
and  often  localized  to  the  frontal  or  occipital  regions ;  occasionally, 
however,  it  is  more  general.  From  time  to  time  there  are  acute  exacer- 
bations, causing  the  patient  to  cry  out — the  hydrocephalic  cry.  The 
skin  is  hypersesthetic ;  all  the  sensory  nerves  have  their  functions 
increased ;  there  is  photophobia  and  inability  to  tolerate  noises.  Fre- 
quently there  is  paresis  of  the  vasomotors  of  the  skin,  so  that  localized 
cutaneous  irritation,  such  as  may  be  produced  by  drawing  the  end  of 
a  blunt  object  across  the  surface,  gives  rise  to  a  persistent  red  mark 
(tache  cerebrate).  The  patient  usually  lies  with  the  head  drawn  far  back 
and  the  muscles  of  the  neck  tense  and  rigid.  This,  however,  occurs 
only  when  the  cervical  portion  of  the  spinal  cord  is  also  involved.  It 
is  an  exceedingly  important  and  an  almost  pathognomonic  symptom. 
Any  attempt  to  straighten  the  head  causes  intense  pain.  Examination 
of  the  eye-grounds  usually  shows  intense  congestion  and  more  or  less 
perineuritis.  Sometimes  there  is  very  distinct  choked  disk.  The 
pupils  are  often  unequal,  and  strabismus  and  even  nystagmus  fre- 
quently occur.  Paralysis  of  any  of  the  cranial  nerves  indicates  that 
the  process  is  chiefly  localized  at  the  base,  as  in  tuberculous  meningitis. 
Paralysis  of  the  oculomotor  or  some  of  its  branches  is  exceedingly  com- 
mon. The  facial  nerve  may  also  be  paretic.  The  tendon  reflexes  are 
usually  somewhat  exaggerated,  muscular  tone  is  increased,  and  occa- 
sionally there  is  distinct  monoplegia  or  hemiplegia.  Fever,  headache, 
and  delirium  usually  persist  throughout  the  course  of  the  disease ;  and 
the  former  is  often  very  high.  The  different  forms  of  meningitis  are 
often  difficult  to  discriminate.  By  means  of  Quincke's  lumbar  puncture 
it  is  sometimes  possible  to  make  a  bacteriological  diagnosis  from  the  fluid 
withdrawn.  Meningitis  due  to  certain  pyogenic  micro-organisms,  such  as 
the  pneumococcus,  staphylococcus,  etc.,  may  be  suspected ;  when  the 


DISEASES  OF  THE  NERVOUS  SYSTEM.  1053 

fever  is  high  there  is  marked  retraction  of  the  head,  indicating  spinal 
involvement,  and  the  course  is  steadily  progressive  to  death.  Some 
other  disease  may  often  be  associated  with  the  meningitic  symptoms, 
or  it  may  have  occurred  previously,  as  pneumonia,  typhoid  fever,  etc. 
Epidemic  cerebro-spinal  meningitis  may  simulate  the  symptoms  of 
purulent  meningitis  exactly.  In  some  cases,  however,  the  course  is 
more  prolonged,  and  even  when  the  termination  is  fatal  there  is  apt  to 
be  a  remission  of  longer  or  shorter  duration.  Tuberculous  meningitis 
is  usually  characterized  by  the  presence  of  paralyses  of  some  of  the 
cranial  nerves,  particularly  those  of  the  eye  muscles,  and  the  absence 
of  symptoms  of  spinal  involvement.  This  disease  may  run  an  exceed- 
ingly slow  course,  and  the  diagnosis  is  often  for  a  time  impossible. 
Kernkjs  sign  is  said  to  be  pathognomonic  of  menhigitis.  It  consists 
of  the  inability  of  the  patient  to  straighten  the  leg  when  the  thigh 
has  been  flexed  upon  the  abdomen  and  the  leg  upon  the  thigh. 

Cerebral  Hemorrhage  (apoplexy).  This  is  characterized  by  a  great 
variety  of  symptoms,  depending  largely  upon  the  location  of  the  lesion. 
They  may  be  divided  into  those  of  the  attack  and  those  that  are  perma- 
nent. The  symptoms  of  the  attack  consist  of  prodromata — that  is,  head- 
ache, tendency  to  vertigo,  a  sense  of  fulness  in  the  head,  roaring  in  the 
ears,  and  perhaps  some  thickness  of  speech.  These  may  pass  off  without 
an  attack  or  may  lead  directly  to  it.  The  attack  itself  is  usually  char- 
acterized by  the  sudden  occurrence  of  complete  unconsciousness.  The 
patient  falls  to  the  ground,  and  there  is  at  first  a  temporary  pallor. 
This  is  succeeded  by  flushing  of  the  face,  which  may  become  almost 
purple.  The  pulse  is  full  and  bounding  and  with  difficulty  compress- 
ible. The  breathing  is  stertorous,  the  eyes  are  partially  opened ;  the 
pupils  are  usually  contracted  and  often  unequal.  Often  there  may  be 
vomiting,  or  involuntary  micturition  or  defecation.  The  limbs  remain 
completely  paralyzed,  or  in  some  cases  there  are  unilateral  convulsions. 
If,  as  is  commonly  the  case,  the  hemorrhage  has  involved  the  motor 
tract,  there  is  complete  flaccid  paralysis  of  one  side,  with,  however, 
increased  reflexes.  If  death  does  not  occur  in  the  course  of  the  first 
twenty-four  hours,  the  patient  usually  begins  to  show  signs  of  con- 
sciousness, and  may  be  aroused  from  his  comatose  condition  by  sharp 
questioning.  The  patient  then  may  go  into  a  still  more  deeply  coma- 
tose condition,  with  rise  of  temperature,  followed  by  death,  or  there 
may  be  no  further  indications  of  hemorrhage,  and  recovery  may  set  in. 
As  a  rule,  in  those  cases  in  which  the  prognosis  is  favorable  no  rise  of 
temperature  occurs.  It  may  now  be  found  that  the  patient  has  hemian- 
opsia, usually  the  visual  fields  on  the  same  side  of  the  lesion  being 
blinded.  Conjugate  deviation  may  or  may  not  have  existed  from  the 
first,  the  patient  ordinarily  looking  toward  the  sound  side.  If  the 
speech  centre  has  been  involved,  there  is  absolute  aphasia ;  but  even 
when  it  is  not  directly  affected  partial  aphasia  is  very  common..  The 
hemiplegic  limbs  remain  paralyzed  ;  the  others  regain  their  power.  It 
is  now  necessary  to  determine  the  extent  of  the  damage  and  to  locate 
as  nearly  as  possible  the  situation  of  the  lesion.  Complete  hemiplegia 
may  involve  the  lower  branch  of  the  facial,  the  arm,  and  the  leg.  The 
upper  branch  of  the  facial  and  the  muscles  of  the  trunk  commonly 


1054  SPECIAL  DIAGNOSIS. 

escape,  although  the  former  may  show  slight  paresis.  Sensory  disturb- 
ances may  or  may  not  be  present.  There  is  sometimes  loss  of  all  forms 
of  sensation  and  sometimes  disturbance  of  only  the  tactile  or  the  mus- 
cular sense.  Occasionally  when  tactile  sense  is  preserved  there  may 
be  loss  of  the  stereognostic  sense.  Complete  hemiplegia  with  disturb- 
ance of  sensation  almost  invariably  indicates  destruction  of  the  internal 
capsule  upon  the  opposite  side.  Motor  disturbances  hi  the  form  of  clonic 
convulsions  may  also  occur  in  the  paralyzed  limbs,  and  occasionally, 
probably  as  the  result  of  a  double  lesion,  in  the  limbs  of  the  sound 
side.  They  are  commonly  the  result  of  cortical  lesion,  irritating  in 
character,  either  infarction,  or  else  some  growth  pressing  upon  and 
involving  the  cortex.  As  the  case  progresses  there  is  usually  more 
or  less  return  of  motor  power  and  almost  complete  return  of  sensation. 
This  may,  however,  be  exceedingly  gradual,  several  weeks  elapsing  be- 
fore the  sensory  disturbances  have  entirely  disappeared.  The  muscles 
that  remain  permanently  paralyzed  gradually  atrophy,  but  nearly  always 
give  normal  qualitative  electrical  reactions  until  the  muscular  substance 
disappears,  leaving  contracted  fibrous  tissue.  The  muscles  themselves 
may  show  early  contractions,  the  flexors  ordinarily  overcoming  the 
extensors.  Repeated  attacks  of  apoplexy  are  by  no  means  uncommon, 
and  the  double  lesions  thus  produced  may  give  rise  to  very  complex 
symptom-groups.     (See,  also,  Cerebral  Localization  and  Aphasia.) 

Cerebral  Embolism  and  Thrombosis.  This  is  a  condition  characterized 
by  symptoms  very  similar  to  those  of  cerebral  hemorrhage.  Prodromal 
symptoms,  in  the  form  of  headache,  vertigo,  weakness,  and  malaise,  are 
often  present.  At  times  there  also  may  be  slight  impairment  of  speech, 
or  the  patient  may  be  dull  and  apathetic.  The  attack  usually  comes 
on  more  gradually  than  hemorrhage,  although  this  is  not  invariably 
the  case.  In  some  instances  consciousness  is  not  entirely  lost,  and  as 
a  result  the  hemiplegia  may  develop  before  the  coma.  When  uncon- 
sciousness does  occur  there  is  usually  less  congestion  of  the  face  and 
not  such  marked  evidence  of  increased  arterial  tension  as  we  find  in 
hemorrhage.  Among  the  other  general  symptoms  may  be  mentioned 
convulsions,  vomiting,  and  occasionally  delirium.  The  permanent 
symptoms  resemble  exactly  those  produced  by  hemorrhage,  but 
recovery  is  usually  more  rapid  and  more  complete  than  in  the  former 
condition.  Apoplexy  occurring  iu  children  differs  from  that  occurring 
in  adults  only  by  the  fact  that  the  initial  symptoms  are  more  severe,  and 
the  convulsions  are  frequent  and  may  be  repeated.  The  permanent 
symptoms  differ  slightly,  inasmuch  as  aphasia  rarely  persists.  The 
paralysis  may  be  partial,  and  may  in  some  instances  be  replaced  by 
athetoid  movements.     Sensation  is  rarely  impaired. 

Bulbar  paralysis  is  a  disease  of  the  peripheral  motor  neurons  arising- 
iu  the  medulla.  It  is  characterized  by  the  degeneration  of  the  muscles 
of  the  lips,  tongue,  and  pharynx.  The  course  is  slowly  progressive. 
The  earliest  symptom  is  dysarthria,  then  difficulty  in  swallowing, 
chewing,  and  phonation.  The  face  becomes  expressionless,  the  mouth 
remains  open,  saliva  dribbles  from  it,  and  occasionally  the  eyelids  are 
involved  and  the  eye  remains  open  (logophthalmus).  The  cardiac 
action  and  respiration  may  be  rapid.     Death  usually  occurs  as  a  result 


DISEASES  OF  THE  NERVOUS  SYSTEM.  1055 

of  inspiration  pneumonia,  or  exhaustion.  In  the  variety  known  as 
asthenic  bulbar  paralysis  there  may  be  long  remissions  or  even  per- 
manent recovery. 

Encephalitis.  This  is  a  condition  that  rarely  can  be  diagnosed  during 
life.  It  may  be  suspected,  however,  if,  in  the  course  of  some  other 
acute  infectious  disease,  the  patient  develops  intense  headache,  severe 
delirium,  and  perhaps  local  palsies.  There  may  be  general  exaggera- 
tion of  all  the  reflexes,  with  ankle  clonus,  and  usually  hyperesthesia  of 
the  skin,  and  exaltation  of  the  special  senses.  Examination  of  the 
eye-grounds  usually  fails  to  reveal  optic  neuritis. 

Abscess  of  the  Brain.  This  is  a  local  disease,  giving  rise  to  local 
and  general  symptoms.  General  disturbances  are  chiefly  fever,  chills, 
leukocytosis,  headache,  and  delirium.  The  symptoms  of  focal  dis- 
ease depend,  of  course,  upon  the  location  of  the  abscess.  The  com- 
monest seat  is  in  the  temporo-sphenoidal  lobe,  as  a  result  of  infection 
following  ear  disease.  This  often  gives  rise  to  mind-blindness  or 
amnesia.  Sometimes  there  are  no  general  symptoms  if  the  abscess  is 
located  in  the  blind  regions  of  the  brain.  The  focal  symptoms  may 
not  be  manifest  until  rupture  has  occurred.  This  often  gives  rise  to 
an  epileptiform  attack. 

Tumors  of  the  Brain.  Like  the  preceding  lesion,  these  give  rise  to 
two  groups  of  symptoms  :  general,  which  are  merely  those  of  increased 
intracranial  pressure ;  or  local,  due  to  the  involvement  of  centre  and 
tracts.  The  general  symptoms  of  brain  tumor  are  (1)  headache.  This 
is  usually  very  severe,  of  a  boring  character,  and  subject  to  exacer- 
bations ;  (2)  vomiting.  This  is  paroxysmal,  and  often  occurs  without 
nausea ;  (3)  papillitis.  It  usually  occurs  early,  is  intense,  and  often 
leads  rapidly  to  blindness.  The  local  symptoms  are,  of  course,  numer- 
ous. Tumors  in  the  frontal  lobe  give  rise  to  none,  or  at  most  to  some 
disturbance  of  intelligence  and  perhaps  a  tendency  to  make  puns. 
Tumors  in  the  motor  region  may  cause  irritative  or  destructive  changes 
in  the  tissue.  Irritation  is  manifested  by  local  spasms,  which  may  or 
may  not  be  succeeded  by  general  convulsions  (Jacksonian  epilepsy). 
Paralytic  lesions  are  those  of  monoplegia  or  hemiplegia.  Tumors  in 
the  parietal  lobes  may  cause  interference  with  the  muscle  sense  or 
some  disturbance  of  vision  or  speech  centres,  according  to  their  situa- 
tion. Tumors  in  the  occipital  lobes  usually  cause  mind-blindness — 
that  is,  inability  to  recognize  objects,  and  preservation  of  the  pupillary 
reflexes.  Tumors  in  the  different  fossa  of  the  skull  often  give  rise  to 
symptoms  dependent  upon  pressure  upon  the  cranial  nerves.  In  the 
anterior  fossa  there  may  be  loss  of  the  power  to  smell  upon  one  side. 
In  the  middle  fossa  the  nerves  chiefly  affected  are  the  optic,  giving 
rise  to  unilateral  blindness,  or,  if  the  tumor  involve  the  chiasm,  to 
bitemporal  hemianopsia ;  the  oculomotor  nerves,  the  abducens  and 
the  pathetic,  giving  rise  to  more  or  less  complete  ophthalmoplegia. 
Tumors  in  the  posterior  fossa  commonly  involve  the  facial  and 
auditory  nerve,  and  it  is  said  that  facial  paralysis  with  nerve-deafness 
on  the  same  side  is  characteristic  of  tumor  in  this  situation.  The 
hypoglossal  nerve  may  also  be  involved.  Tumors  may,  of  course, 
grow  slowly,  rapidly,  or  cease  to  increase  in  size,  and  the  symptoms 


1056  SPECIAL  DIAGNOSIS. 

show  a  corresponding  rate  of  development.  In  rapidly  growing 
tumors  apoplectiform  attacks  are  frequent,  but  a  certain  amount  of 
compensation  occurs,  and  remissions  are  not  uncommon.  In  slowly- 
growing  tumors  the  symptoms  may  remain  apparently  stationary  for 
long  periods.  Tumors  are  sometimes  entirely  latent,  and  are  simply 
discovered  accidentally  at  the  autopsy. 

Sclerosis  of  the  Brain.  This  is  usually  a  diffuse  or  a  multiple  lesion 
that  gives  rise  to  a  great  variety  of  symptoms,  more  or  less  indefinite 
in  character.  Ordinarily  the  lesion  is  congenital,  or  develops  shortly 
after  birth.  The  patient  remains  an  imbecile  or  an  idiot,  and  soon 
develops  epileptic  convulsions.  If  the  sclerosis  is  more  pronounced 
on  one  side  than  the  other  there  is  usually  a  tendency  to  fall  toward 
the  opposite  side.  There  may  be  arrest  in  development  in  these  limbs, 
and  more  or  less  muscular  paralysis.  Occasionally,  apparently  as  a 
result  of  foetal  thrombosis  or  embolism,  the  sclerosis  may  be  limited 
to  one  portion  of  the  brain  or  even  to  one  hemisphere.  In  this  case 
there  is  always  arrest  in  the  growth  of  the  opposite  side  of  the  body. 

Hydrocephalus  (chronic  infantile  form).  This  is  characterized  by  an 
extraordinary  alteration  in  the  contour  of  the  head,  which  becomes 
greatly  enlarged  and  globular  in  shape,  while  the  face  remains  small 
and  infantile  in  appearance.  The  symptoms  are  sometimes  exceedingly 
pronounced  ;  at  other  times  entirely  absent.  Persons  with  a  moderate 
degree  of  hydrocephalus  have  displayed  through  life  a  normal  intelli- 
gence. In  other  cases  the  head  is  heavy  and  the  muscles  of  the  neck 
unable  to  support  it.  The  child  is  an  imbecile  or  an  idiot,  and  epileptic 
convulsions  are  very  common.  Occasionally  ocular  symptoms  may  be 
present.  These  consist  of  ptosis,  strabismus,  or  nystagmus,  and  some- 
times of  atrophy  of  the  optic  nerve,  and  blindness. 

Acute  Delirium.  This  is  a  disease  characterized  by  prodromata  and 
a  stage  of  excitation,  and  usually  terminates  in  death.  The  prodromata 
consist  of  disturbances  of  the  general  health,  loss  of  appetite,  and  in- 
somnia. The  patient  is  restless,  anxious,  and  may  show  diminution  of 
intelligence,  and  become  more  or  less  violent.  He  then  rapidly 
passes  into  the  stage  of  excitation,  is  restless,  noisy,  and  frequently 
homicidal,  shouting  disconnected  words  or  sentences,  singing  or  shriek- 
ing. Sometimes  there  are  delusions  of  persecution,  and  he  attempts  to 
escape.  In  addition,  there  are  the  symptoms  of  the  so-called  typhoid 
state,  high  fever,  profound  prostration,  dry  tongue,  and  rapid  and  weak 
pulse.  The  patient  refuses  all  food,  is  continually  active,  and  emaciates 
very  rapidly.  Among  the  objective  symptoms  are  increase  of  the 
reflexes,  narrowing  of  the  pupils,  and  hyperesthesia,  with  more  or  less 
hypalgesia.  From  this  stage  the  patient  passes  into  a  state  of  collapse, 
lies  in  a  condition  of  muttering  delirium,  with  carphology,  and  usually 
dies  from  exhaustion. 

General  paralysis  of  the  insane  is  a  form  of  progressive  dementia 
characterized  by  delusions  of  grandeur  or  states  of  depression  associ- 
ated with  exacerbations  of  maniacal  character.  There  are,  in  addition, 
weakness  and  tremors  of  the  muscles  of  the  face,  paresis  of  the  extremi- 
ties, the  Argyll-Robertson  pupil,  and  peculiar  disturbances  of  speech. 
It  is  usual  to  recognize  three  stages.     The  prodromal  stage,  character- 


DISEASES  OF  THE  NERVOUS  SYSTEM.  1057 

ized  by  irritability  or  sometimes  by  depression ;  diminution  or  loss  of 
the  moral  sense ;  impaired  judgment,  particularly  in  business  affairs ; 
and  a  tendency  to  extravagance  and  dissipation.  Frequently  symptoms 
associated  with  degeneration,  such  as  intolerance  for  alcohol,  intense 
egotism,  etc.,  appear.  The  sexual  function  in  this  stage  is  often  greatly 
increased.  Memory  fails  and  the  intellectual  capacity  is  considerably 
diminished.  There  are  often  slight  disturbances  of  speech,  and  some- 
times paralytic  pupils.  Frequently  there  is  insomnia  and  occasional 
attacks  of  migraine.  In  the  second  stage,  which  usually  develops 
gradually,  the  attacks  of  migraine  are  replaced  by  apoplectic  or  epileptic 
attacks  or  by  distinct  maniacal  conditions  ;  memory  is  greatly  impaired, 
the  intellect  is  considerably  disturbed,  the  patient  becoming  unable  to 
do  easy  mathematical  problems,  to  comprehend  his  environment,  or 
to  sustain  a  simple  conversation.  Usually  there  are  delusions  of  gran- 
deur, the  patient  believing  himself  rich,  beautiful,  successful,  intelligent, 
and  reiterating  constantly  his  advantages,  although  from  time  to  time 
there  will  be  states  of  depression  and  partial  recognition  of  the  failure 
of  power.  In  other  cases,  however,  particularly  chronic  alcoholics, 
there  is  distinct  melancholia ;  the  patient  is  hypochondriacal,  or  may 
have  delusions  of  persecution,  or  a  sense  of  misfortune.  The  disturb- 
ances of  speech  are  characteristic ;  the  most  common  is  the  omission 
of  syllables.  This  may  best  be  tested  by  asking  the  patient  to  repeat 
certain  words,  particularly  those  containing  a  number  of  r's  and  l's,  as 
"  third  riding  artillery  brigade,"  "  truly  rural,"  etc.  There  is  marked 
tremor  of  the  lips  and  of  the  tongue,  producing  a  sort  of  ataxia  in  the 
speech,  with  the  disturbance  of  the  formation  of  nearly  all  the  sounds. 
The  pupillary  changes  are  similar  to  those  described  in  the  prodromal 
stage,  but  usually  are  more  pronounced.  The  extremities  are  weak, 
and  often  exhibit  distinct  tremors.  Finally,  the  patient  becomes  com- 
pletely demented,  usually  lies  quietly  and  placidly  in  bed,  or  occasion- 
ally mutters  unintelligible  sounds.  Sensation,  either  as  a  result  of 
impaired  perception  or  because  of  degenerative  changes  in  the  periph- 
eral nervous  system  or  the  spinal  cord,  becomes  greatly  impaired, 
particularly  the  pain-sense.  The  patient  is  unable  to  stand,  and  has 
involuntary  or  rather  unperceived  micturition  and  defecation,  and  fre- 
quently develops  bed-sores  or  cystitis.  A  curious  and  quite  common 
symptom  is  the  gnashing  of  the  teeth,  which  in  some  cases  is  almost 
persistent.  Death  usually  occurs  from  exhaustion.  Among  the  less  fre- 
quent symptoms  are  a  curious  unsteadiness  of  gait,  exaggeration  of  the 
reflexes,  rapid  diminution  in  weight,  particularly  in  the  last  two  stages. 
Epilepsy.  This  is  a  condition  characterized  by  attacks  of  clonic 
convulsions,  associated  with  loss  of  consciousness  and  usually  some 
impairment  of  intelligence.  In  the  characteristic  epileptic  fit  we  can 
usually  distinguish  three  stages  :  the  prodroma,  the  attack,  and  the 
postepileptic  stage.  In  the  prodromal  stage  aura?  are  frequently 
present.  These  may  be  of  the  most  varying  character.  A  patient 
may  either  have  a  curious  sensation  in  the  epigastrium,  paresthesia? 
in  a  limb,  and  the  subjective  sensation  of  movement,  or  disturbance  of 
the  special  senses,  particularly  an  unpleasant  odor  or  a  whirring  sound. 
Sometimes  the  sensations  are  painful  or  distressing,  as  a  sense  of  con- 

67 


1058  SPECIAL  DIAGNOSIS. 

striction  about  the  throat.  At  other  times  there  is  giddiness,  vertigo, 
or  nausea,  or  the  recurrence  of  some  particular  idea.  Occasionally  the 
aurse  consist  of  some  imperative  movement,  such  as  whirling  about, 
running,  or  jumping.  At  the  commencement  of  the  attack  there  is 
usually  a  cry — the  epileptic  cry.  Ordinarily  this  is  a  curious  sort  of 
gasping,  due  to  the  forcible  contraction  of  the  thorax  and  partial  closure 
of  the  glottis.  In  some  cases,  however,  it  may  be  a  loud  shriek.  The 
patient  then  falls  to  the  ground,  and  the  convulsive  movements  com- 
mence. These  are  rarely  of  equal  vigor  on  both  sides ;  the  head  and 
eyes  show  conjugate  deviation  ;  the  face  is  bluish  and  pallid ;  the  mouth 
is  filled  with  frothy  fluid,  which  is  often  blood-stained,  on  account  of 
biting  the  tongue ;  the  limbs  may  be  extended  or  flexed  in  tonic  con- 
traction. This  is  soon  replaced  by  a  violent  to-and-fro  tremor.  The 
patient  is  completely  unconscious,  and  may,  in  falling,  cause  himself 
serious  injury.  There  is  no  conjunctival  reflex,  the  pupils  are  widely 
dilated ;  frequently  the  urine  is  passed  during  the  attack,  and  there  is 
occasionally  profuse  sweating.  Toward  the  end  the  convulsions  become 
less  frequent.  Respiration  is  re-established ;  at  first  irregular,  then  gradu- 
ally it  becomes  more  and  more  steady.  The  cyanosis  disappears,  and 
the  patient  usually  passes  into  a  profound  sleep.  This  may  last  several 
hours,  and  he  then  awakes,  feeling  dull  and  fatigued,  but  otherwise 
normal.  At  other  times,  immediately  after  the  attack,  there  is  vomit- 
ing or  nausea,  and  sometimes  a  feeling  of  excessive  hunger.  He  may 
become  maniacal,  usually  with  homicidal  mania,  or  the  postepileptic 
stage  may  be  manifested  by  nothing  more  serious  than  some  imperative 
movement,  such  as  running  or  shouting.  The  convulsive  stage  may  be 
replaced  by  purely  sensory  phenomena,  without  complete  loss  of  con- 
sciousness, or  there  may  be  merely  a  fine  tremor,  or  the  patient  may 
simply  run  or  be  otherwise  violent,  while  wholly  unconscious. 

Petit  Mai.  In  this  condition  the  loss  of  consciousness  is  so  transitory 
and  the  motor  symptoms  are  so  slight  that  its  nature  often  escapes 
detection.  The  patient,  if  talking,  will  suddenly  stop  for  a  moment ; 
there  is  a  peculiar  rigidity  of  the  expression  and  perhaps  slight  sway- 
ing. This  will  disappear  almost  immediately,  and  the  patient  will 
resume  the  conversation.  Sometimes  after  these  attacks  there  will  be 
a  feeling  of  drowsiness  for  a  short  period.  Aurse  may  be  present  in  the 
form  of  giddiness  or  twitching  of  the  limb.  The  attack  may  also  occa- 
sionally be  ushered  in  with  a  scream  or  a  peculiar  gasping  expiration. 
Immediately  after  the  attack  automatic  movements  may  be  performed. 
Attacks  of  petit  mal  often  occur  during  sleep,  and  the  only  symptoms 
then  that  point  to  the  existence  of  the  disease  are  a  feeling  of  heaviness 
in  the  morning,  perhaps  a  sore  and  bitten  tongue,  and  nocturnal  enuresis. 

Focal  epilepsy  (Jacksonian  epilepsy).  This  form  resembles  general 
epilepsy,  with  the  difference  that  the  motor  or  the  sensory  disturbances 
always  commence  in  the  same  part  of  the  body,  and  from  this  part 
gradually  extend  until  they  become  general.  Thus,  the  thumb  may 
first  be  affected,  showing  a  tonic  and  then  a  clonic  spasm ;  then  the 
hand,  the  arm,  the  whole  of  that  side,  or  both  sides ;  or  the  disturbance 
may  commence  in  the  foot.  The  disease  almost  invariably  indicates 
the  existence  of  a  focal  lesion  in  the  brain. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  1059 

General  Symptoms  in  Epilepsy.  Epileptics  are  usually  dull,  apathetic, 
having  a  tendency  to  excess  in  eating.  An  excess  of  indican  is  often 
present  in  the  urine.  Often  there  is  distinct  mental  impairment,  or, 
when  the  disease  occurs  early  in  life,  there  may  be  congenital  imbe- 
cility or  idiocy.  The  temper  of  epileptics  is  usually  irritable,  and  they 
are  likely  to  commit  acts  of  violence. 

Migraine  (hemicrania).  This  is  a  disease  characterized  by  parox- 
ysmal attacks  of  headache  associated  with  nausea  and  vomiting,  and 
frequently  with  disturbances  of  the  special  senses.  The  attacks  are 
usually  followed  by  prolonged  sleep.  The  headache  is  peculiar,  in  that 
it  commences  slowly  as  a  dull  but  severe  pain  that  gradually  increases 
in  intensity,  with  occasional  exacerbations  or  throbbing,  and  is  limited 
to  one  side  of  the  head.  Occasionally,  however,  it  is  bilateral,  but  is 
then  usually  unequal.  At  the  same  time  the  patient  experiences  a 
sensation  of  intense  nausea  that  may  be  followed  by  vomiting.  The 
special  senses  are  affected  in  various  ways.  There  may  be  photophobia, 
hyperacusis,  and  occasionally  the  appearance  of  peculiar  scotomata, 
which  commence  as  a  bright  spot  that  spreads,  the  outer  edge  being  of 
an  irregular,  jagged  character,  and  finally  disappears  at  the  periphery 
of  the  field  of  vision.  New  lines  constantly  form  at  the  centre,  and 
follow  those  first  appearing.  Sometimes  the  patient  complains  of  dim- 
ness of  vision,  and  this  may  affect  only  part  of  the  visual  field.  Occa- 
sionally there  is  temporary  aphasia,  particularly  if  the  pain  occurs  in 
the  left  side  of  the  head.  In  addition,  the  patients  may  observe  vaso- 
motor symptoms,  paresthesia,  or  occasionally  stiffness  or  spasms  in  the 
limb.  The  paroxysm  usually  terminates  in  sleep,  which  may  be  pro- 
longed, and  when  the  patient  awakens  all  symptoms  have  disappeared. 
Sometimes  there  is  a  severe  attack  of  polyuria. 

Meniere's  Disease.  This  is  characterized  by  attacks  of  vertigo,  asso- 
ciated with  nausea.  The  attack  usually  begins  with  tinnitus,  then 
intense  vertigo,  which  may  come  on  so  suddenly  that  the  patient  falls 
to  the  ground,  or  else  he  is  obliged  to  lie  down,  and  remain  hi  this 
position  until  the  attack  is  over. 

Hysteria  is  a  disease  due  to  disturbance  of  the  self-control,  producing 
a  curious  complex  of  symptoms  that  appear  to  be  the  result  of  imitation 
or  of  a  desire  to  attract  attention  or  sympathy,  associated  with  certain 
disturbances  of  the  special  senses  and  of  sensation.  The  psychical  symp- 
toms are  a  certain  tendency  to  self-consciousness,  so  that  the  patient  is 
anxious  to  describe  his  or  her  sufferings  to  surrounding  persons ;  is  in 
the  habit  of  performing  ludicrous  or  startling  acts  for  the  purpose  of 
attracting  attention ;  is  emotional,  weeping  or  laughing  readily,  and 
is  often  irritable  and  suspicious.  Among  the  sensory  symptoms  are 
areas  of  tactile  anaesthesia  or  analgesia.  These  may  involve  exactly 
one-half  of  the  body,  including  the  accessible  mucous  membranes,  or 
they  may  be  symmetrical  in  distribution  on  both  sides  of  the  median 
line,  and  often  form  geometrical  figures.  These  are  not  the  result 
apparently  of  simulation  on  the  part  of  the  patient,  because  they  remain 
unchanged  for  a  number  of  days.  Tenderness — that  is,  hyperalgesia 
— may  be  present  over  the  ovaries  and  the  spine.  The  areas  of  anaes- 
thesia may  be  transferred  from  one  part  of  the  body  to  the  other, 


1060  SPECIAL  DIAGNOSIS. 

either  spontaneously  or  as  a  result  of  suggestion.  The  latter  is  most 
effectual  when  the  transfer  is  made  by  means  of  a  magnet  or  metals. 

The  special  senses  may  have  their  function  exalted,  so  that  the 
patients  have  an  extraordinary  acuteness  of  smell  or  hearing,  or  find 
it  difficult  to  endure  strong  lights. 

Depression  of  the  function  of  the  special  senses  is  perhaps  more 
common,  particularly  loss  of  the  sense  of  smell  and  taste.  Hysterical 
deafness  is  exceedingly  rare.  Hysterical  blindness  not  infrequently 
occurs,  is  characterized  by  widely  dilated  pupils,  that  usually  react 
to  light,  and,  of  course,  by  normal  eye-grounds.  The  hysterical  stigmata 
associated  with  the  eye  are  of  great  importance,  partly  on  account  of 
their  peculiarities,  partly  on  account  of  their  persistence.  The  most  fre- 
quent is  simple  contraction  of  the  formed  field.  This,  however,  occurs  in 
other  conditions,  and  is,  therefore,  not  as  characteristic  as  contraction  of 
the  formed  field  with  inversion  of  the  color  field — that  is  to  say,  a  red 
object  will  be  seen  further  from  the  central  visual  point  than  a  blue  one. 
Monocular  diplopia,  in  the  absence  of  structural  defect  in  the  eyeball,  is 
pathognomonic  of  hysteria.    In  rare  cases  three  images  may  be  perceived. 

The  motor  symptoms  are  paresis,  or  occasionally  complete  paralysis. 
The  commonest  form  of  this  is  hysterical  aphonia,  in  which  the  patients 
are  unable  to  contract  the  vocal  cords  for  the  purpose  of  producing 
sound,  but  may  be  perfectly  able  to  cough  or  perform  any  other  func- 
tion with  them.  In  these  cases  speech  usually  returns  suddenly  under 
the  influence  of  a  strong  emotion  or  suggestion.  The  paralysis  in  other 
parts  of  the  body  occurs  in  imitation  of  some  form  of  organic  disease. 
Thus  there  may  be  paraplegia,  hemiplegia,  or  monoplegia.  Loss  of 
power  is  rarely  complete,  and  occasionally  patients  move  the  limbs 
when  they  believe  themselves  unobserved.  The  electrical  reactions 
remain  normal,  although  the  degree  of  resistance  in  the  skin  may  be 
greatly  increased.  The  reflexes  are  exaggerated,  especially  those  due 
to  cutaneous  irritations,  such  as  the  plantar  reflex,  but  ankle  clonus 
does  not  occur.  The  gait  may  be  staggering,  imitating  cerebellar 
ataxia  or  the  ataxia  due  to  intoxication ;  sometimes  there  are  tremors, 
coarse  and  irregular,  and  rarely  constant.  In  some  cases  of  hysteria 
actual  contractures  of  the  muscles  occur,  indicating  the  existence  of 
trophic  disorders.  Spasmodic  contractions  sometimes  occur  in  the 
muscles  of  the  abdomen,  giving  rise  to  an  apparent  or  hysterical 
abdominal  tumor.  Actual  trophic  changes  may  also  occur  in  hys- 
terical patients,  but  these  are  rare  in  this  country.  There  may  be 
hemorrhages  into  or  from  the  skin,  particularly  from  the  forehead, 
palms  of  the  hands,  and  the  soles  of  the  feet  (stigmata  of  the  passion), 
or  there  may  be  localized  areas  of  gangrene  in  the  skin. 

The  attack  (prise  hysterique)  may  be  divided  into  the  prodromal  period 
and  the  convulsive.  The  aura?  consist  of  a  variety  of  sensory  disturb- 
ances, of  which  the  most  common  is  the  sensation  of  a  ball  rising  in 
the  throat  (globus  hystericus).  The  patient  may  also  have  a  sensation 
of  heat  or  cold,  or  moisture  of  the  skin,  or  various  painful  impressions. 
Occasionally  the  tenderness  over  the  ovary  is  greatly  increased  (ovaria), 
and  the  attack  may  be  precipitated  by  pressure  in  this  region.  It  is 
impossible  to  describe  all  the  movements  that  occur  in  the  grande  crise. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  1061 

The  convulsion  may  be  tonic  or  clonic.  The  patient  may  assume  the 
most  extraordinary  positions.  Among  the  most  characteristic  is  opis- 
thotonos, in  which  the  heels  and  the  back  of  the  head  rest  upon  the 
floor  or  bed,  while  the  body  forms  an  arch ;  or  the  patient  may  assume 
attitudes  that  suggest  or  are  characteristic  of  mirth,  sorrow,  fear,  pas- 
sion, etc.  Consciousness  is  rarely  entirely  lost,  although  there  may  be 
subsequently  total  amnesia  for  the  period  of  the  attack,  and,  no  matter 
how  violent  the  movements  of  the  patient,  injury  to  any  part  never 
occurs.  Gradually  the  movements  become  less  violent,  the  patient  be- 
comes quiet,  and  consciousness  returns.  During  the  attack  the  pupils 
are  usually  dilated,  the  reflexes  may  be  increased,  and  respirations  are 
commonly  extremely  rapid,  in  one  case  that  I  observed  they  reached 
100  per  minute.  Occasionally  the  attack  may  be  cut  short  by  pressure 
upon  one  of  the  hysterogenic  zones.  After  the  attack  the  patient  may 
be  perfectly  normal.  At  times  there  may  be  persistent,  curious,  per- 
verse tendencies,  such  as  unwillingness  to  eat,  or,  at  least,  a  simulation 
of  fasting. 

Neurasthenia  is  a  disease  characterized  by  an  exceedingly  complex 
symptomatology.  The  symptoms  may  be  divided  into  the  general  and 
special  groups  :  the  former  including  those  common  to  all  forms  of 
neurasthenia,  the  latter  those  associated  particularly  with  subjective 
and  objective  functional  disturbance  of  the  various  organs.  The  mental 
symptoms  are  various.  The  patients  are  usually  querulous,  depressed, 
and  hypochondriacal.  They  are  very  irritable,  but  incapable  of 
prolonged  emotional  exaltation.  They  find  difficulty  in  concentrat- 
ing their  attention,  particularly  upon  those  subjects  with  which  they 
have  previously  been  familiar.  Memory  is  impaired  and  the  intellec- 
tual capacities  apparently  diminished.  It  must  be  remembered,  how- 
ever, that  careful  testing  of  the  memory  or  judgment  rarely  shows 
that  it  is  seriously  affected.  An  important  symptom  is  the  insomnia. 
This  may  be  of  all  varieties,  but  ordinarily  the  patient,  after  sleeping 
in  the  early  part  of  the  night,  will  awaken  and  be  unable  to  sleep  again 
for  some  hours.  The  statements  by  the  patients  in  regard  to  this  symp- 
tom are  very  unreliable.  Frequently  they  complain  of  unpleasant  or 
frightful  dreams  when  they  actually  have  slept.  Among  the  sensory 
symptoms  the  most  important  is  headache.  This  is  of  a  peculiar  but 
almost  typical  form.  The  patient  complains  of  a  heavy,  dull  feeling, 
as  if  wearing  some  heavy  object,  the  usual  simile  being  a  lead  helmet. 
Occasionally  the  pain  is  localized ;  sometimes  to  the  occipital  region 
and  sometimes  to  a  circumscribed  area,  the  latter  usually  the  result  of 
suggestion.  Another  symptom  that  is  very  common  is  pain  in  the 
back.  This  is  usually  felt  in  the  neck  or  the  lumbar  and  sacral  region  ; 
it  is  of  a  dull,  persistent  character,  and  may  be  associated  with  points  of 
tenderness  over  the  spine.  Occasionally  there  arc  disturbances  of  the 
special  senses.  The  patient  may  complain  of  inability  to  see  sharply, 
or  there  may  be  muscre  volitantes.  At  other  times  lie  will  fail  to  hear 
distinctly  or  may  complain  of  roaring  or  tinnitus.  Actual  diminution 
of  the  visual  power  or  of  the  sense  of  hearing  does  not  occur.  The 
patients  may  complain,  however,  of  paresthesia?  in  the  limbs  and  of 
various  symptoms  usually  the  result  of  suggestion.    Sensation  is  other- 


1062  SPECIAL  DIAGNOSIS. 

wise  normal.  There  is  usually  a  general  decrease  in  muscular  power. 
Sometimes  this  may  be  preserved  for  short  periods  of  activity,  but 
fatigue,  as  a  rule,  comes  on  very  rapidly.  At  other  times  it  is  impos- 
sible for  the  patient  to  exert  the  amount  of  force  that  would  be  normal 
for  his  muscular  development.  Occasionally  this  weakness  is  localized 
to  one  limb  or  side  of  the  body.  When  the  patient  is  directed  to  hold 
a  limb  rigid  or  to  extend  the  fingers  forcibly  a  fine  tremor  of  the 
extremities  occurs.  This  may  be  persistent  or  readily  exhausted ;  in 
addition,  fibrillary  twitchings  of  the  muscles  not  infrequently  occur. 
The  tendon  reflexes  are  generally  exaggerated.  Ankle  clonus,  however, 
excepting  the  form  spoken  of  as  pseudoclonus,  is  exceedingly  un- 
common. Absence  of  the  knee-jerk  does  not  occur  in  neurasthenia. 
The  cutaneous  reflexes  are  sometimes  greatly  exaggerated,  sometimes 
depressed.  Vasomotor  symptoms  are  very  common.  The  patient 
flushes  easily,  and  there  is  often  dermographia ;  he  complains  of  palpi- 
tation and  occasionally  of  irregularity  of  the  heart's  action.  Often 
perspiration  is  produced  by  slight  exertion. 

In  addition  to  these  symptoms,  the  neurasthenic  may  complain  of 
various  local  disorders  of  the  nervous  system ;  he  usually  suspects  that 
he  has  locomotor  ataxia,  and  he  will  probably  have  learned  the  symp- 
toms of  this  condition  sufficiently  well  to  imitate  them  more  or  less 
accurately,  or  he  may  believe  himself  suffering  from  general  paresis  or 
brain  tumor,  or  any  other  condition  with  which  he  may  be  familiar. 
From  general  paresis  the  diagnosis  is  sometimes  quite  difficult  unless  the 
Argyll-Robertson  pupil,  which  never  occurs  in  neurasthenia,  is  present. 
Another  common  form  is  gastro-intestinal  neurasthenia.  The  patient 
may  complain  of  excessive  acidity,  and,  in  fact,  vomit  from  time  to 
time  masses  of  acid  material,  or  there  may  be  difficulty  with  digestion 
and  hypochlorhydria  or  anacidity.  Constipation  is  an  exceedingly  fre- 
quent symptom.  From  time  to  time  the  patient  may  also  evacuate 
large  quantities  of  mucus,  and  sometimes  there  may  be  persistent 
mucous  diarrhoea.  This  is  one  of  the  most  intractable  forms  of  the 
disease.  Finally,  the  patient  may  be  a  sexual  neurasthenic  and  be- 
lieve himself  to  be  suffering  from  organic  or  functional  disease  of  the 
genital  organs.  To  this  variety  is  usually,  but  I  believe  incorrectly, 
reckoned  the  various  types  of  sexual  perversion.  The  degree  of  neu- 
rasthenia is  spoken  of  as  mild  or  severe,  according  as  the  symptoms 
are  slight  or  pronounced. 


INDEX. 


A  BASIA,  74 

i\-    Abdomen,  aspiration  of,  358 
color  of,  727 
enlargement  of,  general,  729 

local,  733 
inspection  of,  727 
markings  on,  727 
palpation  and  percussion  of,  735 
retraction  of,  735 
shape  of,  729 
topography  of,  725 
Abscess  of  brain,  1055 

fecal,  743 

of  kidney,  966 

pelvic,  744 

pericecal,  743 

perinephritic,  913 

in  precordial  region,  584 

retropharyngeal,  717 

subdiaphragmatic,  753,  764 
Acetonemia,  958 
Acetonuria,  936 

Achromia  of  red  corpuscles,  375 
Acroparesthesia,  1043 
Acne,  143 
Acromegalia,  169 
Actinomyces,  352 

in  sputum,  536 
Actinomycosis,  350 

of  mouth,  694 

pulmonic  type  of,  351 
Addison's  disease,  124 
Adenoid  vegetations  in  nasopharynx,  714 
Adherent  pericardium,  648 
iEgophony,  513 

in  pleurisy,  571 
iEsthesiometer,  974 
Age  in  the  etiology  of  disease,  24 
Ague,  dumb,  285 
Albumin  in  urine,  tests  for,  921 

quantitative  estimation  of,  926 
Albuminuria,  927 

in  renal  calculus,  905 
Albumosuria,  929 
Alexia,  1000 
Alkaptonuria,  937 
Allochiria,  974 
Alveolar  cells  in  sputum,  523 
Amaurosis,  uremic,  966 
Amnesia,  1010 
Amceba  dysenterie  or  coli,  344 

in  feces,  830 

in  pus,  363 

in  sputum,  528 


Amcebic  dysentery,  342 
Amyloid  degeneration  of  kidney,  968 
Anemia,  389,  401 
blood  in,  394 
classification  of,  390 
from  disease,  391 
fever  in,  209 
in  gastric  disease,  794 
from  hemorrhage,  391 
local,  402 

from  malnutrition,  392 
murmurs  in,  arterial,  641 
cardiac,  637 
venous,  641 
in  nephritis,  959 
neuralgia  in,  48 
parasitic,  391 

pernicious  or  idiopathic,  393 
in  phthisis,  558 
splenic  enlargement  in,  392 
symptoms  of,  370 
toxic,  390 
Anesthesia,  972 

dolorosa,  973 
Analgesia,  972 
Anarthria,  1006 
Anasarca,  153 
Aneurism,  674 
of  heart,  656 
thoracic,  674 

diagnosis  of,  681 
hemorrhage  in,  467 
pain  in,  584 
physical  signs  of,  678 
sphygmogram  in,  612 
Angina  Ludovici,  706,  717 
pectoris,  585 

in  aortic  regurgitation,  657 
arterial  tension  in,  606 
in  coronary  artery  disease,  654 
Angle  of  Ludwig,  472 
Ankle  clonus,  988 
Ankylostomum  duodenale,  838 
Anorexia,  772,  799 
Anosmia,  419 
Anthracosis,  327 
Anthrax,  277 

bacillus  of,  278 

distinguished  from  carbuncle,  279 
intestinal  form  of,  277 
wool- sorter's  type  of,  278 
Antrum,  abscess  of,  429 
Aorta,  aneurism  of,  674.     See  also  Aneu- 
rism. 


1064 


INDEX. 


Aorta,  atheroma  of,  murmurs  in,  637 
pain  in,  584 
pulsation  of,  596 
Aortic  area,  632 

obstruction,  659 

distinguished   from   atheroma  of 

aorta,  639 
thrill  in,  603 
regurgitation,  657 

presystolic  murmur  in,  665 
pulsation  in,  distinguished   from 

aneurism,  683 
pulse  in,  639 
sphygmogram  in,  612 
thrill  in,  603 
Apex-beat.     See  Heart,  impulse  of. 
Aphasia,  1000 
Aphonia,  hysterical,  1060 

in  pericardial  effusion,  645 
Apoplexy,  1053 

relation  of  arterio-sclerosis  to,  673 
Appendicitis,  738 

abscess  formation  in,  741 
catarrhal,  738 
decubitus  in,  69 

distinguished    from    acute    intestinal 
obstruction,  851 
from  hip-joint  disease,  742 
from  perinephritic  abscess,  743 
from  typhoid  fever,  302,  740 
gangrenous,  742 
pain  in,  818 
palpation  in,  737 
perforating,  741 

distinguished  from  acute  tubercu- 
lous peritonitis,  743,  755 
recurrent,  740 
tuberculous,  755 
Appetite,  alteration  of,  772,  799 
Apraxia,  1006 
Aprosexia,  715 
Arcus  senilis,  96 
Argyria,  126 
Arrhythmia,  587 

in  auto-intoxication,  203,  211 
Arsenic-poisoning,  216 
Arteries,  murmurs  in,  in  arterial  sclerosis, 
673  _ 
palpation  of,  605 
pulsation  of,  visible,  596 

in  aortic  regurgitation,  658 
sclerosis  of,  672 
tension  of,  606 
Arterio-capillary  fibrosis,  672 

pulsation  of  arteries  in,  598 

Arthritis,  gonorrhoea^  178 

rheumatoid,  185 

hand  in,  113 

tuberculous,  178 

Ascaris  lumbricoides,  833 

symptoms  of,  815 
Ascites,  729 

character  of  fluid  in,  730 
distinguished    from    enlargement    of 
liver,  871 
from  hydronephrosis,  912 


Aspiration,  technique  of,  357 
Astasia,  74 
Asthma,  459 

causes  of,  460 

decubitus  in,  69 

in  nasal  disease,  420 

sputum  of,  524 
Atavism,  29 
Ataxia,  979 
Atelectasis,  548 
Atheroma  of  arteries,  672 

murmurs  in,  641 
Athetosis,  983 
Auscultation  of  chest,  502 

sounds  in  health,  503,  505 

of  voice,  512 
Auto-intoxication,  760 


BACELLI'S  sign  of  empyema,  572 
Bacilli  of  Booker,  836 
Bacillus  of  anthrax,  278 
of  cholera,  338 
coli  communis,  363,  835 
of  diphtheria,  333 
general  characteristics  of,  221 
of  influenza,  536 
of  leprosy,  349 
mallei,  336 

mucous  capsulatus,  535 
of  pertussis,  536 
smegmse,  532 

in  gangrene  of  lung,  530 
of  syphilis,  363 
of  tetanus,  353 
of  tuberculosis,  530,  836 
of  typhoid  fever,  298 
of  yellow  fever,  305 
Backache,  57 

in  infectious  fevers,  201 
Bacteria,  general  characteristics  of,  220 
Bacteriological  diagnosis,  229 
methods,  230 

apparatus,  231 
collection  of  material,  232 
cover-slip  preparations,  244 
culture  media,  242 
examination  of  blood,  232 
hanging-drop  preparations,  241 
identification  of  organisms,  245 
inoculation  of  animals,  244 
plate  culture,  243 
smear  culture,  244 
staining,  240 

of  capsule,  535 
of  tubercle  bacillus,  532 
sterilization,  231 
Bacteriuria,  948 
Bamberger's  sign  of  pericardial  effusion, 

648 
Baruch's  sign  of  typhoid  fever,  301 
Belching,  802 
Bell  tympany  in  chest,  412 
Beri-beri,  1046 

oedema  in,  152,  153 
Bile  in  urine,  test  for,  936 


INDEX. 


1065 


Bile-ducts,  cancer  of,  distinguished   from 
hepatic  cancer,  882 

inflammation  of,  885 

obstruction  of  by  gallstones,  886 
Biliousness,  855 

bad  taste  in,  764 
Black  tongue,  696 
Blasts,  375 
Blepharospasm,  92 
Blood,  alkalinity  of,  386 

bacteriological  examination  of,  232 

color  index  of,  385 

counting  the  corpuscles  of,  376 

cover-slip  preparations  of,  372 

in  gastric  contents,  test  for,  782 

haemoglobin  of,  384 

leucocytes  of,  379 

parasites  in,  388 

physical  appearance  of,  371 

pigment  in,  386 

pressure  of,  414 

red  corpuscles  of,  375 
number  of,  379 

serum  as  culture  media,  242 

specific  gravity  of,  387 

staining  of,  373 

in  stools,  820 

in  urine,  928,  940 
Boils  in  diabetes,  934 
Bones,  the,  169 

in  osteitis  deformans,  170 

in  rickets,  172 
Bothriocephalus  latus,  833 

symptoms  of,  814 
Boulimia,  772 
Bradycardia,  609 

in  jaundice,  861 

in  typhus  fever,  249 
Bradylalia,  1006 
Brain,  abscess  of,  1055 

general  symptoms  of  disease  of,  1024 

sclerosis  of,  1056 

tumors  of,  1055 

choked  disk  in,  100 
Brawny  induration,  157 
Breath,  fetor  of,  687,  708 
Breathing.     See  also  Respiration. 

amphoric,  508 

bronchial,  503,  507 

in  pleural  effusion,  571 

broncho-vesicular,  504,  509 

cavernous,  508 

jerking  inspiration  in,  506 

prolonged  expiration  in,  506 

tubular,  508 

vesicular,  503 

exaggerated,  505 
feeble  or  absent,  505 
Broadbent's  sign  of  adherent  pericardium, 

596 
Bronchi,  obstruction  of,  458,  488 
Bronchiectasis,  566 

distinguished  from  phthisis,  567 
Bronchitis,  acute,  542 

diagnosis  of,  543 

capillary,  545 


Bronchitis,  chronic,  544 

fibrinous  coagula  in,  524 

lithaemic,  856 

plastic,  546 

putrid,  547 
Bronchophony,  513 
Bronchorrhcea,  545 
Bronzing  of  skin,  124 
Brown-Sdquard's  syndrome,  1025 
Bulbar  paralysis,  1054,  1056 


rtJECUM,  abscess  about,  743 
\J     inflammation  of,  742 
Cachexia,  cancerous,  412 
in  gastric  cancer,  810 
malarial,  289 
varieties  of,  67 
Calculus,  biliary,  885 

renal,  902 
Cancer.     See  Carcinoma. 
Cantering  rhythm  of  heart,  627 
Capillary  pulse,  598,  659 
Caput  Medusa?,  728,  877 
Carbuncle  in  diabetes,  934 

distinguished  from  anthrax,  279 
Carcinoma,  cachexia  of,  412 
fascies  of,  81 
gastric,  808 

pain  in,  771 

supraclavicular  glands  in,  159 
general  symptoms  of,  411 
of  larynx,  441 
of  lung,  567 

haemoptysis  in,  467 
of  oesophagus,  722 
of  peritoneum,  754 
of  skin,  158 
Cardialgia,  770 

Cardio-hepatic  triangle,  615,  646 
Carreau,  736,  758 
Case-records,  22,  536 
Casts  in  urine,  941 

in  renal  calculus,  905 
without  nephritis,  944 
Cataract,  99 
Catarrh,  nasal,  427.     See  also  Rhinitis. 

suffocative,  545 
Catarrhe  sec,  544 
Cavities,  pulmonary,  514 

bronchophony  in,  413 
distinguished    from    pneumotho- 
rax, 578 
physical  signs  of,  514 
Cercomonas  intestinalis,  831 
Cerebellar  gait,  73 
Cerebellum,    symptoms    of    affections   of, 

1020 
Cerebral  localization,  1011 
basal  centres,  1018 
cortical,  1015 
medullary,  1019 
hemorrhage,  1053 
thrombosis  and  embolism,  1054 
( 'erebro-spinal  fever.     See  Meningitis. 
Chalicosis,  551 


1066 


INDEX. 


Charcot-Leyden  crystals  in  nasal  discharge, 
426 
in  sputum,  526,  546 
Chest  in  adenoid  disease,  715 
angles  of,  471 
auscultation  of,  502 
barrel-shaped,  477 
bilateral  diminution  in  size  of,  480 

enlargement  of,  477 
in  chronic  interstitial  pneumonia,  550 

pleural  effusion,  576 
counting  the  ribs  of,  472 
deficient  expansion  of,  487 
deformities  of,  483 
fluoroscopic  examination  of,  488 
fluctuation  in,  492 
inspection  of,  473 

local  changes  in  size  and  shape  of,  485 
mensuration  of,  515 
movements  of,  476 
in  disease,  486 
palpation  of,  490 
percussion  of,  492 
phthisical,  480 

regions  and  landmarks  of,  471 
respiratory  capacity  of,  516 
rhachitic,  172,  480 
shape  of  normal,  475 
topographical  anatomy  of,  472 
transverse  groove  in,  483 
unilateral  changes  in  shape  of,  583 
Cheyne-Stokes  respiration,  487 
Chickenpox,  253 
Chills,  191 

malarial,  280 
Chin-jerk,  985 
Chlorosis,  392 
Choked  disk,  100 
Cholangitis,  862,  885 
Cholecystitis,  888 
Cholera,  Asiatic,  336 

diagnosis  of,  338 
spirillum  of,  338 
fascies  in,  81,  337 
infantum,  839 

bacilli  of  Booker  in,  836 
morbus,  839 
nostras,  840 

spirillum  of,  835 
Cholesterin  crystals  in  pus,  363 
in  sputum,  327 
in  urine,  954 
Choluria,  935 
Chorea,  1039 

as  a  sequel  to  rheumatism,  181 
in  heart  disease,  589 
movements  in,  983 
Choroiditis,  100 

Chvostek's  sign  of  tetany,  985,  1041 
Chyluria,  948 

Claudication,  intermittent,  979 
Clonic  spasms,  982 
Clonus,  ankle,  988 
patellar,  987 
wrist,  986 
Clubbed  fingers  in  thoracic  aneurism,  677 


Coin  test  in  pneumothorax,  577 
Colic,  hepatic,  817,  885 
intestinal,  816 
lead,  817 
renal,  817,  902 
uterine,  562 
Colitis,  chronic  ulcerative,  841 
Collapse,  65 

Colon,  dilatation  of,  732,  824 
Color  index  of  blood,  385 
Coma,  diabetic,  958 

in  heart  disease,  589 
uraemic,  956 
Comma  bacillus,  338 
Congestion.     See  Hyperemia,  402. 
Conjunctiva,  the,  96 
Constipation,  822 

Consumption.     See  Tuberculosis,  pulmon- 
ary, 555. 
galloping,  552 
Convulsions,  983 

in  heart  disease,  589 
uraemic,  956 
Coprolalia,  1040 
Cor  bovinum,  657 
Cornea  in  general  diagnosis,  96 
Coronary  arteries,  disease  of,  653 
Corrigan's  pulse,  658 
Coryza,  acute,  427 
syphilitic,  429 
Costal  angle  in  rickets,  481 
Cough  in  aneurism  of  aorta,  676 
in  bronchiectasis,  566 
in  capillary  bronchitis,  546 
characteristics  of,  465 
in  chronic  bronchitis,  544 
dry,  465 

in  gastric  disease,  773 
in  heart  disease,  588 
laryngeal,  435 
in  mediastinal  disease,  684 
moist,  465 

in  nasal  disease,  420 
nervous,  436 
in  pertussis,  466 
in  phthisis,  560 
in  pleurisy,  575 
of  puberty,  465 
in  pulmonary  affections,  464 
reflex  and  central,  464 
Coxalgia  distinguished  from  appendicitis, 

743 
Cracked-pot  sound,  501 

in  pneumothorax,  577 
Cramps  in  uraemia,  957 
Cranial  nerves,  location  of  nuclei  of,  1020 

symptoms  of  affections  of,  1025 
Craniotabes,  87 

Cranium,  auscultation  and  percussion  of,  87 
Crepitation,  510 
Cretins,  facial  appearance  of,  82 
Crises  of  pain,  44 

in  tabes  dorsalis,  45,  800 
Croup,  diagnosis  of,  442,  443 
Culture  media,  242 
Curschman's  spirals,  525,  546 


INDEX. 


1067 


Cyanosis,  122 

in  capillary  bronchitis,  546 

in  emphysema,  £64 
Cylindroids,  945 
Cyrtometer,  515 
Cysticercus  of  skin,  158 
Cystin  in  urine,  953 
Cysts,  hydatid,  366 

of  kidney,  367 

ovarian,  367 

pancreatic,  367 


DEAF-MUTISM,  hysterical,  109 
Deafness  in  adenoid  disease,  714 
hysterical,  109 
in  nasal  affections,  420 
nervous,  108 
Decubitus,  68 

(abed-sore),  409,  1007 
Degeneration,  fatty,  amyloid,  etc.,  410 
Delirium,  1010 
acute,  1056 
in  uraemia,  956 
Delusions,  1011 
Dengue,  267 

Dental  arch  in  thumb-sucking,  687 
Dermatitis  distinguished  from  erysipelas, 

311 
Diabetes  insipidus,  916 
mellitus,  933 

acetonemia  in,  958 
asthma  in,  461 
bronzing  in,  126 
neuralgia  in,  48 
Diaceturia,  936 
Diagnosis,  bacteriological,  229 

conditions  rendering  it  impossible,  19 
data  upon  which  based,  18 
Diaphragm,  movements  of,  476 
paralysis  of,  461 
phenomenon  of  Litten,  477 
Diarrhoea,  catarrhal,  819 
chronic,  822 
in  gastric  disease,  773 
membranous,  822 
nervous,  821 
stools  in,  820 
uraemic,  957,  965 
Diatheses,  varieties  of,  66 
Diazo-reaction  in  typhoid  fever,  294 
Dietl's  crises,  908 
Diphtheria,  330 
bacillus  of,  333 
diagnosis  of,  333 
distinguished  from  scarlet  fever,  260 

from  tonsillitis,  713 
false  membrane  in,  332 
heart  in,  333 
laryngeal  stenosis  in,  332 
sequelae  of,  333 
uraemia  in,  332 
Diplococcus    intracellularis    meningitidis, 
329 
pneumoniae.    Sec  Micrococcus  Lanceo- 
latus. 


Diplophonia,  433 

Diplopia,  94 

Dipping  in  abdominal  palpation,  730 

Distoma  hepaticum,  833 

Dropsy.     $ee  (Edema. 

ovarian,  745 
Drowsiness  in  dyspepsia,  773 
Dulness  on  percussion,  496 
Duodenal  catarrh,  839 

ulcer,  841 
Dupuytren's  contraction,  115 
Dysentery,  amoeba  of,  344 

amoebic  or  tropical,  342 

catarrhal,  341 

diphtheritic  and  gangrenous,  345 
Dyspepsia,  atonic,  803 

flatulent,  804 

in  heart  disease,  589 

nervous,  803 

reflex,  805 
Dysphagia,  435 

in  aneurism  of  aorta,  720 

in  disease  of  larynx,  430 
of  pharynx,  708 
of  oesophagus,  721 

from  foreign  body  in  oesophagus,  722 

mediastinal  tumor,  720 

from  paralysis  of  oesophagus,  724 

in  pericardial  effusion,  645 

from  pressure  on  oesophagus,  720 
Dysphasia,  1006 
Dysphonia,  432 
Dyspnoea  in  adenoid  disease,  716 

in  aortic  aneurism,  677 

in  asthma,  459 

in  capillary  bronchitis,  545 

causes  of,  456 

dyspeptic,  463 

in  emphysema,  564 

expiratory,  435,  464 

in  gastric  disease,  773 

in  heart  disease,  588 

inspiratory,  434 

in  laryngeal  disease,  433  ■ 

in  mediastinal  tumor,  684 

in  nephritis,  962 

in  obstruction  of  trachea  or  bronchi, 
456 

in  pericardial  effusion,  645 

in  pharyngeal  disease,  708 

in  phthisis,  560 

rate  of  respiration  in,  463 

in  retropharyngeal  abscesses,  717 

uraemic,  957,  965 
Dystrophies  of  connective  tissue,  156 

muscular,  163 


EAR-cough,  465 
discharge  from,  107 
hsematoma  of,  107 
tophi  in,  107 
Echolalia,  1006 
Eczema  distinguished   from    chickenpox, 

255 
Elastic  fibres  in  sputum,  523 


1068 


INDEX. 


Electrical  diagnosis,  991 
Elephantiasis,  162 

Embolism,  in  aortic  obstruction,  659 
in  arterio-sclerosis,  403 
capillary,  404 
fat  and  air,  404 
in  malignant  endocarditis,  651 
of  mesenteric  arteries,  815 
pulmonary,  541 
Embryocardia,  627 

in  dilatation,  672 
Emphysema,  564 
atrophic,  566 

barrel-shaped  chest  in,  479 
breath-sounds  in,  505 
distinguished  from  pneumothorax,  578 
interlobular,  566 
physical  signs  of,  565 
subcutaneous,  155,  719 
Emprosthotonos,  70 
Empyema,  572 

necessitatis,  572 
pulsating,  574 

distinguished  from  aneurism,  683 
Encephalitis,  1055 
Endocarditis,  650 
chronic,  653 
malignant,  651 

from  pneumococcus  infection,  318 
in  rheumatic  fever,  180 
in  septicaemia,  227 
simple,  650 
Enophthalmos,  92 
Enteralgia,  816 
Enteritis,  membranous,  822 
Entero-colitis,  840 
Enteroptosis,  748 
Enuresis  in  adenoid  disease,  715 
Eosinophilia,  382 
Ephemeral  fever,  212 
Epiglottis,  inflammation  of,  435 
Epilepsy,  1058 

focal  or  Jacksonian,  982,  1059 
Epistaxis,  426 
Ergotism,  215 
Eructations,  802 
Eruption  in  measles,  261 
in  pharynx,  709 
in  scarlet  fever,  259 
in  syphilis,  269 
in  typhoid  fever,  296 
in  typhus  fever,  248 
in  varicella,  254 
in  variola,  251 
Erysipelas,  309 
Erythema,  135 

of  infectious  diseases,  139 
medicinal,  139 
multiforme,  137 
nodosum,  138 

non-contagious,  causes  of,  136 
Erythromelalgia,  115 
Exophthalmic  goitre,  88 

pulse  in,  608 
Exophthalmos,  92 
Exploratory  puncture.     See  Aspiration. 


Exudations,  360 

chylous,  365 

hemorrhagic,  364 

purulent,  360 

seropurulent,  364 

serous,  365 
Eye,  affections  of  muscles  of,  92 

in  scurvy,  188 
Eyelids,  oedema  of,  91 


FACE  in  acromegalia,  169 
in  adenoid  disease,  82,  714 

in  erysipelas,  310 

hemiatrophy  of,  83 

in  hereditary  syphilis,  82 

in  hydrocephalus,  82 

in  nervous  diseases,  82 

in  osteitis  deformans,  170 

in  peritonitis,  751 

in  scurvy,  188 

in  tetanus,  352 

in  uraemia,  959 

in  yellow  fever,  304 
Family  relations  in  the  etiology  of  disease, 

26,  27 
Farcy,  335.     See  also  Glanders. 
Fascies  of  various  diseases,  81 
Fat  in  stools  in  pancreatic  disease,  894 

in  urine,  947 
Fauces,  examination  of,  708 
Fecal  abscess,  743 

impaction,  737,  824  _ 

epigastric  pulsation  in,  597 
Feces,  825  _ 

bacteria  in,  835 

blood  in,  827,  829  _ 

chemical  examination  of,  836 

gallstone  in,  827 

microscopical  examination  of,  828 

protozoa  in,  830 

vermes  in,  831 
Feigned  disease,  detection  of,  33.     See  also 

Pain,  Simulated. 
Festination,  1040 
Fever,  arterial,  tension  in,  199 

aseptic,  209 

ataxic  state  in,  200 

in  auto-intoxication,  211 

in  carcinoma,  228 

cerebral  symptoms  in,  199 

cerebro-spinal,  326 

clinical  causes  of,  203 

course  and  stages  of,  196,  204 

daily  range  of,  198 

defervescence  of,  mode  of,  197,  204 

eruptive,  247 

glandular,  265 

hepatic  intermitting,  206 

influence  of  age  on,  204 

intermittent,  280 
in  phthisis,  558 

in  intoxication,  209 

malarial,  279 

Malta,  305 

miliary,  272 


INDEX. 


1069 


Fever,  in  morphinism,  212 

onset,  mode  of,  197 

pathology  of,  191 

in  phthisis,  558 

pulse-rate  in,  199,  211 

in  reaction  from  apoplexy,  202 

recrudescence  of,  198 

relapsing,  274 

renal,  paroxysmal,  905 

respiration  in,  199,  211 

rheumatic,  178 

scarlet,  255 

in  septicaemia,  210 

simple  continued,  212 

sudden  fall  of,  205 
onset  of,  204 

in  sunstroke,  211 

in  suppuration,  408 

symptoms  of,  19S 

in  syphilis,  206,  229 

tongue  in,  701 

in  trichinosis,  354 

in  tuberculosis,  205 

types  of,  195 

typhoid,  289 

in  typhoid  fever,  204 

typhoid  state  in,  199 

typhus,  247 

urinary  intermitting,  206 

yellow,  303 
Fibrinous  coagula  in  sputum,  524 
Fibroid  change  in  tissues,  411 

tumors  of  uterus,  745 
Filaria  sanguinis  hominis,  388 

in  urine,  948 
Fits,  64 

Flagellar,  staining  of,  158 
Flat-foot,  pain  in,  54 
Flatulency,  769 

in  diarrhoea,  821 
Flint,  murmur  of,  658 
Fluctuation  in  abdomen,  730 
Fontanelles,  87 
Foot-and-mouth  disease,  273 
Freckles  in  rheumatoid  arthritis,  126 
Fremitus,  friction,  491 
.hydatid,  883 

peritonea],  754 

vocal,  490 
Friction  fremitus,  491 

in  pericarditis,  643 

sound, 511 

distinguished   from   pleural  fric- 
tion, 642 
from  rales,  510 
from  vascular  murmur,  642 
mediastinal,  650 
in  pericarditis,  629,  641 
pleural,  511 
Friedreich's  ataxia,  1044 

respiratory  change  of  sound,  515 
Funnel- breast,  483 


Gall-bladder,  cancer  of,  889 

enlargement  of,  887 

palpation  of,  868 

tumors  of,  888 

diagnosis  of,  889 

distinguished  from  movable  kid- 
ney, 909 
Gallstones,  885 

accidents  resulting  from,  887 

colic  due  to,  817 

obstruction  of  common  duct  by,  886 
Gangrene,  409 

of  lung,  563 

haemoptysis  in,  467 

from  trophic  disturbance,  1007 
Gastralgia,  770,  771,  779 

neurasthenic,  800 
Gastrectasis,  807 
Gastric  crises,  769 
Gastritis,  acute,  795 
pain  in,  771 

chronic,  805 

distinguished  from  ulcer  and  can- 
cer, 811 

mycotic  and  diphtheritic,  796 

phlegmonous,  796 

toxic,  796 
Gastrodiaphany,  774 
Gastrodynia,  770 
Gastroxynsis,  802 
Gerhardt's  change  of  sound,  515 
Girdle  pain,  55 
Glanders,  335 

bacillus  of,  336 

diagnosis  of,  336 

mallein  test  for,  336 
Glands,  lymphatic,  enlargement  of,  159 
Glandular  fever,  265 
Glenard's  disease,  748 
Globulin  in  urine,  937 
Globus  hystericus,  769,  1061 
Glossitis,  696 

dissecting,  698 
Glycosuria,  933,  935 

in  pancreatic  disease,  894 
Goitre,  exophthalmic,  88 
Gonococcus,  363 

in  blood,  308 
Gonorrhoeal  septicaemia,  307 
Gout,  183 

acute  articular,  184 

blood  in,  184 

chronic,  184 

gastric  symptoms  in,  762 

hand  in, 114 

relation  to  lithreinia,  856 

retrocedent,  184 

teeth  in,  691 
Gram's  stain,  241 
Gums  in  cachexia,  690 

in  lead-poisoning,  691 

in  scurvy,  189,  691 


GAIT  in  disease,  70 
Gall-bladder,  aspiration  of, 


II 


ABIT  spasm,  1040 

Habits  in  etiology  of  disease,  25 


1070 


INDEX. 


Hematemesis,  792 

distinguished  from  haemoptysis,  793 
in  gastric  ulcer,  812 

cancer,  810 
in  hepatic  cirrhosis,  676 
Hematocele,  pelvic,  744 
Hematoidin  crystals,  364 

in  pus,  527 
Hematokrit,  378 
Hematoporphyrinuria,  936 
Hematuria,  928,  940 
malarial,  288 
from  overexertion,  904 
in  renal  calculus,  904 
cancer,  911 
Hemocytometer,  376 
Haemoglobin,  384 
Hemoglobinometers,  384 
Hemaglobinuria,  929 
Hemopericardium,  648 
Haemophilia,  129 

diagnosis  of,  130 
Haemoptysis,  468,  521.     See   ako  Hemor- 
rhage, pulmonary. 
Hemothorax,  593 
Hair  in  diagnosis,  85 
Hallucinations,  1011 
Hands  in  acromegaly,  170 
deformities  of,  110,  113 
swelling  of,  113 
Hanging-drop,  method  of  making,  241 
Harrison's  groove,  172 
Hay-fever,  420,  547 
Head  in  rickets,  173 
Headache,  anemic,  42 

character  of  pain  in,  52 
chronic,  causes  of,  52 
in  indigestion,  770 
in  infectious  fevers,  201 
in  inflammation  of  frontal  bones,  49 
lithemic,  770,  856 
ocular,  51 
in  syphilis,  52 
in  uremia,  956 
Hearing  impaired  by  drugs,  108 

tests  for,  107 
Heart,  aneurism  of,  656 

area  of  absolute  dulness,  614 
change  in,  615 
graphic  record  of,  619 
in   pericardial    effusion, 
646 
of  deep  dulness,  616 
arrhythmia  of,  587 
auscultation  of,  619 
dilatation  of,  670 
acute,  671 

area  of  dulness  in,  616 
valve,  shock  in,  603 
disease  of,  etiological  factors  in,  582 
bradycardia  in,  609 
cough  in,  588 
dropsy  in,  588 
dyspeptic  symptoms  in,  589 
dyspnea  in,  588 
general  pathology  of,  580 


Heart,  disease  of,  hemoptysis  in,  467,  588 
inspection  in,  592 
kidneys  in,  589 
nervous  symptoms  in,  588 
pain  in,  583,  585 
precordia  in,  592 
retraction  of  interspaces  in,  595 
in  emphysema,  565 
fatty  overgrowth  of,  656 
hypertrophy  of,  667 

area  of  dulness  in,  616 
diagnosis  of,  670 
impulse  in,  593,  602 

epigastric,  597 
physical  signs  of,  668 
in  valvular  disease,  657 
impulse  of,  592 

absence  of,  594 

additional,  595 

area  of,  595 

changes  in  position  of,  in  health, 

593 
in  dilatation,  671 
displacement  of,  593 
palpation  of,  601 
strength  of,  602 
inflammation  of  muscles  of.     See  Myo- 
carditis, 
irregular,  in  pericardial  effusion,  645 
irritable,  587 
murmurs.     See  Murmurs, 
neuroses  of,  581 
palpitation  of,  586 
percussion  of,  614 
pleximetric,  617 
repercussion  of,  618 
physiology  of,  591 
in  pleural  effusion,  571 
right  side  of,  hypertrophy  of,  669,  670 
rupture  of,  656 
sounds,  aortic  accentuated,  625 
diminished,  626 
mitral,  diminished,  626 
normal,  620 

diastolic,  623 
differentiation  of,  623 
systolic,  621 
transmission  of,  623 
pulmonary,  accentuated,  625 

diminished,  626 
reduplication  of,  627 

false,  629 
systolic,  accentuation  of,  624 
topography  of,  590 
valves  of,  position  of,  591 
valvular  disease  of,  chronic,  656 

effects  on  heart  and  pulse,  639 
gastric  symptoms  in,  761 
weakness  of,  sphygmogram  in,  612 
Heat  exhaustion,  212 
Heberden's  nodes,  114 
Hemianopsia,  102 
Hemiplegia,  977 
Hemorrhage,  405 

in  central  nervous  disease,  131 
cerebral,  1053 


INDEX. 


1071 


Hemorrhage,  gastric,  792 

distinguished     from     pulmonary 
hemorrhage,  469 
gastro-intestinal,  in  portal  congestion, 

858 
internal,  symptoms  of,  406 
intestinal,  824 

in  duodenal  ulcer,  841 
from  mucous  membrane  of  mouth,  687 
from  cesophagus,  719 
from  pharynx,  709 
pulmonary,  466 

in  capillary  bronchitis,  546 

character  of  blood  in,  468 

in  chronic  interstitial  pneumonia, 

551 
distinguished  from  other  forms, 

469,  793 
in  heart  disease,  588 
in  infarction  of  lung,  542 
in  phthisis,  553,  560 
symptoms  of,  468 
in  scurvy,  189 
in  thoracic  aneurism,  677 
into  skin,  126 

in  anaemia,  127 
in  fever,  127 
in  jaundice,  862 
in  septicaemia,  227 
toxic,  131 
in  uraemia,  959 
Hemorrhoids,  853 
Hepatic  colic,  885 

fever,  864 
Hepato- pulmonary  abscess  from  dysentery, 

346 
Heredity,  transmission  of  nervous  diseases 
by,  961 
pulmonary  diseases  by,  455 
Hernia  as  a  cause  of  intestinal  obstruction, 

859 
Herpes  labialis,  138 

zoster,  187,  1006 
Hiccough  in  gastric  diseases,  773 
Hippocratic  fascies,  81 
Hippus,  97 

Hodgkin's  disease,  160,  399 
Hutchinson's  teeth,  270,  691 
Hydatid  cyst  of  liver,  883 

of  lung,  568 
Hydrocephalus,  1056 

physiognomy  of,  86 
Hydronephrosis,  911 

distinguished    from    hydatid   cyst    of 
liver,  884 
Hydropericardium,  648 
Hydrophobia,  273 
Hydrothorax,  573 
Hypaesthesia,  971 
Hypalgesia,  972 
Hyperacidity,  gastric,  801 
Hyperaemia,  active,  401 

passive  or  venous,  402 
Hyperaesthesia,  971 
of  stomach,  798 
Hyperalgesia,  972 


Hyperorexia,  799 
Hyperpyrexia,  194 
Hyperthermoaesthesia,  973 
Hysteria,  1059 

detection  of,  89 

joint  in,  189 

pseudo-angina  in,  586 
Hysterical  mimicry  of  disease,  33 


[DIOCY,  1010 
L     Impetigo,  255 

Impulse  of   heart,  592.     See  Heart,  im- 
pulse of. 
Indicanuria,  935 

in  empyema,  573 

in  gastric  cancer,  810 

in  intestinal  obstruction,  849 
Indigestion,  gastric,  797 

intestinal,  836 
Infarction,  404 

of  lung,  467 
infections,  classification  of,  219 

etiology  of,  218 

fever  in,  203 

history  in  diagnosis  of,  246 

pulse  in,  608 

terminal,  228 
Inflammation,  407 

of  mucous  membrane,  408 

of  serous  membrane,  408 
Influenza,  323 

bacillus  of,  536 

diagnosis  of,  325 

ophthalmic  neuralgia  in,  48 
Inheritance  in  the  etiology  of  disease,  27 
Inoculation  of  animals,  244 
Intermittent  fever.      See  Malarial  Fever, 

280. 
Intestines,  amyloid  degeneration  of,  841 

cancer  of,  852 

catarrh  of,  acute,  837 
chronic,  840 

disease  of,  physical  signs  in,  825 

obstruction  of,  acute,  causes  of,  843 
symptoms  of,  846 
chronic,  causes  of,  844 
symptoms  of,  846 
diagnosis  of,  847,  850 

parasites  in,  814 

tuberculosis  of,  842 

ulceration  of,  841 
Intoxication,  alcoholic,  214 

fever  in,  209 

by  food,  213 

by  grain,  214 

by  lead,  215 
Intussusception,  744,  844,  849 
Iritis,  97 


"JAUNDICE,  121 
J      acute  febrile,  271 
bradycardia  in,  609 
catarrhal,  862,  866 
in  cholelithiasis,  886 


1072 


INDEX. 


Jaundice,  in  congestion  of  liver,  859 

fever  in,  864 

hematogenous,  863 

hepatogenous,  862 

infantile,  865 

malignant,  864 

symptoms  of,  861 
Joints,  crepitus  in,  177 

enlargement  of,  176 

fluctuation  in,  177 

hysterical,  189 

movability  of,  177 

pain  in,  176 

pathological  processes  in,  177 

position  assumed,  177 

in  rheumatic  fever,  179 

in  tabes  dorsalis,  189 

trophic  lesions  of,  1008 

tuberculosis  of,  178 

KERNIG'S  sign  of  cerebro-spinal  fever, 
330,  1053 
Kidney,  abscess  of,  913 
congestion  of,  960 
cystic,  911,  967 
degeneration  of,  967 
enlargement  of,  910 

distinguished  from  enlarged  spleen, 
892 
granular,  964 
in  heart  disease,  589 
horseshoe,  909 
hydatid  cyst  of,  914 
inflammations  of.     See  Nephritis, 
movable,  907 

distinguished  from  tumor  of  gall- 
bladder, 889 
pain  in  disease  of,  901 
palpation  of,  906 
percussion  of,  907 
sarcoma  and  carcinoma  of,  910 
topography  of,  906 
Knee-jerk,  986 
Koch's  postulates,  218 
Koplik's  sign  of  measles,  261 

"I  AGOPHTHALMOS,  92,  1026,  1054 
JL     Landry's  paralysis.  1050 
Laryngismus  stridulus,  434 

in  rickets,  174 
Laryngitis,  acute,  441 

with  stenosis,  442 

chronic,  432 

membranous  and  diphtheritic,  443 

spasmodic,  443 

submucous,  445 
Laryngoscopy,  437 
Larynx,  color  of  mucous  membrane  in,  439 

cough  in  disease  of,  435 

dysphagia  in  disease  of,  435 

dyspncea  in  disease  of,  433 

foreign  bodies  in,  distinguished  from 
whooping-cough,  445 

hemorrhage  from,  436 


Larynx,  inco-ordination  of  muscles  of,  436 
lupus  of,  440 
cedema  of,  443 

distinguished   from   membranous 
laryngitis,  444 
pain  in,  431 

paresthesia,  hyperesthesia,  and  anes- 
thesia of,  432 
paralysis  of  muscles  of,  445 
perichondritis  of,  431 
syphilis  of,  439,  440,  448 
tuberculosis  of,  439,  440,  447_  _ 

distinguished  from  syphilis,  448 
tumors  of,  440,  447 
Lathyrism,  215 
Lead- poisoning,  215 

colic  in,  817 
Leprosy,  349 

in  mouth,  694 
organism  of,  349 
Leptomeningitis,  1052 
Leptothrix  buccalis,  690 

in  sputum,  529 
Leucin  in  urine,  953 
Leucocythemia,  396 
acute,  399 
blood  in,  397 
lymphatic  form  of,  399 
spleen  in,  892 

splenomedullary  form  of,  396 
Leucocytosis,  381 

absence  of,  in  typhoid  fever,  299 
in  infectious  disease,  238 
in  pneumonia,  315 
Leucopenia,  382 

Leukemia.     See  Leucocythemia,  396 
Linea  albicantes,  728 
Lipemia,  386 
Lipomata,  peritoneal,  733 
Lips  in  diagnosis,  85 
Lipuria,  947 
Lithemia,  855 

neuralgia  in,  48 
Liver,  abscess  of,  346,  872 
diagnosis  of,  874 
distinguished  from  cancer,  882 
acute  yellow  atrophy  of,  864 
amyloid  disease  of,  866,  880 
arterial  pulsation  of,  604 
auscultation  of,  868 
cancer  of,  880 

palpation  in,  867 
cirrhosis  of,  atrophic,  876 

collateral  circulation  in,  877 
gastric  symptoms  in,  762 
hypertrophic,  878 

distinguished    from    cancer, 
882 
syphilitic,  879 
congestion  of,  857 
constriction  of,  from  lacing,  867 
diminution  in  size  of,  869 
enlargement  of,  869 

conditions  with  which  confounded, 
870 
etiological  factors  in  disease  of,  859 


INDEX. 


1073 


Liver,  fatty,  866,  880 

floating,  867 

functional  disturbances  of,  855 

hydatid  disease  of,  883 
tumor  in,  867 

pain  in,  873 

palpation  of,  866 

syphilis  of,  879 

topographical  anatomy  of,  860 
Localization  of  lesions  of  nervous  system, 

1011 
Locomotor   ataxia.      See  Tabes   dorsalis, 

1043 
Logorrhoea,  1006 
Ludwig's  angina,  717 
Lumbago,  167 
Lumbar  puncture,  359 

in  cerebro- spinal  fever,  3'28 
Lung  or  lungs,  abscess  of,  563 

boundaries  of,  in  disease,  498 

collapse  of,  548 

congestion  of,  540 

cough  in  diseases  of,  464 

diminution  of  air  space  in,  458 

embolism  and  thrombosis  of,  541 

gangrene  of,  521,  563 

general  symptomatology  of  disease  of, 
452 

history  in  disease  of,  455 

hydatid  disease  of,  568 

neuroses  of,  540 

oedema  of,  540 

percussion  sounds  in  disease  of,  498 

relationship  of.  to  heart,  453 

size  of,  in  phthisis,  561 

topographical  anatomy  of,  473 

tuberculosis  of,  552.  See  Tuberculosis, 
pulmonary. 

tumors  of,  567 
Lupus  of  larynx,  440 
Lymphadenoma,  399 
Lymphangitis,  161 

in  septicaemia,  227 
Lymphatic  glands  in  leucocythaemia,  399 
Lymphatism,  162 
Lymphocytosis,  382 
Lymphosarcoma,  158,  160 


"WACROGLOSSIA,  700 

IU     Main  en  griffe,  1009 

Malarial  cachexia.  289 

neuralgia  in,  48 
spleen  in,  892 
fever,  279 

diagnosis  of,  283 
intermittent,  285 
irregular  forms  of,  285 
pernicious,  287 
Plasmodia  of,  282 
remittent,  287 

Mallein  test  for  glanders,  336 

Malta  fever,  305 

Mania,  1010 

McBurney's  point,  739 

Measles,  260 


Measles,  distinguished  from  scarlet  fever, 

259 
Meat- poisoning,  213 
Mediastinal  friction,  650 

tumors,  684 
Mediastinitis,  683 

Mediastino-pericarditis,  [indurative,  650 
Medicinal  rashes,  139 
Melaena,  825 
Melanaemia,  386 
Melancholia,  1011 
Melanuria,  954 
Meniere's  disease,  108,  1059 

station  in,  74 
Meningitis,  1052 

chronic  internal  spinal,  1048 
epidemic  cerebro-spinal,  326,  1047 
complications  and  sequela?  of,  328 
distinguished  from  typhoid  fever, 

302 
Kernig's  sign  of,  330 
lumbar  puncture  in,  328 
organism  of,  329 
symptoms  of,  327 
temperature  in,  326 
from  pneumococcus  infection,  318 
syphilitic,  1047 
Mensuration  of  chest,  515,  517 
Mental  disturbances,  1010 
Meralgia  paraesthetica,  1043 
Merycismus,  803 
Metallic  tinkling  in  chest,  512 
in  pneumothorax,  578 
Metatarsalgia,  54 

Micrococci,  general  characteristics  of,  220 
Micrococcus  lanceolatus,  363,  534 
.Micturition,  frequent,  906 
Migraine,  49,  1059 
Miliaria,  140 
Miliary  fever,  272 
Milk-poisoning,  214 

sickness,  273 
Mitral  area,  632 

insufficiency,  660 

broken  compensation  in,  661 
physical  signs  of,  662 
stenosis,  663 

physical  signs  of,  664 
pulmonary  second  sound  in,  626 
thrill  in,  603 
Monoplegia,  979 
Morphinism,  212 
Morphoea,  157 

Morton's  painful  affection  of  foot,  54 
Mor van's  disease,  1051 
Motor  points  of  muscles,  994 
Mountain  fever,  identitv  with  typhoid,  303 
Mouth-breathing,  417,  426 

color  of  mucous  membrane  of,  687 
dryness  of,  686 

hemorrhage    into    mucous  membrane 
of,  687 
Mumps,  84,  265 
Murmurs  of  anaemia,  637 
in  aortic  aneurism,  680 
area,  633,  634 


68 


1074 


IXDEX. 


Murmurs  in  aortic  obstruction,  659 
regurgitation,  658 
arterial,  640 
double,  641 
from  pressure,  641 
cardio-muscular,  638 
-respiratory,  638 
character  of,  635 
combined,  640,  667 
disappearance  of,  637 
of  Flint,  658 

influence  of  pressure  on,  638 
loudness  of,  636 
at  mitral  area,  633,  634 
of  mitral  insufficiency,  662 

stenosis,  664 
position  of  maximum  intensity  of,  631 
presystolic,  664,  665 
at  pulmonary  area,  634 
in  relative  incompetency,  637 
time  of,  632 
transmission  of,  635 
in  tricuspid  stenosis,  666 
at  tricuspid  area,  633,  634 
vascular,  629 
Muscular  atrophy,  164,  989 
diagnosis  of,  164 
peroneal  type  of,  164 
progressive,  1034 

consecutive     to     disease     of 

nerves,  1037 
spinal,  1038 
table  of,  165 
hypertrophy,  166 
ossification,  167 

paralysis,  pseudohypertrophic,  1036 
tone,  983 
Muscles,  extra-ocular,  actions  of,  92 
affections  of,  93 
disturbed  balance  of,  95 
functional  classification  of,  1027 
lack  of  tone  in,  78 
Myalgia,  167 

distinguished  from  neuralgia,  45 
occipital  and  frontal,  47 
Mydriasis,  98 
Myelitis,  acute,  1049 
chronic,  1049 
disseminated,  1049 
Myelocytes,  383 
Myocarditis,  654 
Myoidema,  163 
Myosis,  98 
Myositis,  166 
Myotonia  congenita,  166 
Myotonic  reaction,  999 
Myxoedema,  154 


"VTAILS  in  diagnosis,  116 

IN      disturbed  nutrition  of,  1007 

Nasal  discharge,  a  portent  of  uraemia,  418 

Nasopharynx,  adenoid  vegetations  in,  714 

Nausea  in  gastric  disease,  764 

in  headache,  52 

ursemic,  957 


Necrosis  of  tissue,  409 
Nephritis,  acute  exudative  or  glomerulo, 
961 
with  pus  formation,  962 
productive,  962 
chronic  productive,  962 

without  exudation,  964 
erythema  in,  140 
gastric  symptoms  in,  762 
interstitial,  964 
retinitis  in,  100 
suppurative,  966 
tubercular,  967 
Nephrolithiasis,  902 

colic  in,  817 
Nervousness,  34 
Neuralgia,  1041 
causes  of,  53 
character  of  pain  in,  47 
distinguished  from  myalgia,  45 
intercostal,  distinguished   from   pleu- 
risy, 470,  576 
from  local  irritation,  47 
malarial,  285 
points  of  tenderness  in,  45 
reflex  from  eye,  teeth,  or  tongue,  48 
secondary,  49 
symptoms  of,  52 
from  systemic  conditions,  48 
trigeminal,  47 
Neurasthenia,  1061 
Neurasthenic  gastralgia,  S00 
Neuritis,  1047 

of  optic  nerve,  100 
Neuromata  multiple,  1046 
Neurons,  motor,  lesions  of,  1013 

sensory,  lesions  of,  1012 
Neuroses,  gastric,  797 

of  lungs  and  bronchi,  540 
of  occupation,  1041 
reflex,  420 
Neusser's  granules,  383 
Night-blindness,  189 

restlessness  in  adenoid  disease,  716 
sweats  of  phthisis,  559 
Nigrities,  696 
Nodes  on  bone,  175 
Nose,  426 

appearance  of  mucous  membrane  of, 

423 
auxiliary  cavities  of,  disease  of,  429 
deformity  of,  421 
examination  of,  421 
obstruction  of,  420 
polypi  in,  424 

relation  of  disease  of,  to  asthma,  420 
ulceration  in,  424 
Nucleo-albumin  in  urine,  928 
Nyctalopia,  189 
Nystagmus,  95 

OBJECTIVE  symptoms,  methods  of  ob- 
serving, 60 
Obstipation,  822,  825 
Occipital  neuralgia,  1042 


INDEX. 


1075 


Occupation  in  etiology  of  disease,  26 

neuroses  of,  10-11 
(Edema,  angio-neurotic,  153 

of  arms  and  thorax,  151 

diagnosis  of,  150 

of  feet,  151 

general,  153 

in  heart  disease,  5S8 

inflammatory,  150 

local,  150 

significance  of,  152 

of  lungs,  540 

mode  of  recognition  of,  149 

in  nephritis,  961 

pathology  of,  148 

in  trichinosis,  151,  354 

in  uraemia,  959 
Oesophagitis,  721 
Oesophagus,  abscess  of,  721 

carcinoma  of,  722 

dilatation  of,  723 

examination  of,  719 

foreign  body  in,  722 

obstruction  of,  720 

spasm  of,  723 

stricture  of,  721 
Oidium  albicans,  690 

in  sputum,  529 
Oligochromasia,  585 
Oligocythemia,  379,  395 
Ophthalmoplegia,  105 
Ophthalmoscopy,  99 
Opisthotonos,  70 
Opium  habit,  212 

Optic  atrophy  in  tabes  dorsalis,  101 
Osteitis  deformans,  170 
Osteo-arthropathy,  pulmonary,    bones  in, 

171 
Osteomalacia,  174 
Osteomyelitis,  175 
Ovarian  cysts,  367 

diagnosis  of,  745 
Oxaluria,  952 
Oxyuris  vermicularis,  833 

symptoms  of,  815 
Ozsena,  425 

in  glanders,  335 


PACHYMENINGITIS,    external    cere- 
bral, 1052 
hypertrophic  cervical,  1047 
Pain  in  abdomen,  726 

in  appendicitis,  739,  818 

in  arms,  54 

character  of  onset  of,  41 

in  chest  in  phthisis,  360 

crises  of,  44 

deep  seated,  44 

definition  of,  36 

in  diarrhoea,  821 

duration  of,  41 

in  epigastrium,  584,  770 

in  relapsing  fever,  275 

in  uraemia,  957 
estimation  of,  38 


Pain,  etiology  of,  37 

in  extra-uterine  pregnancy,  817 

in  foot  in  flat-foot,  54 

in  gastric  disease,  771,  775,  818 

ulcer,  812 
general,  43 

in  rickets,  173 
girdle,  55 
in  heel  in  gout,  54 
indicating  location  of  disease,  43 

nature  of  disease,  42 
inframammary,  56 
intermittent  or  remittent,  41 
in  intestinal  obstruction,  818 
in  joints,  176 
kinds  of,  42 
in  larynx,  431 
in  legs,  53,  54 

in  cerebral  hemorrhage,  54 
in  loins,  57 
measurement  of,  40 
modes  of  expression  of,  37 
in  mouth,  686 
muscular  in  trichinosis,  354 
in  nasal  disease,  419 
in  oesophagus,  718 
in  otitis  media,  49 
in  pancreatic  disease,  818 
paroxysmal,  42 
in  pericarditis,  643 
periodic,  42 
peripheral  of  central   origin,  [36,  44, 

54 
in  peritonitis,  750,  818 
in  pharynx,  707 
in  pleurisy,  469,  569,  575 
in  praecordia,  583 
in  rectum,  817 
referred,  43,  44 
in  scalp,  46 
sense,  973 
in  shock,  40 

simulated,  39.     See  also  Feigned  dis- 
ease, 
in  spine,  55,  56 

in  and  behind  sternum,  55,  175 
superficial,  43 
sympathetic,  43 
in  thoracic  aneurism,  676 
in  vertebral  disease,  819 
visceral,  973 
Palpitation  of  heart,  586 
in  gastric  disease,  773 
in  litha?mia,  856 
Palsies,  local  and  multiple,  978 
Pancreas,  cancer  of,  894 

distinguished  from   hepatic  can- 
cer, 882 
cysts  of,  898 

distinguished  from  enlarged  liver, 
871 

fluid  in,  367 
diseases  of,  893 
hemorrhage  into,  895 
tumors  of,  746,  894 
Pancreatitis,  acute  hemorrhagic,  895 


1076 


INDEX. 


Pancreatitis,  acute  hemorrhagic,  distin- 
guished from  acute  intestinal  ob- 
struction, 851 

gangrenous,  897 

suppurative,  897 
Papillitis,  100 
Papilloma  of  larynx,  440 
Paradoxical  contraction  of  Westphal,  989 
Paresthesia,  970 
Paralysis,  976 

agitans,  1040 

bulbar,  1054,  1056 

crossed,  1014 

diphtheritic,  333 

Landry's,  1050 

local,  in  uraemia,  957 

myopathic,  978 

of  orbital  nerves,  106 

periodic,  1039 

pseudo-hypertrophic  muscular,  1036 
gait  in,  72 
station  in,  74 
Paramyoclonus  multiplex,  166,  1040 
Paranoia,  1011 
Paraphasia,  1001 
Paraplegia,  978 

hysterical,  gait  in,  72 

primary  spastic,  1046 
gait  in,  71,  72 

from  Pott's  disease,  1048 
Parasites,  anaemia  due  to,  391 

in  intestines,  814 

in  mouth,  693 

in  sputum,  528 
Paresis,  979 

general,  of  the  insane,  1057 
Parosmia,  419 
Parotitis,  epidemic,  84 

symptomatic,  718 
Pectoriloquy,  413 
Peliosis  rheumatica,  129 
Pellagra,  215 
Percussion,  492 

auscultatory,  497 

of  chest,  amphoric  sound  in,  501 
cracked-pot  sound  in,  501 
dulness  in,  500 
hyper-resonance,  498 
impaired  resonance,  499 
normal  sounds  in,  494 
tympany  in,  499 

respiratory,  497 

superficial  and  deep,  497 
Pericardial  friction  sound,  603,  629 

distinguished  from  pleural,  630 
Pericarditis,  641 

acute  fibrinous,  641 

adhesive,  648 

with  effusion,  644 
impulse  in,  593 

pain  in,  584 

physical  signs  of,  645 

from  pneumococcus  infection,  318 
Pericardium,  aspiration  of,  358 
Perinephritic  abscess,  913 
Periostitis,  175 


Peristalsis,  visible,  729,  774 
Peritonitis,  750 

chronic,  754 

diagnosis  of,  752 

in  dysentery,  347 

hysterical,  753 

localized,  753 

tuberculous,  755 
Perspiration  in  crisis  of  pneumonia,  145 

diminished,  146 

increased,  145 

local,  146 

in  miliary  fever,  272 

in  phthisis,  559 

in  rheumatic  fever,  145,  180 

in  rickets,  173 

in  tuberculosis,  145 
Pertussis,  265 

bacillus  of,  536 

cough  in,  466 
Petit  mal,  1058 
Phantom  tumor,  734,  1061 
Pharyngitis,  acute,  716 

chronic,  717 

lithsemic,  856 

phlegmonous,  717 

rheumatic,  717 
Pharynx,  adenoids  of,  714 

anaesthesia  of,  710 

color  of  mucous  membrane  of,  709 

examination  of,  708 

pseudomembrane  on,  710 

spasm  of,  708 

ulcers  in,  709 
Phlebitis  in  septicaemia,  227 
Phlegmasia  alba  dolens,  403 
Phosphates  in  urine,  950 
Phosphorus-poisoning,  865 
Photophobia,  92 
Phrenic  nerve,  paralysis  of,  461 
Phthisis.      See  Tuberculosis,  pulmonary, 

555. 
Physical  signs,  pictoric  record  of,  536 
Pica,  772 

Pigeon-breast,  715 
Pigmentation  of  skin,  124 
Plague,  bubonic,  347 

bacillus  of,  348 
Plasmodia  of  malaria,  2S2 

staining  of,  284 
Plate  cultures,  243 
Plethora,  401 
Pleural  friction  sound,  distinguished  from 

pericardia],  630 
Pleurisy  acute,  569 

distinguished  from  intercostal  neu- 
ralgia, 470,  576 
from  pleurodynia,  469,  576 
from  pneumonia,  575 
physical  signs  of,  570 

chronic,  576 

with  thickening,  576 

cough  in,  465 

diaphragmatic,  574 

etiology  of,  569 

with  effusion,  570 


INDEX. 


1077 


Pleurisy,  with  effusion,  segophony  in,  513 
aspiration  of,  358 
character  of  fluid  in,  365 
distinguished  from  consolidation, 
575 
from  enlarged  liver,  870 
from   hydatid  cjst  of  liver, 
884 
heart  in,  571 

shape  and  size  of  chest  in,  484 
movements  of  chest  in,  487,  488 
pain  in,  469 

from  pneumococcus  infection,  318 
tuberculous,  574 
Pleurodynia,  167 

distinguished  from  pleurisy,  469,  488, 
576 
Plumbism,  215 
Pneumatosis,  802 
Pneumococcus,  363 

septicaemia  due  to,  31 8 
Pneumokoniosis,  550 
Pneumonia-broncho-,  549 

distinguished    from    collapse    of 

lung,  549 
physical  signs  of,  549 
tuberculous,  550 
bronchophony  in,  513 
chronic  interstitial,  550 
crepitant  rales  in,  510 
croupous  or  lobar,  311 

bacteriological  diagnosis  of,  318 
central  variety,  311 
cerebral  symptoms  in,  314 
chlorides  in  urine  in,  315 
critical  sweats  in,  145 
diagnosis  of,  317 
distinguished    from    collapse    of 

lung,  548 
in  drunkards,  317 
duration  and  course  of,  316 
heart  and  pulse  in,  314 
massive,  315 
organism  of,  534 
physical  signs  of,  315 
respiration  in,  312 
sputum  in,  312 
varieties  of,  316 
in  infants,  317 
movements  of  chest  in,  487 
pulmonary  second  sound  in,  625 
sputum  of,  521 
Pneumopericardium,  648 
Pneumoperitoneum,  751 
Pneumothorax,  577 
diagnosis  of,  578 

distinguished  from  emphysema,  566 
Poikilocytosis,  375 
Poisoning.     See  Intoxication,  209 
Poliomyelitis,  anterior,  1038 
Polyphagia,  803 
Polypi,  nasal,  424 
Pons,  lesions  of,  1019 
Portal  vein,  obstruction  of,  858 

pysemia,  858 
Pott's  disease,  paraplegia  in,  1048 


Prsecordia,  prominence  of,  592 

Previous  disease,  bearing  of,  on  diagnosis, 

29 
Pregnancy,  pigmentation  in,  125 

vomiting  in,  767 
Pressure,  sense  of,  975 
Proctitis,  839 
Pruritus,  134 

in  jaundice,  861 

in  uraemia,  957 
Ptosis,  91 
Ptyalism,  694 
Pulmonary  disease.     See  Lung. 

valve  disease,  666 

area,  632 
Pulsation  of  arteries,  587,  596 

a  subjective  symptom,  590 

epigastric,  596,  7^8 

of  veins,  599 
Pulse  in  aortic  aneurism,  681 

capillary,  598,  659 

Corrigan's,  658 

in  fever,  199 

frequency  of,  604,  608 

high  tension,  sphygmogram  in,  613 

irregular,  sphygmogram  in,  614 

low  tension,  sphygmogram  in,  613 

method  of  taking,  604 

in  peritonitis,  752 

in  rheumatoid  arthritis,  186 

rhythm  of,  607 

tension  of,  606 
in  fever,  199 

venous,  600 

volume  of,  606 
Pulsus  paradoxus  in  adherent  pericarditis, 
649 
in  pericardial  effusion,  645 
Puncture,  exploratory,  357 
Pupillary  reflex,  97 
Purpura,  128 
Pus,  bacteria  of,  240,  360 

chemical  examination  of,  364 

physical  characteristics  of,  360 

staining  of,  240 

tubercular,  362 

in  urine,  936,  941 
Pyseinia,  224 
Pyelitis,  912 

Pylephlebitis,  suppurative,  875 
Pylorus,  stenosis  of,  808 
Pyonephrosis,  912 
Pyopneumothorax,  577 

subphrenicus,  578,  747 
Pyorrhoea  alveolaris,  691 
Pyrosis,  772,  802 
Pyuria,  936 

absence  of  in  renal  calculus,  905 


RHACHITIS.     See  Rickets,  172 
Rales,  509 

distinguished  from  friction  sound, 
510 
Ranula,  697,  700 
Rashes,  medicinal,  139 


1078 


INDEX. 


Ray  fungus,  351 
Raynaud's  disease,  115,  1006 
Reactions  of  degeneration,  996 

atypical,  999 
Records  of  cases,  21 
Rectum,  diseases  of,  852 
Reflex,  abdominal,  986 
patellar,  987 
plantar,  989 
reinforcement  of,  987 
tendo-Achillis,  988 
tendon,  985 
Regions  of  chest,  471 
Regurgitation  of  food,  772 

in  disease  of  oesophagus,  723 
Reichman's  disease,  801 
Relapsing  fever,  274 

serum  diagnosis  in,  276 
spirillum  of,  275 
Renal  calculus,  902 

colic,  902 
Residence  in  etiology  of  disease,  26 
Resistance  to  finger  in  percussion,  496 
Resonance,  pulmonary,  494 
Respiration,  Cheyne-Stokes,  487 
in  fever,  199 
rate  of,  476,  486 

ratio  of  inspiration  to  expiration,  486 
types  of,  476 
Restlessness,  70 
Retinitis,  100 

albuminuric,  959,  965 
Retraction  of  interspaces  in  adherent  peri- 
cardium, 649 
Retroperitoneal  sarcoma,  754 
Retropharyngeal  abscess,  717 
Rhabdenoma  intestinale,.834 
Rheumatic  fever,  178 

complications  and  sequelae  of,  181 
diagnosis  of,  181 
endo-  and  pericarditis  in,  180 
temperature  in,  180 
Rheumatism,  acute  articular.     See  Rheu- 
matic fever, 
chronic  articular,  183 
gastric  symptoms  of,  762 
gonorrhceal,  178 
hand  in,  113,  114 
muscular,  167 

relation  of,  to  lithaemia,  856 
subacute  articular,  182 
subcutaneous  nodules  in,  158 
Rheumatoid  arthritis,  185 
diagnosis  of,  187 
fingers  in,  114 
pulse  in,  186,  608 
Rhinitis,  atrophic,  425 
caseous,  425 

chronic  hypertrophic,  424,  428 
idiopathic,  420 
sicca,  429 
simple  acute,  427 
syphilitic,  429 
Rhinoscopy,  421 
Rickets,  172 

diagnosis  of,  174 


Rickets,  fontanelles  in,  87 

shape  of  chest  in,  480 

sweating  of  head  in,  146 
Rigidity  of  abdomen  in  peritonitis,  751 
Roseola,  139 
Rotheln,  264 
Rubella,  264 

distinguished  from  scarlet  fever,  259 
Rumination,  803 


OALIVA,  687 
O     in  disease,  689 
Salivation,  687 
Saltatoric  spasm,  1040 
Sarcina,  220 

in  gastric  contents,  784 

in  urine,  948 
Sarcoma,  retroperitoneal,  754 

of  skin,  157 
Scalp,  pain  in,  46 
Scanning  speech,  1006 
Scaphoid  abdomen,  735 
Scarlet  fever,  255 

complications  and  sequelae  of,  258 
diagnosis  of,  258 
pulse  in,  608 
tongue  in,  701 
varieties  of,  257 
Scars,  significance  of,  in  diagnosis,  146 
Sciatica,  53,  1043 
Scleroderma,  157 
Sclerosis,  amyotrophic  lateral,  1046 

multiple  or  insular,  1047 
gait  in,  71 
Scotoma,  102 
Scurvy,  188 

gums  in,  691 

hemorrhage  in,  128 

-rickets,  189 
Seitz's  sign  of  cavity,  515 
Sensation,  971 

delayed,  975 

dissociation  of,  973 

of  locality,  974 

muscular,  975 

of  pain  from  induced  current,  975 

of  pressure,  975 

stereognostic,  976 

tactile,  971 

of  temperature,  973 
Septicaemia,  225 

fever  in,  210 
Septico-pysemia,  334 
Serum  diagnosis,  233 

dilution  and  time  limit  in,  236 

the  appearance  of  the  reaction,  236 

in  relapsing  fever,  276 

in  typhoid  fever,  235,  299 

value  of,  237 

with  dried  blood,  236 

with  fluid  serum  or  blood,  234 
Sex  in  etiology  of  disease,  25 
Shell-fish  poisoning,  214 
Shock,  65 

effect  of,  on  pain,  39,  40 


INDEX. 


1079 


Shock  from  hemorrhage,  406 
Shortness  of  breath,  462.     See  Dyspnoea. 
Siderosis,  551 
Skin,  color  of,  119 

hemorrhage  into,  126 
lesions  of,  artificial,  41 
classification  of,  132 
general  diagnosis  of,  141 
syphilitic,  142 
traumatic,  141 
ulcerative,  144 
malignant  nodules  under,  157 
nutrition  of,  144 
pigmentation  of,  125 
Skodaic  resonance,  499 

in  pleural  effusion,  570 
in  pneumonia,  315 
Smallpox.     See  Variola,  250 
Smell,  disturbance  of  sense  of,  419 
Spasm,  habit,  1040 
muscular,  981 
saltatoric,  1040 
Speech,  disturbances  of,  1000 
Spermatozoa  in  urine,  946 
Sphygmograph,  609 

Spinal  cord,  general  symptoms  of  disease 
of,  1024 
hemorrhage  into,  1050 
pressure  on,  symptoms  of,  1050 
traumatism  of,  1051 
tumor  of  membranes  of,  1048 
localization,  1021 
Spirilla,  general  characteristics  of,  222 
Spirillum  of  cholera  Asiatica,  338 
nostras,  835 
of  relapsing  fever,  275 
Spirometry,  516 
Spleen,  amyloid,  893 
diseases  of,  890 
enlargement  of,  891 

in  cirrhosis  of  liver,  877 
in  Hodgkin's  disease,  161 
in  infants,  893 
in  leucocythsemia,  396 
in  malaria,  289 
in  pneumonia,  314 
in  simple  anaemia,  392 
floating,  890 
hydatid  cyst  of,  893 
malignant  tumors  of,  893 
palpation  of,  890 
percussion  of,  890 
puncture  of,  360 
syphilis  of,  893 
topography  of,  890 
Splenitis,  acute,  891 
Spores  of  bacilli,  221 
Sputum,  519 

in  bronchiectasis,  566 

in  bronchitis,  capillary,  546 

plastic,  546 
chemistry  of,  536 
in  gangrene  of  lung,  563 
from  larynx,  441 
in  liver  abscess,  529 
in  lobar  pneumonia,  312 


Sputum,  method  of  collecting,  519 
micrococcus  lanceolatus  in,  534 
microscopic  examination  of,  522 
in  phthisis,  561 
physical  characteristics  of,  520 
tubercle  bacilli  in,  530 
Staining  of  bacteria,  240 
Staphylococci,  361,  362 
Station  in  disease,  74 
Stelwag's  sign,  89 
Sterilization  in  bacteriology,  231 
Stethoscope,  502 
Stiff  neck  in  oesophagitis,  719 
Stigmata  of  the  passion,  1061 
Stokes- A  dams'  syndrome   in   myocarditis, 

589,  655 
Stomach,  absorptive  power  of,  790 
anaesthesia  of,  803 
atony  of,  803 
auscultation  of,  778 
auscultatory  percussion  of,  777 
carcinoma  of,  808 

distinguished    from    ulcer    and 

chronic  gastritis,  811 
gastric  contents  in,  810 
cirrhosis  of,  806 
catarrh  of.     See  Gastritis. 
contents,  acetic  acid  in,  788 
alcohol  in,  test  for,  788 
anacidity  of,  791 
bile  in,  782 
blood  in,  782 
butyric  acid  in,  788 
carbohydrates  in,  789 
chemical  examination  of,  784 
clinical  value  of  examination  of, 

791  _ 
free  acid  in,  test  for,  784 
hydrochloric  acid  in,  test  for,  785 
hyperacidity  of,  791 
lactic  acid  in,  significance  of,  792 

test  for,  787 
method  of  securing,  779 
microscopical  examination  of,  783 
mucus  in,  782 
pepsinogen  in,  789 
rennin  in,  789 
syntonin  in,  789 
total  acidity  of,  784 
cough,  465 

digestive  power  of,  789 
dilatation  of,  777,  807 
diminution  in  size  of,  777 
general  condition  in  disease  of,  793 
history  in  disease  of,  763 
hyperacidity  and  hypersemia  of,  801 
inspection  of,  774 
internal  exploration  of,  775 
motor  power  of,  790 
neuroses  of,  797 
nervous  mechanism  of,  760 
in  other  diseases,  761 
palpation  of,  775 
percussion  of,  776 
position  of,  776 
relaxation  of  orifices  of,  803 


1080 


INDEX. 


Stomach,  tumor  of,  775 

ulcer  of,  811 
Stomatitis,  692 

aphthous,  693 

catarrhal,  693 

gangrenous,  694 

materna,  693 

mercurial,  694 

parasitic,  693 

ulcerative,  693 
Stools  in  amoebic  dysentery,  343 

in  catarrhal  dysentery,  345 

in  cholera,  337 

in  diarrhoea,  820 
Streptococcus  pyogenes,  362 
Strongylus,  symptoms  of,  815 
Stuttering  and  stammering,  1006 
Subdiaphragmatic  abscess,  746 
Sublingual  ulcer,  695 
Succussion,  Hippocratic,  512 

in  pneumothorax  577 

splash  in  stomach,  778 
Sudamina,  140 
Sugar  in  urine,  931 

Sulphocyanide  of  potassium  in  saliva,  689 
Sunstroke,  211 

fever  in,  203 
Suppuration,- symptoms  of,  408 
Suprarenal  capsules,  disease  of,  734 
Sweat.     See  Perspiration. 
Symptoms,  evolution  of,  31 

objective,  definition  of,  17 

subjective,  definition  of,  17 
valuation  of,  32 
Syncope,  64 
Synovitis,  178 
Syphilis,  acquired,  269 

caries  of  frontal  bone  in,  87 

coryza  in,  429 

effect  of  mercury  on  haemoglobin  in, 
271 

fever  in,  206,  229 

headache  in,  49,  592 

hereditary,  270 

of  larynx,  439,  448 

of  liver,  879 

lymphatic  glands  in,  159 

nasal  ulceration  in,  424 

neuralgia  in,  48 

of  pharynx,  709 

skin  lesions  in,  142 

teeth  in,  691 
Syringomyelia,  1050 


TABES  dorsalis,  1043 
cervical  type  of,  1044 
gait  in,  70 
joints  in,  189 
pain  in,  55 
pulse  in,  608 
mesenterica,  748 
Tache  ce"r6bral,  1052 
Tachycardia,  608 

in  exophthalmic  goitre,  89 
Taenia,  831 


Taenia,  symptoms  of,  814 
Teeth,  691 _ 

Hutchinson's,  271 

in  rickets,  172 

time  of  eruption  of,  692 
Teething,  692 
Temperature.     See  also  Fever. 

danger  limit  of,  194 

determination  of,  192 

influence  of  age  and  sex  on,  208 

normal  variation  in,  194 

pathological  variations  in,  194 

sense  of,  973 

subnormal,  201 

when  to  take,  193 
Tendon  reflexes,  985 
Tenesmus,  42 

in  diarrhoea,  821 
Tension  in  arteries,  606 
Tetanus,  352 

bacillus  of,  353 
Tetany,  1040 

in  dilatation  of  stomach,  807 

in  rickets,  174 
Thermoansesthesia,  973 
Thirst  in  gastric  disease,  764 
Thomsen's  disease,  166,  1041 
Thorax.     See  Chest. 
Thrill  in  aortic  aneurism,  679 
obstruction,  659 

cardiac,  603 

in  mitral  stenosis,  664 

in  tricuspid  stenosis,  666 
Throat  in  scarlet  fever,  256 
Thrombosis,  403 

in  arterio-capillary  fibrosis,  673 

cerebral,  1054 
Thrush,  690 

Thumb-sucking,  effect  on  dental  arch,  687 
Thyroid  gland,  enlargement  of,  88 
Tic  douloureux,  47,  53,  1042 

facial,  982 

general,  1040 
Tinea,  143 
Tinnitus  aurium,  107 
Tongue,  695 

atrophy  of,  700 

coating  of,  700 

cysts  of,  700 

diagnostic  significance  of,  704 

discoloration  of,  695 

dryness  of,  704 

furrows  in,  697 

geographical,  700 

hypertrophy  of,  700 

movements  of,  in  disease,  706 

in  prognosis  and  treatment,  705 

of  scarlet  fever,  257 

ulcers  of,  698 

white  patches  on,  699 
Tonsillitis,  acute,  711 

chronic,  714 

distinguished  from  diphtheria,  713 

follicular,  712 

suppurative,  712 
Tonsils,  the,  710 


INDEX. 


1081 


Tonsils,  foreign  body  in,  714 
leptothrix  in,  711 
pseudoniembraue  on,  711 
ulcers  of,  711 
Tooth-cough,  465 
Tophi  in  gout,  184 
Tormina  ventriculi,  803 
Torticollis,  168 
Toxaemia,  fever  in,  203 
Toxins  and  toxalbumins,  221 
Trachea,  obstruction  of,  457 
Tracheal  tugging  in  aneurism,  88,  681 
Transudations,  365 
Traube's  semilunar  space,  776 
Tremor,  980 

in  exophthalmic  goitre,  90 
Trichina  spiralis,  354,  834 
Trichinosis,  354 

eosinophilia  in,  356 
face  in,  84 
oedema  in,  151 
Trichoaesthesia,  973 

Trichomonas  in  genito-urinary  tract,  949 
Trichterbrust,  483,  715 
Tricocephalus  dispar,  834 
Tricuspid  area,  632 
regurgitation,  665 

venous  pulse  in,  600 
stenosis,  666 
Trismus  neonatorum,  353 
Trophic  disturbances,  1006 
Trousseau's  sign  of  tetany,  1041 
Tubercle  bacillus,  530 
Tuberculin  test,  321 

in  tubercular  adenitis,  161 
Tuberculosis,  319 

acute  miliary,  322 

distinguished  from  typhoid  fever, 

302,  555 
pulmonary  type  of,  554 
bacillus  of,  530 
cervical  glands  in,  159 
fever  in,  205 

hereditary  tendency  to,  320 
of  intestine,  842 
of  kidney,  967 
of  pharynx,  709 
pulmonary,  acute,  552 

distinguished  from  pneumo- 
nia, 554 
chronic,  555 

diagnosis  of,  319 

excursion  of  diaphragm  in, 

477 
fever  in,  558 
gastric  symptoms  in,  761 
haemoptysis  in,  467,  560 
inspiratory  capacity  in,  518 
modes  of  invasion  in,  556 
movements  of  chest  in,  488 
pain  in  chest  in,  560 
physical  signs  of,  561 
sputum  in,  561 
sweats  in,  559 
of  tongue,  699 
Tuberculous  peritonitis,  755 


Tuberculous     peritonitis,     acute,     distin- 
guished  from   perforating   ap 
pendicitis,  743 
diagnosis  of,  758 
tumors  in,  757 
Twitching,  fibrillary  muscular,  989 
Tympany,  a  percussion  sound,  495 
Tympanites  in  peritonitis,  732,  751 
Typhlitis,  742 

stercoral,  824 
Typhoid  fever,  289 

absence  of  leucocytosis  in,  299 
bacillus  of,  298,  300 
Baruch's  sign  of,  301 
complications  and  sequelae  of,  298 
diagnosis  of,  301 

distinguished  from   appendicitis, 
740 
from  malignant  endocarditis, 

652 
from  typhus  fever,  249 
eruption  in,  296 
heart-sounds  in,  294 
incubation  of,  289 
nervous  symptoms  of,  294 
pulse  in,  291 
spleen  in,  290 
temperature  in,  290 
tongue  in,  702 
urine  in,  294 
varieties  of,  297 
Widal     reaction     in     233.       See 

Serum  diagnosis, 
without  fever,  229 
without  intestinal  lesions,  298 
state,  199 
Typhus  fever,  247 
Tyrosin  crystals,  in  sputum,  528 
in  urine,  953 


ULCER  in  mouth,  694 
of  skin,  diagnosis  of,  144 

of  stomach,  611 

sublingual,  695  . 

of  tongue,  698 

trophic,  1008 
Umbilicus  in  tuberculous  peritonitis,  728, 

755 
Unconsciousness,  64 
Uraemia,  956,  965 

asthma  in,  461 

cardio-vascular  symptoms  of,  958 

dropsy  in,  959 

dyspnoea  in,  957,  965 

gastro-intestinal    symptoms    in,    965, 
977 

hemorrhage  in,  959 

latent,  95S 

nervous  symptoms  in,  956,  965 

retinal  changes  in,  959,  965 

temperature  in,  956,  965 
Urates  in  urine,  950 
Urea,  estimation  of,  920 
Ureters,  catheterization  of,  955 
Uric  acid  in  blood,  test  for,  386 


1082 


INDEX. 


Uric  acid  diathesis,  184.     See  Gout. 

Neusser's  granules  in,  383 

in  urine,  949 
Urine,  acetone  in,  936 

albumin  in,  causes  of,  927 

quantitative  estimation  of,  926 

tests  for,  921 
albumose  in,  929 
alkapton  in,  937 
bacteria  in,  948 

bile-pigments  and  bile-acids  in,  935 
blood  in,  928,  940 
cancer  cells  in,  949 
casts  in,  941 
centrifugation  of,  938 
chemical  examination  of,  919 
chlorides  in,  920 

in  gastric  cancer,  794 

in  pneumonia,  315 
cholesterin  in,  954 
color  of,  914 
cylindroids  in,  945 
cystin  in,  953 
diacetic  acid  in,  936 
entozoa  in,  948 
epithelium  in,  946 
extraneous  matter  in,  938 
fat  and  chyle  in,  947 
in  gastric  disease,  794 
globulin  in,  937 
indican  in,  935 
leucin  and  tyrosin  in,  953 
in  lithsemia,  856 
melanin  in,  954 

in  nephritis,  acute  exudative,  961 
productive,  962 

chronic  productive,  963,  964 
nucleo-albumin  in,  928 
odor  of,  919 
oxalates  in,  952 
phosphates  in,  950 
pus  in,  936,  941 
reaction  of,  918 
in  rheumatic  fever,  180 
sediments  in,  918 

solids  in,  estimated  from  specific  grav- 
ity, 918 
specific  gravity  of,  917 
spermatozoa  in,  946 
sugar  in,  test  for,  936 

quantitative  estimation  of,  932 
suppression  of,  916 
urates  in,  950 
urea  in,  919 

quantitative  estimation  of,  920 
uric  acid  in,  949 
volume  of,  914,  916 
Urticaria,  138 
Uvula,  710 


VALLEIX,  points  of,  45 
Valve-shock,  602 
Varicella,  253 


Variola,  250 

varieties  of,  252 
Varioloid,  252 
Vasomotor  changes  in  hysterical  joints,  190 

mechanism,  415 

symptoms  in  migraine,  50 
in  neuralgia,  53 
Veins,  diastolic  collapse  of,  601 

in  adherent  pericarditis,  649 

distention  of,  598 

murmurs  in,  641 

pulsation  of,  599 

thrombosis  of,  614 
Venous  hum,  641 

pulse,  600 
Vertebral  canal,  aspiration  of,  359 
Vertigo  in  dyspeptic  headache,  52 

paralyzing,  109 
Vision,  field  of,  101 
Vocal  resonance,  513 
Voice  in  adenoid  disease,  715 

in  central  nervous  disease,  449 
Volvulus,  843 
Vomiting,  764 

cerebral,  768 

cyclic,  768 

in  gastric  cancer,  767,  809 
ulcer,  767,  812 

in  gastritis,  766 

in  migraine,  50 

in  peritonitis,  751,  768 

in  phthisis,  561 

of  pregnancy,  767 

reflex,  767 

in  toxaemia,  768 

uremic,  768,  957,  965 
Von  Graefe's  sign,  89 


WATERBRASH,  872 
Weight  of  body  in  disease,  76 
Weil's  disease,  271 
Wernicke's  sign,  104 
Whooping-cough,  265 
Widal  reaction,  233.    See  Serum  diagnosis. 
Williams'  tracheal  tone,  514 
Wintrich's  change  of  note  over  cavity,  414 

in  pneumothorax,  577 
Wool-sorter's  disease,  278 
Word-blindness  and  word-deafness,  1000 
Wrist-drop,  113 
Writer's  cramp,  1041 


XANTHELASMA,  695 
Xerostoma,  686 
X-ray  examination  of  chest,  488 
of  stomach,  775 


YELLOW  fever,  303 

I     bacillus  of,  305 

general  diagnosis  of,  305 
serum  diagnosis  of,  305 


COLUMBIA  UNIVERSITY 

This  bqgk  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

C28'636)ME0 

RC71 

M97 

1899 

Musser 

A  Dractical 

treatise 

on 

medical 

yatft 


Ssft 


Wst 


n 


1 


ill 


